Body Contouring: Art, Science, and Clinical Practice

Body Contouring

Melvin A. Shiffman Alberto Di Giuseppe (Eds.)

Body Contouring Art, Science, and Clinical Practice

Melvin A. Shiffman, MD, JD 17501 Chatham Drive Tustin, CA 92780-2302 USA [email protected]

Alberto Di Giuseppe, MD Department of Plastic and Reconstructive Surgery, School of Medicine University of Ancona 1, Pizza Cappelli 60121 Ancona Italy [email protected]

ISBN: 978-3-642-02638-6

e-ISBN: 978-3-642-02639-3

DOI: 10.1007/978-3-642-02639-3 Springer Heidelberg Dordrecht London New York Library of Congress Control Number: 2009942715 © Springer-Verlag Berlin Heidelberg 2010 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: eStudio Calamar, Figueres/Berlin Printed on acid-free paper Springer Science+Business Media (www.springer.com)

Dedication

This book is dedicated to the women of my life, to my mother, Sara, who died at the age of 82 in December 2008, who was the dearest angel of my young age and to my wife, Isabella, married for 20 years, who was my unique love and who has been patient and helpful in sustaining all my work and dedication. I wish the new generation of nephews, Diana, Federico, and Saverio, to continue our work following the same principles that have imprinted our lives. Special thanks to my dearest friend, Melvin, a man of special talent and humanity, sensible, and creative, who has made the greatest effort to realize this book. Dr. Alberto Di Giuseppe

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Foreword

As plastic surgeons, we seek to combine art and science to improve the results we see in clinical practice. Through our artistic sensibilities, we try to understand and obtain aesthetic results. Scientific analysis provides the data to predict which approaches will be successful and safe. Both art and science connote a high level of skill or mastery. At the present time, our literature is replete with descriptions of specific procedures for body contouring. However, there remains a need for a definitive reference describing the basic principles to address the complete scope of body contouring including the postbariatric patient and their plastic surgery deformities. Dr. Shiffman and Dr. Di Giuseppe saw this need and sought to address the needs of plastic surgeons faced with the complexities of body contouring surgery. This is a comprehensive text aimed at providing multiple perspectives. The numerous sections, which include adiposity and lipolysis, the breast, abdomen, chest, and buttocks, the extremities, and liposuction, offer various approaches from the foremost authors. Indeed it is with a tremendous amount of skill and mastery that Dr. Shiffman and Dr. Di Giuseppe have successfully edited and collated the numerous contributions to this work. In addition, they have authored individually or, in collaboration, over a dozen of the 87 total chapters. Their combined work as editors and authors are evident throughout their text. The final result is a comprehensive contribution that will benefit all plastic surgeons seeking to improve their approach to body contouring. Division of Plastic Surgery The University of Alabama at Birmingham Birmingham, USA

Jorge I. de la Torre

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Preface

Contouring of the body includes shaping of the neck, torso, breasts, hip, abdomen, and extremities. The types of procedures performed to shape the body involve surgical excisions, liposuction, implantation, injection of fillers, and in rare instances other modalities. Since the advent of bariatric surgery with extreme weight loss and sagging of tissues, body contouring has become more extensive and consequently with more possible complications. Clothes have been used to accentuate the body contour in certain areas and minimize in other areas. However, clothes that expose more of the body contour will accentuate the body’s defects. Therefore, patients are requesting improvement in the shape of their bodies in order to accommodate the clothes that are fashionable. There are limits as to what surgery will accomplish but certainly the procedures that are available can improve the shape but rarely can make it perfect. Patients should be made to understand the limits of the procedures, the limits of correction that can be obtained, and the possibility of complications that may permanently mar the patient’s appearance. The cosmetic surgery patient usually expects perfection without complications even when the possible risks and complications are thoroughly discussed. These are elective procedures on patients who are usually in good health although this is not necessarily true for the post bariatric surgery patient. Obesity increases the risks of surgery and the patient who is overweight should be specifically informed of this problem. This book is an attempt to bring to the student and practicing plastic and cosmetic surgeon, or any specialty where body contouring may be performed, the types of procedures available, the techniques of performing these procedures, and their possible risks and complications. Special attention is paid to the procedures and problems of the post bariatric patient since this is a separate specialty of body contouring. Many international specialists have been selected to contribute to this book in order to expand the knowledge of those performing body contouring surgery. Knowledge is international and should not be restricted to local or national ideas only. The reader will be introduced to old and new techniques and variations in techniques in order to better understand what is available to the aesthetic surgeon. Students and experienced surgeons of body contouring surgery will greatly benefit by the extensive information available that is not otherwise to be found in one book but mainly in a variety of papers in the medical literature. Tustin, California, USA Ancona, Italy

Melvin A. Shiffman Alberto Di Giuseppe

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Contents

Part I Anatomy, Classification of Adiposities, Body Contouring, Injection Lipolysis 1 Mammary Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Michael R. Davis

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2 Gluteal Contouring Surgery: Aesthetics and Anatomy . . . . . . . . . . . . . Robert F. Centeno

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3 Anatomy and Topography of the Anterior Abdominal Wall . . . . . . . . . Michael R. Davis and Matthew R. Talarczyk

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4 History of Classifications of Adiposity Excess . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

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5 Body Contour: A 50 Year Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ivo Pitanguy and Henrique N. Radwanski

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6 Injection Lipolysis for Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . Diane Duncan

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Part II  Breast 7 History of Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

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8 Inframammary Approach to Subglandular Breast Augmentation . . . . Anthony Erian and Amal Dass

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9 Hydrodissection Axillary Approach Breast Augmentation . . . . . . . . . . . Sid J. Mirrafati and Melvin A. Shiffman

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10 Complications of Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . Anthony Erian and Melvin A. Shiffman

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11 Regnault B Mastopexy: A Versatile Approach to Breast Lifting and Reduction . . . . . . . . . . . . . . . . . . . . . . . 119 Howard A. Tobin xi

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12 Mastopexy/Reduction and Augmentation Without Vertical Scar . . . . . 125 Sid J. Mirrafati 13 Breast Reduction and Mastopexy with Vaser in Male Breast Hypertrophy . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Alberto Di Giuseppe 14 Gynecomastia Repair Using Power-Assisted Superficial Liposuction and Endoscopic Assisted Pull-Through Excision . . . . . . . . 139 Yitzchak Ramon and Yehuda Ullmann 15 Mastopexy Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Melvin A. Shiffman 16 History of Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Melvin A. Shiffman 17 Strombeck Breast Reduction Technique . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Pierre F. Fournier 18 Inverted Keel Resection Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . 169 Ivo Pitanguy and Henrique N. Radwanski 19 Vaser-Assisted Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Alberto Di Giuseppe 20 Complications of Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Melvin A. Shiffman Part III  Abdomen, Chest, Buttocks 21 History of Abdominoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Giovanni Di Benedetto and William Forlini 22 Abdominoplasty Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Melvin A. Shiffman 23 Liposculpture of the Abdomen in an Office-Based Practice . . . . . . . . . . 219 Peter M. Prendergast 24 “Anchor-Line” Abdominoplasty: A Comprehensive Approach to Abdominal Wall Reconstruction and Body Contouring . . . . . . . . . . . 239 Paolo Persichetti, Pierfranco Simone, Annalisa Cogliandro, and Nicolò Scuderi 25 Circular Lipectomy with Lateral T ­ high–Buttock Lift . . . . . . . . . . . . . . 249 Héctor J. Morales Gracia 26 Prevention and Management of Abdominoplasty Complications . . . . . 267 Melvin A. Shiffman

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27 Mastopexy with Extended Chest Wall-Based Flap After Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Luiz Haroldo Pereira and Aris Sterodimas Part IV  Extremities 28 Brachioplasty: How to Choose the Correct Procedure . . . . . . . . . . . . . . 287 A. Chasby Sacks 29 Brachioplasty: A Body-Contouring Challenge . . . . . . . . . . . . . . . . . . . . 293 James G. Hoehn, Sumeet N. Makhijani, and Jerome D. Chao 30 “Fish-Incision” Brachioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 Rajiv Y. Chandawarkar 31 Brachioplasty Technique with Molds Combined to Vaser Assisted Lipomyosculpture . . . . . . . . . . . . . . . . . . . . 313 Ewaldo Bolivar de Souza Pinto and Pablo S. Frizzera Delboni 32 Limited Incision Medial Brachioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Andrew P. Trussler and Rod J. Rohrich 33 Augmentation Brachioplasty with Cohesive Silicone Gel Implants . . . . 327 Gal Moreira Dini and Lydia Massako Ferreria 34 Long-Term Outcomes and Complications After Brachioplasty . . . . . . . 331 James Knoetgen III 35 Lymphoscintigraphy: Evaluation of the Lymphatic System . . . . . . . . . . 337 Cristina Hachul Moreno, Aline Rodrigues Bragatto,Américo Helene, Carlos Alberto Malheiros, and Henrique Jorge Guedes Neto 36 Medial Thigh Lift and Declive: Inner Thigh Lift Without Using Colle’s Fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 Daniele Spirito 37 Spiral Lift: Medial and Lateral Thigh Lift with Buttock Lift and Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355 Sadri O. Sozer, Francisco J. Agullo, and Humberto Palladino 38 A Novel Treatment Option for Thigh Lymphoceles Complicating Medial Thigh Lifting Procedures . . . . . . . . . . . . . . . . . . . 365 Wayne K. Stadelmann 39 Fat Augmentation of Buttocks and Legs . . . . . . . . . . . . . . . . . . . . . . . . . . 373 Lina Valero de Pedroza 40 Lower Leg Augmentation with Combined Calf-Tibial Implant . . . . . . . 381 Afshin Farzadmehr and Robert A. Gutstein

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Part V  Liposuction 41 Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications . . . . . . . . . . . . 389 William W. Cimino 42 History of Ultrasound-Assisted Lipoplasty . . . . . . . . . . . . . . . . . . . . . . . 399 William W. Cimino 43 Face and Neck Remodelling with Ultrasound-Assisted Lipoplasty (Vaser) . . . . . . . . . . . . . . . . . . . . . . 405 Alberto Di Giuseppe 44 High Definition Liposculpting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419 Alfredo Hoyos 45 Vaser-Assisted Liposculpture for Body Contouring . . . . . . . . . . . . . . . . 425 Alberto Di Giuseppe 46 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring . . . . . . . . . . . . . . . . . . 459 Andrew T. Lyos 47 Body Contouring with Focused Ultrasound . . . . . . . . . . . . . . . . . . . . . . . 473 Javier Moreno-Moraga and Josefina Royo de la Torre 48 Focus Ultrasound on Limited Lipodystrophies . . . . . . . . . . . . . . . . . . . . 485 Michele Cataldo, Luca Grassetti, and David E. Talevi 49 Aesthetic Body Contouring of the Posterior Trunk and Buttocks Using Third Generation Pulsed Solid Probe Internal Ultrasound-Assisted Lipoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493 Onelio Garcia Jr. 50 Treatment Options in Benign Symmetric Lipomatosis . . . . . . . . . . . . . . 505 Anthony P. Sclafani, Kenneth Rosenstein, and Joseph J. Rousso 51 Liposuction for Madelung’s Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513 Robert Yoho 52 Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517 Alberto Di Giuseppe 53 Liposuction of the Calves and Ankles Associated with Calf Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539 Adrien E. Aiache 54 Management of HIV-Associated Lipodystrophy: Medical and Surgical Options for Lipoatrophy and Lipohypertrophy . . . . . . . . . . . . . . . 545 C. Scott Hultman and Anne Keen

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55 Prevention and Treatment of Liposuction Complications . . . . . . . . . . . 553 Melvin A. Shiffman 56 Comparison of Blood Loss in Suction-Assisted Lipoplasty and Third-Generation Ultrasound-Assisted Lipoplasty . . . . . . . . . . . . . 565 Onelio Garcia Part VI  Fat Transfer 57 Fat Transfer Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577 Melvin A. Shiffman 58 Enhancing Muscle Appearance with Extensive Liposuction and Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 587 Alfredo Hoyos 59 Remodelling Breast and Torso with Liposuction and Fat Grafts . . . . . . 595 Alfredo Hoyos and David Broadway 60 Buttock Remodeling with Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . 599 William L. Murillo 61 Complications of Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617 Hassan Abbas Khawaja, Melvin A. Shiffman, Enrique Hernandez-Perez,  José  Enrique  Hernández-Pérez, and Mauricio Hernandez-Perez Part VII  Body Contouring After Severe Weight Loss 62 History of Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629 Melvin A. Shiffman 63 Psychosocial Aspects of Body Contouring Surgery After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633 Troy W. Ertelt, Joanna M. Marino, and James E. Mitchell 64 Psychosocial Issues in Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . 641 David B. Sarwer 65 Nutrition Issues After Bariatric Surgery for Weight Loss . . . . . . . . . . . 651 George John Bitar and Sally Myers 66 The Body’s Aesthetic Units for Body Contouring Surgery in Massive Weight Loss Patients . . . . . . . . . . . . . . . . . . . . . . . . . 661 Héctor J. Morales Gracia and Alberto Javier Coutté Mayora 67 Classification of Contour Deformities After Massive Weight Loss: Clinical Applications of the Pittsburgh Rating Scale . . . . . . . . . . . . . . . 675 Angela S. Landfair, Dennis J. Hurwitz, Madelyn H. Fernstrom, Raymond Jean, and J. Peter Rubin

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68 Facial Contouring in the Postbariatric Surgery Patient . . . . . . . . . . . . . 687 Anthony P. Sclafani and Vikas Mehta 69 Total Body Lift After Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . 695 Nestor Veitia and Dennis J. Hurwitz 70 Transaxillary Breast Augmentation/Wise-Pattern Mastopexy in the Massive Weight Loss Patient . . . . . . . . . . . . . . . . . . . . 709 George John Bitar 71 Mastopexy with Extended Chest Wall-Based Flap After Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719 Ruth Maria Graf, Daniele Pace, and Alexandre Mansur 72 Medial Thigh Lift Free Flap for Breast Augmentation After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 725 Thomas Schoeller and Georg M. Huemer 73 Rotation-Advancement Superomedial Pedicle Mastopexy Following Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . 735 Albert Losken 74 Flank Reshaping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743 Keith Robertson and Bilal Gondal 75 Perforator Sparing Abdominoplasty: Indications and Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . 757 Ulrich M. Rieger and Martin Haug 76 Abdominal Lipectomy and Mesh Repair of Midline Periumbilical Hernia After Bariatric Surgery Sparing the Umbilicus . . . . . . . . . . . . . 763 Antonio Iannelli 77 Combined Abdominoplasty and Medial Vertical Thigh Reduction Following Severe Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . 769 Mohammed G. Ellabban and Nicholas B. Hart 78 Complications in Abdominoplasty Patients After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775 Mikko Larsen and Peter W. Plaisier 79 Quality of Life After Abdominoplasty Following Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 783 Wilson Cintra, Miguel Luiz Antonio Modolin, Joel Faintuch, Rolf Gemperli, and Marcus Castro Ferreira 80 Algorithm for Surgical Plane in Brachioplasty After Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 789 Claudio Cannistra

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81 L Brachioplasty Following Massive Weight Loss . . . . . . . . . . . . . . . . . . . 795 Daron Geldwert and Dennis J. Hurwitz 82 Brachioplasty After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 803 Franco Migliori 83 Brachioplasty and Axillary Restoration with Treatment Algorithm for Brachioplasty . . . . . . . . . . . . . . . . . . . . . . 809 Charles K. Herman and Berish Strauch 84 Current Techniques in Medial Thighplasty . . . . . . . . . . . . . . . . . . . . . . . 815 David W. Mathes 85 Thighplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827 Cristina Hachul Moreno, Aline Rodrigues Bragatto, Américo Helene Jr, Carlos Alberto Malheiros, and Henrique Jorge Guedes Neto 86 Combined Thigh and Buttock Lift After Massive Weight Loss . . . . . . . 837 Claudio Cannistrà 87 Venous Thromboembolism in Bariatric Body Contouring Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847 Maura Reinblatt and Michele A. Shermak Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 865

Contributors

Francisco J. Agullo, MD  Mayo Clinic, Division of Plastic Surgery, 200 First Street SW, Rochester, MN 55905, USA and Department of Surgery, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA [email protected] Adrien E. Aiache, MD  9884 Little Santa Monica Blvd, Beverly Hills, CA 90212, USA [email protected] George J. Bitar, MD  Bitar Cosmetic Surgery Institute, 8650 Sudley Road 203, Manassas, VA 20110, USA [email protected] Aline Rodrigues Bragatto, Jr, MD  Rua Vergueiro, 1353 cj 407, Paraiso CEP 04101-000, São Paulo, Brazil [email protected] David Broadway, MD  9777 S Yosemite Street, Suite 200, Lone Tree, CO 80124, USA [email protected] Claudio Cannistrà, MD  Department of Surgery, Plastic Surgery Unit, Bichat C. B. University Hospital, 71 rue de Rome, 75008 Paris, France [email protected] or [email protected] Michele Cataldo, MD  via Turati 4, 20060 Trezzano Rosa, Milano, Italy [email protected] or [email protected] Robert F. Centeno, MD  P.O. Box 24330, Christian Sted, VI 00824–0330, USA [email protected] Rajiv Y. Chandawarkar, MD  Department of Surgery, Division of Plastic Surgery, University of Connecticut, School of Medicine, Farmington, CT 06030, USA [email protected]

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Jerome D. Chao, MD  Division of Plastic Surgery , Albany Medical College, 25 Hackett Blvd, MC133, Albany, NY 12208, USA [email protected] William W. Cimino, PhD  Sound Surgical Technologies, 1300 Plaza Court North, Suite 103, Lafayette, CO 80026, USA and 578 W. Sagebrush Ct., Louisville, CO 80027, USA [email protected] or [email protected] Wilson Cintra, JR, MD  Plastic Surgery Service, Hospital das Clínicas, Av. San Gabriel, 201 conj. 704/5, São Paulo, SP 01435001, Brazil [email protected] Annalisa Cogliandro, MD  Division of Plastic and Reconstructive Surgery, Campus Bio-Medico University, Via Fontanellato, 49, 00142 Rome, Italy [email protected] Alberto Javier Coutté Mayora, MD  Belisario Domínguez No. 2501, Colonia Obispado, Monterrey, Nuevo León C.P 64060, México [email protected] Amal Dass, MD  Advanced Aesthetics & Surgery, 1, Grange Rd, Orchard Bldg, #06-06 Singapore 239693 [email protected] Michael R. Davis, MD  Division of Plastic Surgery, University of Alabama, Birmingham School of Medicine, 510 20th Street South, 1164 Faculty Office Tower, Birmingham, AL 35294-3411, USA [email protected] Jorge I. De La Torre, MD  Division of Plastic Surgery, The University of Alabama at Birmingham, 510 20th Street South, 1164 South Faculty Office Tower, Birmingham, AL 35294-3411, USA [email protected] Josefina Royo de la Torre, MD  Instituto Medico Laser, General Martinez-Campos 33, 28010 Madrid, Spain [email protected] Pablo Silva Frizzera Delboni, MD  Plastic Surgery Department, Santa Cecilia University – UNISANTA, São Paulo, Brazil [email protected] or [email protected] Lina Valero de Pedrosa, MD  Carrera 16 No 82-95-Cons: 301, Bogota, DC, Colombia [email protected] Ewaldo Bolivar de Souza Pinto, MD, PhD  Plastic Surgery Department, Santa Cecilia University – UNISANTA, Alameda Santos, 455 – cj. 306, São Paulo, Brazil [email protected] or dePedrosa [email protected] Giovanni Di Benedetto, MD, PhD  Marche Polytechnic University Medical School, Via Tronto, 20, Ancona, Italy [email protected]

Contributors

Contributors

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Alberto Di Giuseppe, MD  Department of Plastic and Reconstructive Surgery, School of Medicine, University of Ancona, 1, Piazza Cappelli, 60121 Ancona, Italy [email protected] Gal Moreira Dini, MD  Department of Plastic Surgery, Universidade Federale de São Paulo, Escola Paulista de Medicina, R. Vicencia faria Versage 400 ap. 113-14, Sorocaba Sao Paulo 18031-080, Brazil [email protected] Diane Duncan, MD  FACS, 1701 East Prospect Road, Fort Collins, CO 80525, USA [email protected] Mohammed G. Ellabban, MD  Plastic and Reconstructive Surgery Unit, Royal Preston Hospital, Sharoe Green Lane North, Fulwood, Preston PR2 9HT, UK [email protected] Anthony Erian, MD  Division of Plastic Surgery, Orwell Grange, 43 Cambridge Road, Wimpole, Cambridge, UK [email protected] Troy W. Ertelt, MD  Department of Psychology, University of North Dakota, Grand Forks, and Neuropsychiatric Research Institute, 120, 8th Street South, Fargo, ND 58102, USA [email protected] Joel Faintuch, MD  Plastic Surgery Service, Hospital das Clínicas, São Paulo, SP, Brazil and Division of Nutrology Residence Program, Plastic Surgery Service, Hospital das Clínicas, São Paulo, SP, Brazil [email protected] Afshin Farzadmehr, MD  Plastic Surgery Center of Beverly Hills, 1125 South Beverly Drive, Suite 600, Los Angeles, CA 90035, USA [email protected] or [email protected] Madelyn H. Fernstrom, PhD  3811 O’Hara Street, Suite 1617, Pittsburgh, PA 15213, USA [email protected] Marcus Castro Ferreira, MD  Plastic Surgery Service, Hospital das Clínicas, São Paulo, SP, Brazil [email protected] Lydia Massako Ferreria, MD, PhD  Department of Plastic Surgery, Universidade Federale de São Paulo, Escola Paulista de Medicina, São Paulo, Brazil [email protected] William Forlini, MD, PhD  Marche Polytechnic University Medical School, Via Tronto, 20, Ancona, Italy [email protected]

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Pierre F. Fournier, MD  55 Boulevard de Strasbourg, 75 010 Paris, France [email protected] Onelio Garcia, Jr. MD  Division of Plastic Surgery, University of Miami, Miller School of Medicine, 3850 Bird Road, Suite 102, Miami, FL 33146, USA [email protected] Daron Geldwert, MD  Hurwitz Center for Plastic Surgery, 3109 Forbes Avenue, Suite 500, Pittsburgh, PA 15213, USA [email protected] Rolf Gemperli, MD  Plastic Surgery Service, Hospital das Clínicas, Rua Pedrosa Alvarenga, 120, São Paulo, SP 04531-004, Brazil [email protected] Bilal Gondal, MB BCh, BAO Dubl, BSc, BA  King Fahd Uni of Petroleum and Minerals, KFUPM, PO Box 372, Dhahran 31261, Saudi Arabia [email protected] Ruth Maria Graf, MD, PhD  Division of Plastic and Reconstructive Surgery, Department of Hospital de Clínicas, Federal University of Paraná (UFPR), Curitiba-PR, Brazil [email protected] or [email protected] Luca Grassetti, MD  Department of Plastic and Reconstructive Surgery, Marche Polytechnic University Medical School, Ancona, Italy [email protected] Robert A. Gutstein, MD†  Plastic Surgery Center of Beverly Hills, 1125 South Beverly Drive, Suite 600, Los Angeles, CA 90035, USA Nicholas B. Hart, MD, FRCS  Plastic Surgery Unit, Castle Hill Hospital, Cottingham Hull, East Yorkshire, HU16 5JQ, UK [email protected] Martin Haug, MD  Department of Plastic and Reconstructive Surgery, Basel University Hospital, Spitalstrasse 21, 4056 Basel, Switzerland Américo Helene, Jr. MD  Av Itacira, 577 Planalto Paulista, CEP 04064-000, Sao Paulo, Brazil [email protected] Charles K. Herman, MD  Department of Plastic Surgery, Albert Einstein College of Medicine, New York, NY, USA and Plastic and Reconstructive Surgery, Pocono Health Systems, 100 Plaza Court, East Stroudsburg, PA 18301, USA [email protected] Enrique Hernandez-Perez, MD  7801 NW 37th St., Club VIP, Suite 369, Miami, FL 33166-6503, USA [email protected]

Contributors

Contributors

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José Enrique Hernández-Pérez, MD  Center for Dermatology and Cosmetic Surgery, Plaza Villavicencio 3er Nivel Local 3-1, Col. Escalón, San Salvador, CP 01-177 [email protected] Mauricio Hernandez-Perez, MD  Center for Dermatology and Cosmetic Surgery, Plaza Villavicencio 3er Nivel Local 3-1, Col. Escalón, San Salvador, CP 01-177 [email protected] James G. Hoehn, MD  Division of Plastic Surgery, Albany Medical College, 25 Hackett Blvd, MC133, Albany, NY 12208, USA [email protected] Alfredo Hoyos, MD  Evolution Medical Center, Calle 119, 11D-30 (nueva), Bogota, Colombia [email protected] Georg M. Huemer, MD  General Hospital Linz, Krankenhausstrasse 9, 4021 Linz, Austria [email protected] C. Scott Hultman, MD, MBA  Division of Plastic and Reconstructive Surgery, University of North Carolina, Suite 7040, Burnett-Womack Building, CB 7195, Chapel Hill, NC 27599-7195, USA [email protected] Dennis J. Hurwitz, MD  Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA and Department of Surgery, New York-Presbyterian Hospital, 3109 Forbes Avenue, Suite 500, Pittsburgh, PA 15213, USA [email protected] Antonio Iannelli, MD  Chirurgie Digestive et Centre de Transplantation Hépatique, Hôpital L’Archet 2, University of Nice Sophia Antipolis, 151 Route Saint Antoine de Ginestière, BP 3079, Nice, Cedex 3, France [email protected] Raymond Jean, MD  Department of Plastic Surgery, Loma Linda University, 11175 Campus Street, Suite 21126, Loma Linda, CA 92354, USA [email protected] Anne Keen, RN  Division of Plastic and Reconstructive Surgery, University of North Carolina, Suite 7040, Burnett-Womack Building, CB#7195, Chapel Hill, NC 27599-7195, USA [email protected] Hassan Abbas Khawaja, MD  Cosmetic Surgery and Skin Center, 53 A, Block B II, Gulberg III, Lahore, 54660, Pakistan [email protected] or [email protected] James Knoetgen III, MD  Private Practice, 20296, Bakersfield, CA 93390-0296, USA [email protected]

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Angela S. Landfair, MD, MPH  Division of Plastic Surgery, University of Pittsburgh, 3553 Terrace Street, Suite 6B, Pittsburgh, PA 15213, USA [email protected] Mikko Larsen, MD  Department of Plastic and Reconstructive Surgery, Free University Medical Center, Amsterdam, The Netherlands; Department of General Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands and Van der Helmstraat 341, 3067HH Rotterdam, The Netherlands [email protected] Albert Losken, MD  Division of Plastic Surgery, Emory University School of Medicine, 550 Peachtree Street, Suite 84300, Atlanta, GA 30308, USA [email protected] or [email protected] Andrew T. Lyos, MD  Division of Plastic Surgery, Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, TX, USA [email protected] Sumeet N. Makhijani, MD  Division of Plastic Surgery, Albany Medical College, 25 Hackett Blvd, MC133, Albany, NY 12208, USA [email protected] Carlos Alberto Malheiros, MD  Rua Vergueiro,1353 cj 407, Paraiso CEP 04101-000, São Paulo, Brazil [email protected] Alexandre Mansur, MD  Rua Alberto Foloni, 575 – ap 23A, Centro Cívico Curitiba, Paraná, CEP 80540-000, Sao Paulo, Brazil [email protected] Joanna M. Marino, MD  Department of Psychology, University of North Dakota, Grand Forks, Neuropsychiatric Research Institute, 120 8th Street South, Fargo, ND 58102, USA [email protected] David W. Mathes, MD  Department of Surgery, Division of Plastic Surgery, University of Washington, School of Medicine, 98195, Seattle, WA, USA [email protected] Vikas Mehta, MD  The NY Eye and Ear Infirmary, 310 East 14th Street, New York, NY 10003, USA [email protected] Franco Carlo Migliori, MD  Plastic Surgery Unit, “San Martino” University Hospital, Largo Rosanna Benzi, 10, Monoblocco 8A Piano Levante, Genoa 16132, Italy [email protected]

Contributors

Contributors

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Sid J. Mirrafati, MD  3140 Redhill Avenue, Costa Mesa, CA 92626, USA [email protected] James E. Mitchell, MD  Department of Clinical Neuroscience, University of North Dakota School of Medicine and Health Sciences, Neuropsychiatric Research Institute, 120 South 8th Street, Fargo, ND, USA [email protected] Miguel Luiz Antonio Modolin, MD  Plastic Surgery Service, Hospital das Clínicas, São Paulo, SP 01486-000, Brazil [email protected] Héctor J. Morales Gracia, MD  Belisario Domínguez 2501, Colonia Obispado, Monterrey, Nuevo León, CP 64060, México [email protected] Cristina Hachul Moreno, MD  Rua Vergueiro,1353 cj 407, Paraiso CEP 04101-000, São Paulo, Brazil [email protected] Javier Moreno-Moraga, MD  Instituto Medico Laser, General Martinez-Campos 33, 28010 Madrid, Spain [email protected] William L. Murillo, MD  Division of Plastic and Reconstructive Surgery, Louisiana State University Medical Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA and Division of Plastic and Reconstructive Surgery, Universidad del Valle, Cali, Colombia [email protected] Sally Myers, RD  Bitar Cosmetic Surgery Institute, Northern Virginia, 8501 Arlington Blvd. Suite 500, Fairfax, VA 22031, USA [email protected] Henrique Jorge Guedes Neto, MD  Rua Vergueiro,1353 cj 407, Paraiso CEP 04101-000, São Paulo, SP, Brazil [email protected] Daniele Pace, MD, MSc  Rua Solimões, 1175, Mercês Curitiba, Paraná, CEP 80810-070, Brazil [email protected] Humberto Palladino, MD  Department of Surgery, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA [email protected] Luiz Haroldo Pereira, MD  Luiz Haroldo Clinic, 45/206 Rua Xavier da Silveira, Rio de Janeiro, 22061-010, Brazil [email protected] Paolo Persichetti, MD, PhD  Division of Plastic Surgery, University Campus Bio-Medico of Rome, Via Bertoloni 19, 00197 Rome, Italy [email protected]

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Ivo Pitanguy, MD  Ivo Pitanguy Clinic, Rua Dona Mariana, 65, Rio de Janeiro, 22280-020, Brazil [email protected] Peter W. Plaisier, MD  Department of General Surgery, Albert Schweitzer Hospital, PO Box 444, 3300 AK, Dordrecht, The Netherlands [email protected] Peter M. Prendergast, MD  Venus Medical Beauty, Heritage House, Dundrum Office Park, Dundrum, Dublin 14, Ireland [email protected] Henrique N. Radwanski, MD  Ivo Pitanguy Clinic, Rua Dona Mariana, 65, Rio de Janeiro, 22280-020 Brazil [email protected] Yitzchak Ramon, MD  Elisha and Rambam Medical Centers, Haifa, Israel [email protected] Maura Reinblatt, MD  Department of Plastic Surgery, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Suite A-513, Baltimore, MD 21224, USA [email protected] Ulrich M. Rieger, MD  Department of Plastic Reconstructive Surgery, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria [email protected] or [email protected] Keith M. Robertson, MD  Whitfield Clinic, Waterford, Ireland [email protected] Rod J. Rohrich, MD  1801 Inwood Road, WA4.238, Dallas, TX 75390, USA [email protected] Kenneth Rosenstein, MD  Department of Otolaryngology, Division of Facial Plastic Surgery, The New York Eye and Ear Infirmary, 310 East 14th Street, North Building, New York, NY 10003, USA [email protected] Joseph J. Rousso, MD  Department of Otolaryngology, Division of Facial Plastic Surgery, The New York Eye and Ear Infirmary, 310 East 14th Street, North Building, New York, NY 10003, USA [email protected] J. Peter Rubin, MD  Division of Plastic and Reconstructive Surgery, 3380 Blvd of the Allies, Suite 180, Pittsburgh, PA 15238, USA [email protected] or [email protected] A. Chasby Sacks, MD  Arizona Cosmetic Surgery, 4202 North 32nd Street, Suite F, Phoenix, AZ 85018, USA [email protected]

Contributors

Contributors

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David B. Sarwer, PhD  University of Pennsylvania School of Medicine, Penn Behavioral Health, 3535 Market Street, Philadelphia, PA 19104, USA [email protected] Thomas Schoeller, MD, MSc  Department for Handsurgery, Microsurgery, and Reconstructive Breast Surgery, Marienhospital Stuttgart, Böheimstraße 37, 70199 Stuttgart, Germany [email protected] Anthony P. Sclafani, MD  Department of Otolaryngology, Division of Facial Plastic Surgery, The New York Eye and Ear Infirmary, 310 East 14th Street, North Building, New York, NY 10003, USA [email protected] Nicolò Scuderi, MD  Department of Plastic and Reconstructive Surgery, La Sapienza University, Rome, Italy [email protected] Michele A. Shermak, MD  Johns Hopkins University School of Medicine, Division of Plastic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Suite A-518, Baltimore, MD 21224, USA [email protected] Melvin A. Shiffman, MD, JD  17501 Chatham Drive, Tustin, CA 92780-2302, USA [email protected] Pierfranco Simone, MD  Division of Plastic and Reconstructive Surgery, Campus Bio-Medico University, Rome, Italy [email protected] Sadri Ozan Sozer, MD  El Paso Plastic Surgery, 1600 Medical Center Drive, Suite 400, El Paso, TX 79902, USA Department of Surgery, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA [email protected] or [email protected] Daniele Spirito, MD  Via delle Baleniere 107/b, 00121, Rome-Ostia, Italy [email protected] Wayne K. Stadelmann, MD  Pillsbury Medical Office Building, 48 Pleasant Street, Suite 201, Concord, NH 03301, USA [email protected] Aris Sterodimas, MD, MSc  Department of Plastic Surgery, Ivo Pitanguy Institute, Pontifical Catholic University of Rio de Janeiro, Rua Dona Mariana 65, Rio de Janeiro 22280-020, Brazil [email protected] Berish Strauch, MD  Department of Plastic Surgery, Albert Einstein College of Medicine, Bronx, NY 10467, USA [email protected] or [email protected]

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Matthew R. Talarczyk, MD  Plastic and Reconstructive Surgery, Wright-Patterson Medical Center, 88 SGOS/SGCQP, 2881 Sugar Maple, Wright-Patterson AFB, OH, USA [email protected] David E. Talevi, MD  Department of Plastic and Reconstructive Surgery, Marche Polytechnic University Medical School, Ancona, Italy [email protected] Howard A. Tobin, MD  Facial Plastic and Cosmetic Surgery Center, 6300 Regional Plaza, Suite 475, Abilene, TX 79606, USA [email protected] Andrew P. Trussler, MD  Department of Plastic Surgery, University of Texas Southwestern, 1801 Inwood Road, WA4.238, Dallas, TX 75390, USA [email protected] Yehuda Ullmann, MD  Department of Plastic and Reconstructive Surgery, Rambam Medical Center, 8 Ha’Aliya Street, Haifa 31096, Israel [email protected] Nestor Veitia, MD  3109 Forbes Avenue, Suite 500, Pittsburgh, PA 15213, USA [email protected] Robert Yoho, MD  797 South Arroyo Parkway, Pasadena, CA 91105, USA [email protected]

Contributors

Part Anatomy, Classification of Adiposities, Body Contouring, Injection Lipolysis

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1

Mammary Anatomy Michael R. Davis

1.1 Introduction A thorough understanding of breast development and anatomy is a requirement for modern plastic surgeons. Advanced techniques of reduction mammaplasty, mastopexy, augmentation, and reconstruction demand a comprehensive knowledge of the current detailed descriptions of breast architecture. As a complicated physiologic and aesthetic structure, the form and function of the breast weighs heavily on a woman’s psyche. Significant improvements or complications can impact greatly on the self image for better or worse. Optimizing results and avoidance of complications takes root in the knowledge of breast anatomy. Only then can a plastic surgeon engage his full creativity in sculpting the breast form.

1.2 Development (Fig. 1.1) As a cutaneous appendage, the breast takes its origin from the ectoderm. The breast bud begins ­differentiation during weeks 8–10 along the milk ridge. The normal human breast develops over the fourth intercostal space of the anterolateral chest wall. Supernumerary nipples and breasts can occur anywhere along the milk ridge

M. R. Davis  Division of Plastic Surgery, University of Alabama, Birmingham School of Medicine, 510 20th Street South, 1164 Faculty Office Tower, Birmingham, AL 35294-3411, USA e-mail: [email protected]

from the axilla to the groin. Statistically, they are most common near the left inframmary crease. Following a brief period of activity shortly after birth in response to maternal hormones, breast development becomes dormant until the onset of puberty. Pubertal onset is becoming ever earlier in modern society but currently occurs at approximately 9 years of age. Typically, by the age of 14, parenchymal growth has extended to its mature borders. These include the sternum medially, the anterior border of the latissimus dorsi laterally, the clavicle superiorly, and the inframammary crease inferiorly. These represent approximate anatomic landmarks and are not rigidly defined borders. Breast tissue can extend across the midline and beyond the inframammary crease. An extension of the breast tissue normally penetrates the axillary fascia into the axillary fat pad and is termed the “Tail of Spence.” Mature breast morphology projects off the chest wall in a conical fashion with its apex deep to the nipple–areola complex. Development of overall breast shape is multifactorial. Breast form is dependent on fat content and location, muscular and skeletal chest wall contour, and skin quality. These structures display complex attachments and interactions to result in the final form. Breast shape and size is unique to each individual and is determined largely by heredity.

1.3 Parenchyma (Fig. 1.2) Embedded within the fibrofatty stroma lays the glandular portion of the breast. Glandular structure consists

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_1, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 1.1  The breast overlies the anterolateral chest wall containing primarily glandular tissue and fibrofatty stroma

of millions of lobules clustered to comprise approximately 20–25 lobes. Interlobular ducts come together to form approximately 20 main lactiferous ducts. Lactiferous sinuses collect milk, and specialized ducts within the nipple transmit milk to the surface. Glandular size remains relatively constant from individual to individual. The bulk of the breast consists of fat. Subcutaneous as well as interlobular fat content determine the texture, contour, and density. The breast parenchyma is encompassed and supported by an intricate fascial system. The superficial fascial system is variable and sometimes indistinct from the overlying dermis anteriorly. Fat content of the subcutaneous tissue between the dermis and superficial fascia determines the clarity of these structures. Continuous with the superficial fascia is a deep component that separates the parenchyma from the pectoral fascia as well as the fascia overlying the adjacent muscles. Interposed between the superficial and deep components of the superficial fascial system are fascial extensions termed Cooper’s ligaments. Anchored to the muscular fascia, these ligaments act to suspend the parenchyma. Attenuation of these tissues is largely responsible for ptosis.

Fig. 1.2  Glandular breast tissue is lobular in structure with 20–25 lobes each drained by a lactiferous duct. Milk then enters the collecting ducts followed by lactiferous sinuses prior to exiting the nipple

1  Mammary Anatomy

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1.4 Musculature At its foundation, the breast sits on a prominent musculature that also impacts form and physiology. The five primary muscle groups that lie deep into the breast are pectoralis major and minor, serratus anterior, upper external oblique, and upper rectus abdominis. Perfo­ rating these structures are the breast’s primary arterial, venous, nerves, and lymphatic supply.

1.5 Skeletal Support Breast symmetry and form is also dependent on normal skeletal support. The breast overlies the antero­ lateral thorax principally over ribs 2–6. Conditions which manifest chest wall abnormalities such as pectus excavatum and carinatum, Marfan’s syndrome, and Poland’s syndrome can present a challenge in optimizing breast aesthetics. It is also important to take note of the changes in the chest wall contour induced by plastic surgical intervention such as breast augmentation.

1.6 Arterial Supply (Fig. 1.3) Breast tissue possesses a rich blood supply from multiple arterial sources. These sources collateralize within the breast to make a redundant system with significant clinical implications. Division of parenchyma is safe provided one of the several primary axes is preserved. Entering the superomedial portion of the breast over intercostal spaces 2–6 are perforators from the internal mammary artery. These vessels supply the medial pectoralis muscle prior to entering the breast tissue and overlying skin. The dominant perforators emanate from the second and third intercostal spaces. These should be spared during reduction mammoplasty utilizing the superomedial pedicle. Of note, they are occasionally of adequate caliber for use as recipient vessels for free flap breast reconstruction. Supplying the breast superolaterally is the lateral thoracic artery, also termed the external mammary artery. This vessel originates from the axillary artery and enters the breast from the inferior axilla. It distributes its main branches in the upper outer quadrant of the breast.

Fig. 1.3  Blood supply: The arterial supply to the breast is predominantly by perforators from the internal mammary artery followed by the lateral thoracic and anterolateral intercostals arteries

Intercostal vessels represent an additional important blood supply to the breast. The lateral breast receives anterior intercostal arteries from the third through sixth interspaces. These perforate the serratus anterior just lateral to the pectoral border. Lateral intercostal vessels enter the breast at the anterior margin of the latissimus dorsi to supply the lateral breast and overlying skin. Medial intercostal perforators are responsible for directly supplying the inferomedial and central parenchyma inferior to the nipple. These perforators course upward through the breast tissue to supply the gland and are one source for nipple–areola complex perfusion.

1.7 Venous Drainage Two systems of veins drain the breast. The subdermal venous plexus above the superficial fascia is quite variable and represents the superficial system. These veins arise from the periareolar venous plexus. Within the parenchyma, the superficial system anastomoses with the deep system. Deep venous drainage of the breast corresponds with the arterial supply. Venous perforators following internal mammary perforators drain via

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the internal mammary vein to the innominate vein. Lateral thoracic veins or external mammary veins drain into the axillary vein. Intercostal veins drain via the azygos vein into the superior vena cava.

1.8 Innervation (Fig. 1.4) Mammary innervation is dense and has considerable redundancy. In addition to the abundant general cutaneous sensitivity, the central portion of the breast including the nipple–areola complex serves as an erogenous zone and therefore is supplied by fibers contributing to a sensual character. Just as with the perfusion of the breast, innervation of the skin comes from all directions. Superiorly the cervical plexus contributes fibers that course beneath the platysma to innervate the upper portion of the breast. These fibers course in the subcutaneous tissue and can be elevated and preserved with skin flaps of proper thickness. Intercostal segmental nerves contribute the remainder of breast sensation and should be viewed as the

Fig. 1.4  Innervation: Branches of the cervical plexus supply the superior breast. The anteromedial and anterolateral intercostal nerves supply the mass of the breast inferiorly from their respective directions

M. R. Davis

primary sensory nerves. Through the interdigitations of the serratus anterior emanate the third through sixth anterolateral intercostal nerves. They enter the lateral breast at the lateral pectoral margin. Entering the medial breast along with the internal mammary perforators are contributions from the second through sixth anteromedial intercostal nerves. As with the anterolateral intercostal nerves, they contribute sensation to the nipple–areola complex.

1.9 Lymphatics (Fig. 1.5) Lymphatic drainage of the breast has been extensively studied for its oncologic implications. Breast surgeons of all disciplines should have an intimate knowledge of the lymphatic anatomy within the breast. The predominance of lymph from the mammary gland passes along the interlobular lymphatic vessels to the subareolar plexus. Lymph is then directed primarily toward the axillary lymph nodes (75%) coursing along the venous drainage. Lateral lymphatics course around the edge of the pectoralis major to enter

Fig. 1.5  Lymphatic drainage: Lymphatic flow from the parenchyma coalesces first in the subareolar plexus and is then directed predominantly to the axilla. Medial lymphatics are directed to the internal mammary nodes or to the contralateral breast. Inferior lymphatics may enter the subperitoneal plexus

1  Mammary Anatomy

the pectoral nodal group. Additional lymphatics route through the pectoral muscles leading to the apical nodal group. From the axilla, the lymph drains into the subclavian and supraclavicular nodes. The medial portion of the breast contributes ­lymphatic vessels which drain via the parasternal or internal mammary nodes. They follow internal mammary perforators. There are occasional lymphatic contributions to the contralateral breast. Inferior lymphatics may enter the rectus sheath and drain into subperitoneal plexus.

1.10 Nipple–Areola Complex As mentioned previously, the nipple–areola complex deserves special attention for its unique aesthetic, sensual, and lactational function. It is an area of dense perfusion and innervation. Every attempt should be made to preserve these meaningful functions. Secondary to its physiologic redundancy, the nipple–areola complex can be reliably preserved with attention to anatomic principles.

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Importantly, the blood supply to the nipple–areola complex is both parenchymal and subdermal. The varied dermoglandular pedicles used in reduction mammaplasty and mastopexy thus preserve potential lactation and perpetuate redundant perfusion. The subdermal plexus encompassing the nipple–areola complex serves to directly perfuse the skin of the nipple and areola. The nipple itself represents the apex of the mammary gland. Specialized contractile lactiferous ducts within the nipple facilitate lactation. Montgomery’s glands, which reside in the areola, lubricate the nipple–areola complex functioning primarily during lactation. Clinically, they appear as small nodules distributed throughout the areola and should be preserved. The nipple serves as a port of entry for bacteria into the mammary gland. Bacteria can be cultured from throughout the glandular portion of the breast. Thus, the division of the gland as in most breast surgery can elaborate bacteria (typically Staphylococcus epidermidis). Bacterial prophylaxis should be strongly considered in any breast surgery, but especially with implant placement.

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Gluteal Contouring Surgery: Aesthetics and Anatomy Robert F. Centeno

2.1 Introduction Most plastic surgeons are probably more familiar with the anatomy of the face, abdomen, or breasts than with the anatomy of the gluteal region. Because only a small percentage of plastic surgery procedures involve the buttocks, retaining knowledge of its clinical anatomy is not a high priority for most surgeons. This picture, however, is changing as increasing number of patients request body contouring and are increasingly aware of the numerous techniques now available for enhancing the gluteal region. These include the use of implants, autologous fat transfer, autologous gluteal augmentation with tissue flaps, excisional procedures (lifts), and liposuction. Combinations of more than one of these techniques often produce superior aesthetic results. Unfortunately, these procedures can produce gluteal deformities as well as serious complications if the anatomical structures of the buttocks are not well understood. Obviously, the buttocks are subjected to a great amount of pressure, especially when sitting or bending. Any wound complication that develops will require a prolonged healing time and keep patients from resuming their daily activities. Even more serious is a surgery that interferes with gluteal muscle function or alters nerve activity in the legs. A well-developed and aesthetically-pleasing gluteal region is a trait unique to primates, which was likely an evolutionary adaptation to erect posture and bipedal locomotion. Buttock projection is largely formed by

R. F. Centeno  P.O. Box 24330, Christian Sted, VI 00824-0330, USA e-mail: [email protected]

the gluteus maximus muscle and fat deposits in the superficial fascia. In addition, our erect posture contributed to the lumbosacral curve, which is also unique to primates. Evolutionary biology suggests that an hourglass figure, with a small waist and full buttocks, has historically been associated with female reproductive potential and physical health across cultures, generations, and ethnicities [1]. A waist-to-hip ratio of 0.7 in women remains the ideal of beauty even as different ethnic groups prefer different gluteal shapes and curvatures. As women age and fertility declines, skin laxity increases and the shape of the gluteal region usually changes as the content and distribution of fat and muscle change [2, 3]. The hourglass shape fades and the waist-to-hip ratio approaches 1.0, similar to men. An aesthetic outcome of gluteal contouring relies on the knowledge of clinical anatomy, both superficial and deep, in and around this region. Such knowledge also reduces the incidence of complications and improves patient satisfaction. Anatomical knowledge is essential for procedures that augment, reduce, or recontour the buttocks in this still evolving area of plastic surgery.

2.2 Codifying the Gluteal Aesthetic To determine the appropriate surgical plan for a patient inquiring about gluteal enhancement or body contouring surgery, the characteristics of ideal gluteal aesthetics must be carefully considered. In 2004, Cuenca-Guerra and colleagues first reported their analysis of more than 2,400 images of the gluteal area taken from various media sources [4, 5]. This study helped to codify four

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_2, © Springer-Verlag Berlin Heidelberg 2010

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Fig. 2.1  Well-defined sacral dimples and sacral triangle, lateral depressions, and a short infragluteal crease are important aesthetic characteristics of the gluteal region

of the most recognizable characteristics of an aesthetically-pleasing gluteal region (Fig. 2.1). The following landmarks are discussed in detail later in this chapter. 1. Two well-defined dimples on each side of the medial sacral crest that correspond to the posterior-superior iliac spines (PSIS). 2. A V-shaped crease (or sacral triangle) that arises from the proximal end of the gluteal crease with each line of the “V” extending toward the sacral dimples. 3. Short infragluteal folds that do not extend beyond the medial two-thirds of the posterior thigh. 4. Two mild lateral depressions that correspond to the greater trochanter of the femur. Most of these characteristics are universally accepted by a variety of cultures. However, Roberts has described specific variations in aesthetic ideals between ethnic groups in the U.S. [2]. Of the four landmarks just described, numbers 1 through 3 are generally constant features of attractive buttocks regardless of ethnicity. Number 4 (mild lateral depressions) is not preferred by Hispanic-Americans or African-Americans. Other aesthetic differences among ethnic groups have also been identified by Roberts. A short buttock with a high point of maximum projection is popular among AsianAmericans because this shape creates the illusion of

R. F. Centeno

longer legs and a balanced proportion between the torso and extremities. In Roberts’ analysis, HispanicAmericans and African-Americans seem to prefer more projection than either Asians or Caucasians, with a higher point of maximum projection and more severe lumbosacral depression. Caucasians in the U.S. trend toward a more athletic ideal with greater definition of the muscular and bony anatomy or a rounded appearance, with either shape having less anterior-posterior projection. Another way of evaluating the buttocks to help plan body contouring procedures and then assess their outcomes is to view the gluteal region as having eight aesthetic units (Fig. 2.2) [6]. From the posterior-anterior view, the gluteal region consists of two symmetrical “flank” units, a “sacral triangle” unit, two symmetrical gluteal units, two symmetrical thigh units, and one “infragluteal diamond” unit. All eight gluteal aesthetic units play a role in improving the aesthetic outcome of body contouring in the gluteal region, and all should be considered during the surgical planning process. Particular units may benefit from being augmented, reduced, preserved, or better defined. To enhance overall gluteal appearance, the junctions between these aesthetic units should guide incision placement during excisional procedures. Procedures performed on the torso, gluteal region, and lower extremities may have an important impact on the aesthetic perception of the buttocks. As an example, patients who have significant intraabdominal fat may have a widened, squared appearance if only abdominoplasty is performed. The same procedure in a patient without significant intraabdominal fat can better define the waist and improve gluteal aesthetics. Gluteal aesthetics can be greatly enhanced by judicious liposuction of the abdomen, anterior thigh, medial thigh, lateral thigh, flanks, and lumbosacral region. However, overly aggressive liposuction of the buttock, infragluteal fold, or hips often produces suboptimal aesthetic results. Poorly placed incisions also detract from the gluteal aesthetic. For example, a circumferential body lift (CBL) incision that runs straight across the back will make the buttock appear too long and rectangular or too square, depending on whether the incision is too high or too low, respectively. An incision that curves into a V shape along the lateral and inferior borders of the sacral triangle can greatly help define this aesthetic unit (Fig. 2.3). This “inverted dart” incision has been previously described [6–8].

2  Gluteal Contouring Surgery: Aesthetics and Anatomy Fig. 2.2  The eight gluteal aesthetic units are: 2 symmetrical “flank” units (1 and 2); 1 “sacral triangle” unit (3); 2 symmetrical buttock units (4 and 5); 1 infragluteal “diamond” unit (6); and 2 symmetrical thigh units (7 and 8)

Fig. 2.3  Preoperative markings and postoperative position of the “inverted dart” modification to the posterior circumferential body lift incision

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A patient’s existing anatomy plays an important role in Mendieta’s gluteal evaluation system, which is helpful for determining the best way to augment or recontour the buttocks [9, 10]. Because of space limitations, only portions of his system can be mentioned here, but it involves analysis of the underlying bony framework of the buttocks, the skin, and the subcutaneous fat distribution, in addition to the musculature that overlies the bony frame. Mendieta suggests that surgeons begin by evaluating the frame, including the height of the pelvis, and the shape of the frame (round, square, A- or V-shaped). The gluteus maximus muscle should be evaluated to determine whether the muscle is tall, intermediate, or short compared with its width. This information can guide the surgeon in selecting the most appropriate procedure for a patient. Also, they should determine where volume is needed by analyzing whether volume should be added or removed from the upper inner, lower inner, upper outer, and lower outer quadrants of the gluteus maximus. Useful information for determining the procedure that would produce a superior aesthetic result additionally requires an evaluation of the four points at which the gluteal maximus muscle and frame join: the upper inner gluteal/ sacral junction, the intergluteal crease/leg junction, the lower lateral gluteal/leg junction, and the lateral midgluteal/hip junction. Finally, from the lateral view, they should determine the degree of ptosis, which is assessed much like breast ptosis, but identifies the degree to which skin droops over the infragluteal fold [9, 11]. Improvement of severe (grade III) ptosis usually requires an excisional procedure such as a buttock lift, and Gonzalez has recently described several techniques: an upper buttocks lift, a lower DTA (dermotuberal anchorage) lift, a lateral buttocks lift, and a medial buttocks lift [12]. Some of these lifts may be incorporated with gluteal implant or autologous tissue augmentation. Patients who have lost a massive amount of weight typically have an excess of lax skin throughout the gluteal region in addition to buttocks ptosis. They may be best served with a CBL and autologous tissue augmentation for additional volume [8]. Although some massive weight loss patients may not need additional volume, they may benefit from moving the volume to another part of the buttocks to produce better gluteal projection at the level of the mons pubis. In these cases, fat transfer provides a good option. Gluteal implants are not a good choice for MWL patients

R. F. Centeno

because the poor quality of their subcutaneous tissue and skin may increase the risk of complications.

2.3 Topical Anatomical Landmarks The superficial features shown in Fig. 2.1 are clinically relevant to gluteal augmentation with Alloplastic implants or autologous tissue, either a flap or transferred fat [2, 13–20]. The definition of these features also can be greatly improved with liposuction and transferred fat [2, 21]. As mentioned earlier, the sacral dimples, sacral triangle, lateral depressions, and infragluteal folds that are well defined and proportioned are judged to be appealing across many cultures [2, 4, 7]. Several bony landmarks important to gluteal procedures are easy to identify in most patients. The palpable and often visible iliac crest forms the superior border of the buttocks and is important for guiding incision placement in a buttock lift or CBL with or without augmentation. The incision can be placed more superiorly or inferiorly with respect to the iliac crest depending on the postoperative result desired. Unfortunately, the incision location requires a trade-off between waist definition and buttock elongation. A higher incision can better maintain a pleasing waist-to-hip ratio, but it violates the sacral triangle aesthetic unit, elongates the buttocks, and limits autologous flap placement so that maximum projection is higher than ideal. A lower incision diminishes waist definition, but preserves the sacral triangle aesthetic unit, shortens the buttocks, and permits the point of maximum projection at the level of the mons pubis. Good waist definition is nearly impossible to achieve in MWL patients with a long history of obesity no matter where the incision is placed because many years of an expanded rib cage have left them with a “barrel chest” deformity that cannot be corrected. The PSIS, which are typically easy to palpate, form two distinct depressions called the sacral dimples produced by the confluence of the PSIS, the multifidus muscles, the lumbosacral aponeurosis, and the insertion of the gluteus maximus. Because the sacral dimples are characteristic of attractive buttocks, attempts should be made to create, enhance, or unmask this anatomical feature [6]. The sacral dimples are also good reference points for aesthetic analysis of the buttocks.

2  Gluteal Contouring Surgery: Aesthetics and Anatomy

Another reason for the sacral dimples being important is that they serve as the superior corners of the sacral triangle, which is defined by the two PSIS with the coccyx as the inferior border of the triangle. Liposuction and/or the “inverted dart” modification of the posterior CBL incision mentioned earlier are useful for enhancing the sacral triangle during body contouring procedures [6]. In all gluteal contouring procedures the location of the sacral triangle feature should be respected and marked prior to surgery. If implants are to be used for augmentation, regardless of their position, the sacral triangle serves as the medial borders of the dissection (Fig. 2.4). Another important topical landmark is the lateral trochanteric depression formed by the greater trochanter and insertions of thigh and buttocks muscles, including the gluteus medius, vastus lateralis, quadratus femoris, and gluteus maximus. This depression is important in the aesthetics of an athletically-toned buttock preferred by many Caucasians, but some ethnic groups – such as

a

c

Fig. 2.4  Implant augmentation locations for (a) submuscular, (b) intramuscular, and (c) subfascial procedures. IC iliac crest; PSIS posterior-superior iliac spine; GT greater trochanter; IGF infragluteal fold

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African-Americans and U.S. Hispanics – request that the trochanteric depressions not be emphasized or even filled in if they are prominent [2]. The infragluteal fold is a fixed and well-defined structure that serves as the inferior border of the buttock proper and is formed by subcutaneous fat and thick fascial insertions from the femur and pelvis through the intermuscular fascia to the skin [22]. The length and definition of the infragluteal fold play important roles in aesthetically-pleasing buttocks. In his study of ideal buttock aesthetics, Cuenca-Guerra determined that an infragluteal fold that does not extend beyond the medial two-thirds of the posterior thigh contributes to a full, taught, and youthful-looking buttock. A longer infragluteal fold typically suggests an aged, ptotic, and deflated-looking buttock with skin and fascial excess [4, 23]. Although not a part of the buttock proper, the ischial tuberosities are the bony prominences upon which people sit.

b

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2.4 Gluteal Aesthetics and Subcutaneous Fat Distribution The amount and distribution of subcutaneous fat content accounts for the round shape and projection of the buttocks. Subcutaneous fat content in the gluteal region is usually greater in women vs. men, infants vs. adults, and in some ethnic groups. Some evolutionary biologists believe that subcutaneous gluteal fat is important for padding the buttock region when sleeping in the supine position and evolved as an adaptive mechanism for heat dissipation while maintaining sufficient adipose stores critical to normal physiology [24]. The distribution of gluteal fat, as well as its volume, also plays an important role in gluteal aesthetics. Cuenca-Guerra and Lugo-Beltran have analyzed gluteal aesthetics from the lateral view that incorporates the buttock, surrounding torso, and lower extremities. Ideally, the ratio of the anterior-superior iliac spine (ASIS) to the greater trochanter and the greater trochanter to the lateral point of maximum projection of the buttock should not exceed 1:2 [5]. The author has found this analytical system based on the lateral view to be very useful and clinically relevant in determining which surgical procedure(s) should best achieve desired results. In addition to attaining the ratio of 1:2 when viewed from the side, attractive buttocks have other characteristics that relate to the distribution of subcutaneous fat. • A visible lumbosacral depression should help to distinguish the back from the buttocks. • There should be no excess fat either in the lumbosacral area or in subgluteal region. Excess fat in areas commonly referred to as the “love handles,” “saddle-bags,” and “banana roll” also detract from gluteal aesthetics. • The point of maximum projection of the buttocks should correspond to the level of the mons pubis. Attaining these characteristics may require the use of combined procedures. Impressive recontouring can be achieved with liposuction alone, especially to better define the lumbosacral depression, the sacral triangle, and the subgluteal area. However, liposuction must not be too aggressive in the area of the “banana roll,” just inferior to the infragluteal fold. Too much liposuction in the most superior portion of the posterior thigh can exacerbate buttock ptosis and cause deformities in the infragluteal fold, a structure that is very difficult to

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replicate surgically [22]. A good understanding of gluteal anatomy reduces the risk of these outcomes. Anthropometric and radiological studies have determined that both aging and weight gain cause the distribution of fat in the buttocks to change. One investigation of 115 randomly selected women ranging in age from 17 to 48 found statistically significant changes in several measurement parameters [23]. Weight gain produces an overall increase in buttock height and width, lengthens the intergluteal crease, and shortens the infragluteal fold. Aging, independent of weight gain, also increases buttock height and lengthens the intergluteal crease, but makes the infragluteal fold longer. Both aging and weight gain are associated with drooping of the infragluteal fold. Although weight gain alone increases buttock width, this measurement decreases with age regardless of weight. Changes in subcutaneous fat content and distribution, in addition to skin and fascial laxity, are believed to explain these findings. Fat distribution has been studied in both men and women, and generalized body types have been described. These include the android, gynoid, and intermediate body types. An individual’s body type may change according to weight loss, aging, or gender. For example, as women age and reach menopause, they tend to develop a more centralized fat distribution (both intraabdominal and subcutaneous fat), and the gynoid body type of youth develops more android characteristics. The most visible differences in the distribution of subcutaneous fat when comparing young and older women occur at the waist and mid-trochanter level. In addition, obesity increases the android tendency or centralized fat distribution of both sexes. This helps explain why body type and overall fat distribution patterns are relatively consistent among people with rapid and significant weight loss [24]. Massive weight loss patients are greatly affected by platypygia, partly because weight loss, whether through diet or surgery, often occurs in an uneven manner. Studies have suggested that adipose tissues in certain body regions are more resistant to weight loss than others [25]. The genetic programming of the resistant adipocytes seems to differ from adipocytes in areas that are more responsive to weight loss, which may mean that genetics influence different somatotypes. Within the android, gynoid, and intermediate body types are subgroups of somatotypes. Following weight loss, the “Apple” somatotype seems to have less adipose tissue in the gluteal region than the “Pear.” Regardless of somatotype, however, many MWL patients tend to lose gluteal

2  Gluteal Contouring Surgery: Aesthetics and Anatomy

volume and projection and want to have this deformity specifically addressed along with the skin laxity. Skeletal changes in massive weight loss patients: In addition to redistribution of subcutaneous fat following massive weight loss, anatomical changes in several areas of the skeleton are common, especially in patients who were morbidly obese before losing weight. Many of these changes relate to posture and permanently affect the morphology of the skeleton, which may limit the effectiveness of gluteal contouring efforts. Spinal column lordosis, vertebral compression, and pelvic rotation all negatively affect gluteal projection [26]. In obese individuals, restrictive pulmonary disease is often associated with a postural obstructive component that produces pulmonary hyperinflation [27], which often leads to permanent expansion of the thoracic cage. This “barrel-chested” appearance cannot be corrected and has a deleterious impact on gluteal aesthetics. Massive weight loss does not improve these skeletal abnormalities, which may be magnified or even worsened as the body mass index is lowered. A worsening of skeletal changes after surgical weight loss procedures may relate to poorly managed chronic hypocalcemia, vitamin D deficiency, and serum telopeptides that lead to osteopenia [28]. Although they cannot be corrected, some of the problematic skeletal changes can be disguised, at least

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partially, with gluteal procedures, especially autologous gluteal augmentation with a tissue flap or fat transfer. Knowledge of the anatomical abnormalities common in MWL patients can help surgeons understand why the buttocks appear flattened after the posterior portion of a CBL or buttock lift. In many patients, a CBL magnifies preexisting gluteal hypoplasia. Understanding where and why more volume is needed to recreate gluteal projection comes from familiarity with the anatomy of the gluteal and hip region.

2.5 The Importance of Fascial Anatomy The aesthetics of the aging buttocks are greatly affected by the fascial anatomy of the gluteal region. In addition to volume loss and skin laxity, which also affect MWL patients, relaxation of the fascial “apron” contributes to gluteal ptosis. This superficial fascial apron and the deep gluteal fascia fuse, become tightly adherent, and form the infragluteal fold, which is an important feature of aesthetically-pleasing buttocks [22, 29, 30]. The fascial apron (Fig. 2.5) is analogous to the superficial fascial system (SFS) described by Lockwood [31]. Liposuction in the infragluteal fold area (for correction of a “banana roll”) must be done carefully and

a

b

Fig. 2.5  Gluteal and SFS fascial anatomy. (a) The structure of the SFS “fascial apron.” (b) The lumbosacral and gluteal fascia

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prudently because this feature is extremely difficult to surgically recreate. Resection and tightening of the skin and this superficial fascial apron are major components of the CBL procedure or buttock lift – with or without autologous gluteal augmentation – and play an important role in improving gluteal ptosis. The deep gluteal fascia, or investing fascia of the gluteus maximus muscles, is critically important as a fixation point in many types of gluteal procedures (e.g., autologous augmentation and/or lifts). It also serves as a strong retaining fascia in the subfascial approach to augmentation with implants.

2.6 Superficial Neurovascular Anatomy Perfusion to musculocutaneous structures in the gluteal region is supplied by perforating branches of the superior and inferior gluteal arteries, both of which are terminal branches of the internal iliac artery and ultimately pass through the greater sciatic foramen into the thigh (Fig. 2.6). As described by Ahmadzadeh and colleagues, the superior gluteal artery can usually be found by envisioning a line between the posterior-superior iliac spine and the greater trochanter [32]. Several perforators from

Fig. 2.6  Superior and inferior gluteal arteries and lumbo-sacral perforator arteries

R. F. Centeno

this artery should lie 5–10 cm adjacent to the medial two-thirds of this line. Before it enters the gluteus maximus muscle to supply perforators to the superior portion of this muscle and overlying skin, the superior gluteal artery passes superior to the piriformis muscle [32, 33]. The inferior gluteal artery passes inferior to the piriformis muscle and supplies the lower half of the gluteus maximus muscle and overlying structures. All perforators from the inferior gluteal artery pass through the gluteus maximus, as do half the perforators from the superior gluteal artery; the other half pass through the gluteus medius muscle. The superior gluteal artery typically has 5 ± 2 cutaneous perforators, with the inferior gluteal artery typically having 8 ± 4 [32]. Some of these perforating vessels must be sacrificed during the posterior portion of a CBL, an autologous gluteal augmentation, or a buttock lift. Even with this loss, however, the rich and reliable vascular supply in the gluteal region provides robust perfusion [32–35]. Many other arteries also supply the region, including the deep circumflex iliac, lumbar, lateral sacral, obturator, and internal pudendal arteries. Sensation to the gluteal region and lateral trunk comes from several sources: the dorsal rami of sacral nerve roots 3 and 4, the cutaneous branches of the iliohypogastric nerve arising from the L1 root (Fig. 2.7), and the superior cluneal nerves that originate from the L1, L2, and L3 roots and then pass over the iliac crest (Fig. 2.8). A lower body or buttock lift with or without autoaugmentation temporarily disrupts protective cutaneous sensation transmitted by these nerves. Consequently, patients should be counseled about the need for frequent positional changes and avoidance of heating pads and blankets to prevent pressure necrosis or burns. As branches of the L1 nerve root, the iliohypogastic and ilioinguinal nerves originate in the sacral plexus (Fig. 2.7). They then travel inferiomedially between the transversus abdominis and internal oblique muscles. The iliohypogastric nerve divides into lateral and anterior cutaneous branches to supply skin overlying the lateral gluteal region and the area above the pubis on the anterior surface. These nerves are put at risk when a CBL incision is made at or below the inguinal crease. The lateral cutaneous branch of the iliohypogastic and the intercostal nerves also can be entrapped laterally during surgery. This is most likely when aggressive lateral plication of the external oblique muscle is performed to enhance waist definition or if “3-point” or quilting sutures are used laterally to close “dead space.”

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Fig. 2.7  The ilioinguinal and iliohypogastric nerves, the latter of which extends around the body to supply the lateral and anterior aspects

Fig. 2.8  Posterior cutaneous nerves: (a) Dorsal rami of S3 and S4. (b) The superior cluneal nerves

While contouring the lateral and anterior trunk and thighs during body contouring procedures, surgeons must be aware of clinically significant anatomic variations of the ilioinguinal, iliohypogastric, and lateral femoral cutaneous nerves. In a fresh cadaveric study, Whiteside and colleagues determined that, on average, the ilioinguinal nerve enters

the abdominal wall 3.1 cm medial and 3.7 cm inferior to the ASIS and terminates 2.7 cm lateral to the midline and 1.7 cm above the pubic symphysis [36]. The iliohypogastric nerve enters the abdominal wall musculature 2.1 cm medial and 0.9 cm below the ASIS and ends 3.7 cm lateral to the linea alba and 5.2 cm above the pubic tubercle.

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However, another study of human cadavers found that the position of the iliohypogastric nerve in relation to the ASIS can vary by as much as 1.5–8 cm on the right side and 2.3–3.6 cm on the left side. The ilioinguinal nerve and its relation to the ASIS vary by as much as 3–6.4 cm on the right and 2–5 cm on the left [37]. A study of 110 patients undergoing hernia repair determined that the course of both nerves was consistent with descriptions in anatomy texts in 41.8% of cases, but varied significantly in 58.2% of patients [38]. Most variations were related to “take-off” angles, bifurcations, aberrant origins, or accessory branches occurring at deeper layers of the abdominal wall. However, in 18 of 64 cases, the ilioinguinal nerve was superficial to the external oblique aponeurosis and the superficial inguinal ring. Injury to the lateral femoral cutaneous nerve (LFCN) was described as early as 1885. Meralgia parasthetica is the clinical syndrome caused by LFCN compression or injury and is characterized by anesthesia, causalgia, and hypesthesias in its dermatomal distribution. Typically, the nerve is described as coursing anterior to the ASIS and inferior to the inguinal ligament. Aszmann et al. showed that in 4% of cadavers dissected, the nerve exited posterior to the ASIS and across the iliac crest [39]. In another cadaveric study, Grothaus and colleagues demonstrated that the LFCN is susceptible to injury as far as 7.3 cm

Fig. 2.9  Gluteus maximus muscle and relationships to nearby neurovascular structures

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medial to the ASIS and 11.3 cm below the ASIS on the Sartorius muscle [40].

2.7 Deep Neuromuscular Anatomy The expansive gluteus maximus muscle (Fig. 2.9) originates in the fascia of the gluteus medius, the external ilium, the fascia of the erector spinae, the dorsum of the lower sacrum, the lateral coccyx, and the sacrotuberous ligament. It inserts on the iliotibial tract and proximal femur. Innervation of the gluteus maximus comes from the inferior gluteal nerve. This muscle is a powerful extensor of the flexed femur and provides lateral stabilization of the hip. Correct positioning of submuscular, intramuscular, and subfascial implants in relation to fascial structures and the gluteal maximus muscle are shown in Fig. 2.10. Originating on the external ilium and inserting on the lateral greater trochanters, the gluteus medius abducts the hip and thigh and helps stabilize the pelvis during standing and walking (Fig. 2.11). Nearby, the gluteus minimus muscle originates on the external surface of the ilium and inserts on the anterior-lateral greater trochanter (Fig. 2.12). This muscle abducts the femur at the hip joint and also serves as a pelvic stabilizer. Both the gluteus medius and gluteus minimus are innervated by

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a

c

Fig. 2.10  Implant position in relation to gluteal anatomy: (a) submuscular, (b) intramuscular, and (c) subfascial augmentation

Fig. 2.11  Gluteus medius muscle and relationships to nearby neurovascular structures

b

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Fig. 2.12  Gluteus minimus muscle and relationships to nearby neurovascular structures

Fig. 2.13  The location of the sciatic nerve in relation to the piriformis muscle

the superior gluteal nerve. The superior gluteal artery and nerve, which supply both muscles, exit the sciatic foramen above the piriformis muscle and travel through the plane between the gluteus medius and minimus. A lateral rotator and abductor of the femur, the piriformis muscle is innervated by branches of L5, S1, and S2. The small, triangular-shaped piriformis, which is obliquely oriented, originates at the anterior sacrum and inserts on the superior medial border of the greater trochanters. The piriformis muscle divides the greater sciatic foramen into inferior and superior portions. The

piriformis overlies the sciatic nerve and plays an important role as a landmark for the gluteal neurovascular structures, as well as the sciatic nerve (Fig. 2.13). For example, the piriformis marks the most inferior extent of an implant pocket for augmentation in the submuscular plane. Many other muscles are lateral rotators and abductors of the femur, including the superior gemellus, inferior gemellus, and obturator internus muscles, which all lie caudal to the piriformis. The most anterior of the gluteal muscles is the tensor fascia lata (Fig. 2.14). It

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Fig. 2.14  Tensor fascia lata with gluteal-lumbosacral fascia removed

originates on the lateral iliac crest and ASIS, passes superficial to the gluteus medius and minimus, and inserts on the iliotibial tract. It helps with flexion, abduction, and rotation of the thigh, and stabilizes the knee during extension. The terminal branch of the lateral femoral circumflex artery provides perfusion, with innervation supplied by the superior gluteal nerve. The sciatic nerve is the largest nerve of the body and originates in the sacral plexus – at the nerve roots of L4 through S3. Its only gluteal branch provides innervation to the hip joint. The sciatic nerve exits the gluteal region through the greater sciatic foramen below the piriformis muscle and above the superior gemellus muscle to enter the posterior compartment of the thigh (Fig. 2.15). Above the popliteal space, the sciatic nerve splits into the common peroneal nerve and the tibial nerve. Compression or injury of the sciatic nerve may cause loss of function of the posterior thigh compartment muscles, all muscles of the leg and foot, and loss of sensation in the lateral leg and foot, as well as the sole and dorsum of the foot [41]. Anatomical studies indicate that the sciatic nerve and its main branches – the tibial and common peroneal nerves – are subject to variability in relation to the piriformis muscle. The sciatic nerve leaves the pelvis through the infrapyriform foramen in 96% of cases. However, in 2.5% of cases, the common peroneal nerve may branch away from the sciatic nerve early and exit through the piriformis muscle while the tibial nerve exits below the piriformis. In another 1.5% of cases, the common peroneal nerve divides from the tibial nerve and exits the pelvis above the piriformis

Fig. 2.15  The sciatic nerve in relation to the superior and inferior gluteal arteries and veins

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muscle, while the tibial nerve exits below the muscle [42,43]. Although uncommon, these anatomic variations must be looked for during gluteal procedures because injury to these nerves could lead to clinical complications during submuscular and intramuscular implant augmentation. Although rare, gluteal compartment syndrome has been reported in the literature. Possible causes include trauma, alcoholism, drug-induced coma, EhlersDanlos syndrome, sickle cell disease, gluteal artery aneurysm rupture, abdominal aortic aneurysm repair, orthopedic surgery, bone marrow biopsy, intramuscular injections, rhabdomyolysis, extreme physical overexertion, and prolonged surgical positioning in the lateral decubitus or lithotomy positions. Even though gluteal surgery rarely causes gluteal compartment syndrome, surgeons need a thorough knowledge of the gluteal compartments and the potential impact different aesthetic procedures may have. A low index of suspicion and early intervention will reduce any permanent negative sequelae of this potentially devastating clinical problem. Three gluteal compartments have relatively inelastic boundaries: the gluteus maximus compartment, the gluteus medius-minimus compartment, and the tensor fascia lata compartment. The gluteus maximus compartment consists of the muscle plus its superficial and deep fibrous fascia, which is contiguous with the fascia lata of the thigh. This compartment attaches superiorly to the iliac crest and laterally to the iliotibial tract. Medially, the superficial and deep gluteal fascia join the sacral, coccygeal, and sacrotuberous ligaments. The gluteus medius-minimus compartment is defined superiorly by the deep gluteal fascia, the tensor compartment, and the iliotibial tract laterally. The ilium comprises the deep surface. The tensor fascia lata compartment is formed by the tensor fascia lata and the iliotibial tract. The gluteus medius-minimus compartment contains most of the critical neurovascular structures. Precise knowledge of their locations will help prevent operative injury and improve understanding of this rare compartment syndrome. The superior gluteal artery, vein, and nerve exit superior to the piriformis muscle. The inferior gluteal artery, vein, and nerve exit beneath the inferior edge of the piriformis and above the superior gemellus muscle to penetrate the gluteus maximus muscle. In addition, the sciatic nerve, posterior femoral cutaneous nerve, pudendal nerve, and nerves to the obturator internus and superior gemellus

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muscles exit in the same compartment, beneath the inferior border of the piriformis muscle. Increased compartment pressures with diminished perfusion to the gluteal muscles and tensor fascia lata can be caused by mass effect within these compartments. Damage to the vessels with bleeding and hematoma formation, or mass effect from a large implant, can theoretically increase compartment pressures beyond a safe limit. While still disputed in the literature, a compartment pressure higher than 30 mmHg may cause necrosis of muscle in as little as 4–6 h and Wallerian nerve degeneration in 8 h [44–46].

2.8 Surgical Injuries Many inadvertent opportunities for injuring patients are possible during gluteal procedures as the common prone and lateral decubitus positions carry risks, such as development of pressure sores, corneal abrasions, peripheral nerve compression, and traction injuries. Although the entire operative team is responsible for being vigilant and preventing these types of injuries, the surgeon possesses the most specialized knowledge of the impact that improper intraoperative positioning can have on a patient. Major peripheral nerve structures are especially at risk in the lateral decubitus position commonly used for a CBL or contouring liposuction of the flanks, back, and lateral thighs. An axillary roll can protect the brachial plexus from compression against the clavicle while in this position. The common peroneal nerve can be protected by using a gel mattress on the operative bed and avoiding compression against hard surfaces. Perioperatively, a gel mattress, “Roho,” or “egg-crate,” will provide extra padding to prevent nerve injury or irritation and also decrease the risk for development of stage 1 pressure sores that may occur during and after long surgical procedures. The prone position required for most gluteal procedures also puts the patient at risk in several ways. Moving a patient from the supine to the prone position should be a controlled process supervised by the surgeon to ensure that the airway is protected by anesthetists, the team is coordinated, and adequate personnel are available to make the turn effortless. The use of chest rolls to prevent hyperextension of the shoulder and compression of the brachial plexus is critical. Areas that include the ulnar

2  Gluteal Contouring Surgery: Aesthetics and Anatomy

nerves, knees, feet, and face should be padded to prevent pressure sores and/or nerve injuries. Protecting the eyes with goggles is more effective than taping the eyes closed because tape can easily be displaced with movement and moisture from lubricating ointment. If flexion of the hip is desired, a gel roll beneath the ASISs is a safe way of providing elevation [47–49]. Patients who are overweight or obese may develop hemodynamic and/or ventilatory problems when in the prone position. For example, the weight of the patient on the chest wall can decrease expansion of the chest and manifest as increased ventilatory pressures. Prone positioning also may decrease venous return, and therefore, affect preload and cardiac output. Careful vigilance and awareness will diminish the deleterious impact of these physiologic responses [50, 51].

2.9 Summary Selection of a gluteal contouring technique begins by evaluating the anatomy and existing distribution of subcutaneous fat in the buttocks and determining

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where gluteal aesthetics could be improved. The surrounding areas of the abdomen, flanks, back, hips, and lower extremities should be part of this analysis because they play a role in identifying the most appropriate procedure. The gluteal contouring algorithm (Fig. 2.16) illustrates the preferred choices for gluteal contouring under various conditions depending on the deformities present, and should help with determining which procedures are most appropriate for patients. If there is a loss of gluteal tissue volume, skin laxity, and buttock ptosis, a lower body or buttock lift with augmentation is the best option. Excisional procedures may also be needed to address the thighs and infragluteal area. Volume excess in areas surrounding the buttocks does not preclude the coexistence of gluteal hypoplasia, which is quite common in massive weight loss patients and effectively treated with autologous tissue. Contouring of the buttocks and surrounding areas is often best achieved with liposuction alone or as an adjunctive procedure. Results may be further refined with fat transfer to better define features common to attractive buttocks. This chapter has described some of the major anatomical issues that confront plastic surgeons when

Loss of volume Yes

No

Gluteal hypoplasia Yes

Volume excess

No Gluteal augment (tissue flap, implant, or fat transfer)

Yes

No

No

Yes Yes Abdomen only

Liposuction of lateral / medial thighs, buttocks or lumbosacrum

Skin laxity

Stop

Yes Yes

Medial thigh

Yes

Posterior thigh

Infragluteal fold ptosis

Posterior thigh lift

Lower buttocks lift

Abdominoplasty Medial thigh lift Extended thighplasty

Circumferential body lift or buttocks lift

Fig. 2.16  Decision-making algorithm for gluteal contouring procedures

Flanks, back and buttocks

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contouring and augmenting the gluteal region. Unless surgeons are very experienced in gluteal procedures, they are encouraged to refresh their anatomical knowledge and the many types of nerve and vascular variations that occur. A better understanding of gluteal anatomy and aesthetics will not only improve cosmetic results, but also reduce the risks of complications, some of which may be long-lasting.

References     1. Singh D. Universal allure of the hourglass figure: an evolutionary theory of female physical attractiveness. Clin Plast Surg. 2006;33(3):359–70.     2. Roberts TL III, Weinfeld AB, Bruner TW, Nguyen K. “Universal” and ethnic ideals of beautiful buttocks are best obtained by autologous micro fat grafting and liposuction. Clin Plast Surg. 2006;33(3):371–94.     3. Toth MJ, Tchernof A, Sites CK, Poehlman ET. Menopauserelated changes in body fat distribution. Ann NY Acad Sci. 2000;904:502–6.     4. Cuenca-Guerra R, Quezada J. What makes buttocks beautiful? A review and classification of the determinants of gluteal beauty and the surgical techniques to achieve them. Aesthetic Plast Surg. 2004;28(5):340–7.     5. Cuenca-Guerra R, Lugo-Beltran I. Beautiful buttocks: character­istics and surgical techniques. Clin Plast Surg. 2006;33(3):321–32.     6. Centeno RF. Gluteal Aesthetic Unit classification: a tool to improve outcomes in body contouring. Aesthetic Surg J. 2006;26(2):200–8.     7. Centeno RF, Young VL. Clinical anatomy in aesthetic gluteal body contouring surgery. Clin Plast Surg. 2006;33(3): 347–58.     8. Centeno RF. Autologous gluteal augmentation with circumferential body lift in the massive weight loss and aesthetic patient. Clin Plastic Surg. 2006;33(3):479–96.     9. Mendieta CG. Classification system for gluteal evaluation. Clin Plast Surg. 2006;33(3):333–46. 10. Centeno RF, Mendieta CG, Young VL. Gluteal contouring surgery in the massive weight loss patient. Clin Plast Surg. 2008;35(1):73–91. 11. Gonzalez R. Etiology, definition, and classification of gluteal ptosis. Aesthetic Plast Surg. 2006;30(3):320–6. 12. Gonzalez R. Buttocks lifting: how and when to use medial, lateral, lower, and upper lifting techniques. Clin Plast Surg. 2006;33(3):467–78. 13. de la Peña JA. Subfascial technique for gluteal augmentation. Aesthetic Surg J. 2004;24(4):265–73. 14. de la Peña JA, Rubio OV, Cano JP, Cedillo MC, Garcés MT. Subfascial gluteal augmentation. Clin Plast Surg. 2006;33(3):405–22. 15. Gonzalez-Ulloa M. Gluteoplasty: a ten-year report. Aesthetic Plast Surg. 1991;15(1):85–91. 16. Mendieta CG. Gluteoplasty. Aesthetic Surg J. 2003;23(6): 441–55.

R. F. Centeno 17. Vergara R, Amezcua H. Intramuscular gluteal implants: fifteen years’ experience. Aesthetic Surg J. 2003;23(2):86–91. 18. Mendieta CG. Intramuscular gluteal augmentation technique. Clin Plast Surg. 2006;33(3):423–34. 19. Cárdenas-Camarena L, Lacouture AM, Tobar-Losada A. Combined gluteoplasty: liposuction and lipoinjection. Plast Reconstr Surg. 1999;104(5):1524–31. 20. Pascal JF, Le Louarn C. Remodeling bodylift with high lateral tension. Aesthetic Plast Surg. 2002;26(3):223–30. 21. Valero de Pedroza L. Fat transplantation to the buttocks and legs for aesthetic enhancement or correction of deformities: long-term results of large volumes of fat transplant. Dermatol Surg. 2000;26(12):1145–9. 22. Da Rocha RP. Surgical anatomy of the gluteal region’s subcutaneous screen and its use in plastic surgery. Aesthetic Plast Surg. 2001;25(2):140–4. 23. Babuccu O, Gozil R, Ozmen S, Bahcelioglu M, Latifoglu O, Celebi MC. Gluteal region morphology: the effect of the weight gain and aging. Aesthetic Plast Surg. 2002;26(2):130–3. 24. Montagu A. The buttocks and natural selection. J Am Med Assoc. 1966;198(1):169. 25. Kopelman PG. The effects of weight loss treatments on upper and lower body fat. Int J Obes. 1997;21(8):619–25. 26. Fabris de Souza SA, Faintuch J, Valezi AC, Sant’ Anna AF, Gama-Rodrigues JJ, de Batista Fonseca IC, et al. Postural changes in morbidly obese patients. Obes Surg. 2005;15(7):1013–6. 27. Ferretti A, Giampiccolo P, Cavalli A, Milic-Emili J, Tantucci C. Expiratory flow limitation and orthopnea in massively obese subjects. Chest 2001;119(5):1401–8. 28. Giusti V, Gasteyger C, Suter M, Heraief E, Gaillard RC, Burckhardt P. Gastric banding induces negative remodeling in the absence of secondary hyperparathyroidism: potential role of serum C telopeptides for follow-up. Int J Obes (Lond). 2005;29(12):1429–35. 29. Lockwood TE. Transverse flank-thigh-buttock lift with superficial fascial suspension. Plast Reconstr Surg. 1991;87(6):1019–27. 30. Lockwood T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6):1112–22. 31. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991;87(6):1009–18. 32. Ahmadzadeh R, Bergeron L, Tang M, Morris SF. The superior and inferior gluteal artery perforator flaps. Plast Reconstr Surg. 2007;120(6):1551–6. 33. Pan WR, Taylor GI. The angiosomes of the thigh and buttock. Plast Reconstr Surg. 2009;123(1):236–49. 34. Lui KW, Hu S, Ahmad N, Tang M. Three-dimensional angiography of the superior gluteal artery and lumbar artery perforator flap. Plast Reconstr Surg. 2009;123(1):79–86. 35. Taylor GI. The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg. 2003;30(3):331–42. 36. Whiteside JL, Barber MD, Walters MD, Falcone T. Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and lower transverse incisions. Am J Obstet Gynecol. 2003;189(6):1574–8. 37. Avsar FM, Sahin M, Arikan BU, Avsar AF, Demirci S, Elhan A. The possibility of nervus ilioinguinalis and nervus iliohypogasticus injury in lower abdominal incisions and effects on hernia formation. J Surg Res. 2002;107(2):179–85.

2  Gluteal Contouring Surgery: Aesthetics and Anatomy 38. Al-dabbagh AK. Anatomical variations of the inguinal nerves and risks of injury in 110 hernia repairs. Surg Radiol Anat. 2002;24(2):102–7. 39. Aszmann OC, Dellon ES, Dellon AL. Anatomical course of the lateral femoral cutaneous nerve and its susceptibility to compression and injury. Plast Reconstr Surg. 1997;100(3): 600–4. 40. Grothaus MC, Holt M, Mekhail AO, Ebraheim NA, Yeasting RA. Lateral femoral cutaneous nerve: an anatomic study. Clin Orthop Relat Res. 2005;(437):164–8. 41. Drake RL, Wayne V, Mitchell AWM. Gray’s anatomy for students. Philadelphia: Elsevier, Churchill; 2005. 42. Babinski MA, Machado FA, Costa WS. A rare variation in the high division of the sciatic nerve surrounding the superior gemellus muscle. Eur J Morphol. 2003;41(1):41–2. 43. Ugrenovic S, Jovanovic I, Krstic V, Stojanovic V, Vasovic L, Antic S, et al. The level of the sciatic nerve division and its relations to the pyriform muscle. Vojnosanit Pregl. 2005; 62(1):45–9.

25 44. Prynn WL, Kates DE, Pollack CV Jr. Gluteal compartment syndrome. Ann Emerg Med. 1994;24(6):1180–3. 45. Hill SL, Bianchi J. The gluteal compartment syndrome. Am Surg. 1997;63(9):823–6. 46. Bleicher RJ, Sherman HF, Latenser BA. Bilateral gluteal compartment syndrome. J Trauma. 1997;42(1):118–22. 47. Kroll DA, Caplan RA, Posner K, Ward RJ, Cheney FW. Nerve injury associated with anesthesia. Anesthesiology 1990;73(2):202–7. 48. Lincoln JR, Sawyer HP Jr. Complications related to body positions during surgical procedures. Anesthesiology 1961; 22:800–9. 49. Parks BJ. Postoperative peripheral neuropathies. Surgery 1973;74(3):348–57. 50. Watson RA, Pride NB. Postural changes in lung volumes and respiratory resistance in subjects with obesity. J Appl Physiol. 2005;98(2):512–7. 51. Brodsky J. Positioning the morbidly obese patient for anesthesia. Obes Surg. 2002;12(6):751–8.

3

Anatomy and Topography of the Anterior Abdominal Wall Michael R. Davis and Matthew R. Talarczyk

3.1 Aesthetic Landmarks Abdominal beauty does not arise from a strictly defined form. There are varied appearances which are considered aesthetically pleasing. Surface landmarks contribute greatly to abdominal aesthetics, but the degree to which they are defined is not necessarily directly related to the level of feminine aesthetic beauty. As with most aesthetic features, proportion plays a significant role. Contour of the abdomen is dependent upon age, genetics, muscle mass, tone, obesity, intraabdominal pathology, parity, and posture. These factors may significantly alter topography. The anterolateral abdominal wall is bounded superiorly by the costal margins and the xiphoid, and below by the iliac crests, inguinal ligaments, pubic crest, and pubic symphysis. Its lateral margins are defined by conventional vertical lines dropped from the costal margins to the most elevated portion of the iliac crests. The linea alba extends in the midline from the xyphoid process to the symphysis pubis. It is divided by the umbilicus into supraumbilical and infraumbilical segments of nearly equal lengths. The rectus muscles produce elevated bands on each side of the linea alba. Transverse tendinous intersections create palpable depressions in muscular persons. There is usually one at the level of the xyphoid, one at the umbilicus, and one between. It is the combination of the linea alba and the linea transversae which form the abdominal “six-

M. R. Davis (*) Division of Plastic Surgery, University of Alabama, Birmingham School of Medicine, 510 20th Street South, 1164 Faculty Office Tower, Birmingham, AL, 35294-3411, USA e-mail: [email protected]

pack” sought by body builders. At the lateral margin of each rectus muscle, there is a depression called the linea semilunaris which is directed inferomedially toward the symphisis pubis. Visible grooves mark the lower limits of the inguinal ligament [1]. The abdominal wall form is created by the relationship between the osteomyofascial system, the subcutaneous fibroadipose tissue, and the skin. These relationships give the appearance of an aesthetic contour through light reflection variations from prominences and shadows from depressions. In the midline from the xiphoid to the navel, a shadow is formed by the depression of a medial sulcus corresponding to the linea alba. Lateral to this sulcus there are two vertical wide strip reflections produced by the prominence of the rectus abdominis muscles that join under the umbilicus. More lateral and slightly more posterior to these prominences there are two wide depressions called semilunar sulci. They produce a “lyre” form by the insertion of the skin at the condensation of the fascia of the oblique muscles into the external margin of the rectus muscles, the inguinal ligaments, and pubis. The silhouette of the abdomen is formed by the lower part of thoracic cage superiorly, the pelvis inferiorly, and the waist in the middle. The waist extends from 7 to 10 cm between the inferior costal margin and the iliac crest. The shape of the waist is dependent on the superior aperture of the pelvis. A wide pelvis produces a more accentuated waist. The waist can be absent when the pelvis is small, when the distance between the pelvis and the ribs is reduced, or when excess adiposity is present [2]. Umbilical position and appearance are important and prominent aesthetic features. The umbilicus represents residual scarring at the point of umbilical cord attachment. Typically, as the scar involutes and the abdominal wall matures, a depression forms. The central recession is a key aesthetic feature. In the inferior extreme of the

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shadow of the medial sulcus, a more accentuated shadow is formed by the triangular depression of the navel. Attractive navels are small and vertical in orientation, or have a T shape, which consists of a thin vertical hollow capped by a superior hood or shelf. Unaesthetic navels are horizontal, large, or protruding [3]. The umbilicus should be situated in the midline at or slightly above the superior iliac crests [4]. Aesthetic units of the abdomen have been defined for both men and women. There are six units (3 pairs) in men corresponding to the epigastrium, periumbilical, lower abdominal regions. Women have a seventh unit, the dorsal back roll region, which is also a con­sideration for treatment at the time of abdominal contour surgery. Men rarely complain of dorsal back rolls [5]. Modern aesthetically pleasing abdomens are varied in appearance and there are no strict criteria accepted as the standard of beauty. Though varied, they typically have in common a medial sulcus in the upper abdomen, two shadows of the semilunar lines that join over the pubis, and two protuberances between the shadows beginning in the thorax that join under the umbilicus, with a lyre shape. Under the umbilicus, the abdomen is typically not flat but slightly prominent [2]. The degree of adiposity represents the most striking and variable feature affecting abdominal wall appearance. Both intraabdominal and extraabdominal fat can act to efface surface landmarks and hip definition to the degree to render them unaesthetic. Modifications of the position and thickness of the tissues will alter the aesthetic appearance of the abdomen due to the changes of the light reflections and shadows. Therefore, the basic surgical principle today in abdominoplasty is to sculpture the tissues and reshape the light reflections and shadows by giving new tension in the musculoaponeurotic layer, sculpturing the overlaying fat under the cutaneous envelope, and by resecting excess skin and adipose when they are present.2

3.2 Skin and Subcutaneous Tissue Abdominal aesthetics are highly dependent on the properties and condition of the skin and subcutaneous tissues. They are the mortar from which improvement can be carved. Improper manipulation, however, can lead to complications. Many minor and major complications in abdominal plastic and reconstructive surgery occur with

M. R. Davis and M. R. Talarczyk

improper handling and violation of strict anatomic principles. Beneath the skin, there is the subcutaneous areolar tissue and superficial fascia. Over the lower thorax and epigastrium, the superficial fascia consists of one layer. This layer is thin and less organized than in the lower abdomen. In the lower abdomen it becomes more definitively bilaminar. Just superior to the inguinal ligament it can be divided into a superficial fatty stratum, termed Camper’s fascia, and a deeper, stronger, and more elastic membranous layer called Scarpa’s fascia [6]. The superficial layer is thick, areolar, and contains a variable amount of fat. This layer continues into the perineum, and in females, it continues over the labia majora. The deep layer is more membranous and contains elastic fibers. It is separated from the underlying deep fascia by a loose areolar layer. Inferiorly, it fuses with the deep fascia of the thigh, medial portion of the inguinal ligament, and pubic tubercle along the line of the fold of each groin [7].

3.3 Arterial Supply The lower anterolateral abdominal wall is perfused by three superficial branches of the femoral artery. From superior to inferior, these are the superficial circumflex iliac artery, the superficial epigastric artery, and the superficial external pudendal artery. These arteries are directed toward the umbilicus in the subcutaneous tissue. Each superficial epigastric artery anastomoses with the contralateral artery and all anastomose with deep epigastric arteries. Huger [8] defined three zones with respect to their corresponding primary blood supplies. Zone I overlying the rectus muscles is perfused by the superior– inferior epigastric system. Zone II lies in the lower abdominal region from a transverse line at the level of the anterior superior iliac spines to the pubis and inguinal creases and is supplied by the superficial epigastric, superficial external pudendal, and circumflex iliac system. Zone III is from the flare of the costal margin to the transverse line corresponding to the anterior superior iliac spines and is supplied by branches from the intercostal and lumbar arteries [8]. The deep arteries pass between the transversus abdominis and internal oblique muscles. They are the 10th and 11th posterior intercostal arteries, the anterior

3  Anatomy and Topography of the Anterior Abdominal Wall

branch of the subcostal artery, the anterior branches of the 4th lumbar arteries, and the deep circumflex iliac artery. The rectus sheath is supplied by the superior epigastric artery, which arises from the internal thoracic artery, as well as the inferior epigastric artery arising from the external iliac artery just above the inguinal ligament. The superior epigastric artery enters the upper end of rectus sheath deep to the rectus muscle. Typically, two vertical rows of musculocutaneous perforators pierce the anterior rectus sheath to supply overlying skin. The inferior epigastric artery lies first in the preperitoneal connective tissue and then enters the sheath above the level of the arcuate line to pass between the rectus muscle and the posterior layer of the sheath [9].

3.4 Venous Drainage The superficial epigastric, circumflex iliac, and pudendal veins converge in the groin to enter the greater saphenous vein. Above the umbilicus, the superficial veins empty into the superior vena cava via the internal mammary, intercostal, and long thoracic veins. Both groups join with one another through the thoracoepigastric vein, which ascends from the groin to the axilla. The two systemic groups of veins communicate indirectly at the umbilicus with the portal vein by means of a potential anastomosis with the paraumbilical vein, which passes from the left branch of the portal vein along the round ligament of the liver to the umbilicus [6].

3.5 Lymphatic Drainage The lymphatic drainage is divided into two general groups. The upper group, which lies in the supraumbilical region, drains into the pectoral and axillary nodes. The lower group in the infraumbilical region drains toward the superficial inguinal nodes. Lymphatics from the liver course along the ligamentum teres to the umbilicus, thereby communicating with the lymphatics of the anterior abdominal wall. Metastasis to the umbilicus from the liver can occur and may spread to the lymph nodes in the groin [1]. It should be noted that the deep inguinal lymph nodes receive most of the drainage from the lower extremity. Efferent vessels

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from the deep nodes drain into the external iliac, common iliac, and lumbar lymph nodes, eventually reaching the cisterna chyli and thoracic duct.

3.6 Innervation The cutaneous nerves are arranged segmentally in a similar manner to the intercostal nerves in the thorax. The lower six nerves sweep around obliquely to supply the abdominal circumference giving lateral cutaneous branches which course through the external oblique muscle. Each cutaneous branch divides into a lesser posterior nerve, extending back over the latissimus dorsi and a larger anterior nerve which supplies the external oblique muscle and overlying subcutaneous tissue and skin. The main stem of the intercostal nerve continues forward and reaches the midabdominal surface by passing through the rectus muscle, then emerging through the anterior rectus sheath approximately a centimeter from the midline. The most caudal nerves of the abdominal wall are derived from the first lumbar nerve. They are the iliohypogastric and ilioinguinal nerves [10].

3.7 Musculofascial Anatomy The abdominal wall contains multiple large, musculofascial units which serve several functional purposes. Laterally, from external to internal, there are two paired external oblique, internal oblique, and transversus abdominis muscles. There are two paired midline muscle groups which include the rectus abdominis muscle and the pyramidalis. All of these muscles contribute to increasing intraabdominal pressure and aid in micturition, defecation, and parturition [11]. The rectus abdominis muscle originates from the symphysis pubis and pubic crest and inserts onto the xiphoid process and costal cartilage five through seven. This muscle is innervated by the intercostal nerves T7–T11. Blood supply is from the same intercostal arteries, the superior epigastric artery, as well as the inferior epigastric artery. The rectus abdominis muscle is a large muscle group positioned on both sides of the midline and contained within the rectus sheath. The rectus sheath is a unique fibrous network with contributions from the internal and external abdominal

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oblique aponeurosis and the transversus abdominis aponeurosis fibers. The arcuate line of the rectus sheath defines where the internal abdominal oblique aponeurosis splits into two layers. One layer passes anterior to the rectus muscle while the other layer passes posterior to the rectus muscle. Therefore, above the arcuate line the anterior rectus sheath is comprised from the aponeuroses of both the external and internal abdominal oblique. The corresponding posterior rectus sheath arises from the internal oblique and transversus abdominis aponeuroses. The arcuate line anatomically defines the inferior limits of the posterior rectus sheath. Below the arcuate line, the internal abdominal oblique aponeurosis no longer bifurcates and the anterior rectus sheath is comprised of the internal and external abdominal oblique aponeuroses, as well as the transversus abdominis aponeurosis. The midline structure, the linea alba, is formed from the confluence of the transversus abdominis aponeurosis and the internal and external abdominal oblique aponeuroses. The external abdominal oblique originates from the lower eight ribs and inserts onto the anterior superior iliac spine as well as the pubic crest and tubercle. Like the rectus abdominis muscle, the external abdominal oblique is innervated by the intercostal nerves T7–T11. It also receives contributions from the iliohypogastric and the ilioinguinal nerves as well as the subcostal nerve (T12). Blood supply to this muscle is complex with perfusion from the intercostal arteries seven through eleven, the superficial and inferior epigastric arteries, the deep circumflex iliac arteries, the superficial circumflex iliac arteries, and the superficial external pudendal arteries. Fibers of this muscle group are directed inferomedially. The internal abdominal oblique muscle originates from the anterior two-thirds of the iliac crest, the lateral two-thirds of the inguinal ligament, as well as from the thoracolumbar fascia. This muscle inserts onto the lower four ribs and pubic crest. The blood supply and innervation to this muscle are similar to that of the external abdominal oblique muscle. Orientation of this muscle group is perpendicular to the fibers of the external abdominal oblique. The plane carrying the neurovascular supply to the anterior abdominal wall lies between the internal oblique and the transversus abdominis muscles. This plane is to be avoided anatomically during surgery to avoid bleeding and denervation of the abdominal wall.

M. R. Davis and M. R. Talarczyk

The anatomic plane between the external oblique and internal oblique muscles, however, is virtually bloodless when defined correctly and is used surgically by plastic surgeons in component separation during abdominal wall reconstruction [12]. The transversus abdominis muscle originates from the lower six ribs, the anterior iliac crests, the lateral inguinal ligament, as well as the thoracolumbar fascia. It inserts onto the pubic crest. The blood supply and innervation are also similar to that of the external and internal abdominal oblique muscle groups. The pyramidalis is an inferior midline structure and lies anterior to the lower third of the rectus muscles originating from the pubic crest and inserting onto the linea alba. It is innervated by the subcostal nerve and its blood supply comes from branches from the subcostal arteries, as well as the inferior epigastric arteries. The transversalis fascia comprises the entire connective tissue sheet lining the musculature of the abdominal cavity. The transversalis fascia extends from the rib cage to the pelvis. In some areas, this fascial layer is given a specific name such as “iliacus” or “psoas” fascia where it covers those muscles. The transversalis fascia varies in nature. It is thin and adherent deep to the transversus abdominis aponeurosis, yet thick and separate in the genitofemoral region. The peritoneum is the innermost layer of the abdominal wall and the inguinal area. It is loosely connected with the transversalis fascia in most areas, except at the internal ring, where the connection is stronger. Between the peritoneum and the transversalis fascia there is a loose layer of extraperitioneal fat used as an important landmark in many surgical operations [8].

3.8 Conclusions The abdominal wall contour is defined by the close relationships between the skeletal, musculofacial, and cutaneous systems. It can be safely manipulated into a more aesthetic form with a thorough understanding of the anatomy as well as pathophysiology. It contains a complex structural myofascial network that supports multifaceted functions of everyday life. Understanding the anatomic relationships of these units is paramount for clinicians in their ability to address and treat complex clinical scenarios.

3  Anatomy and Topography of the Anterior Abdominal Wall

References   1. McVay CB. Surgical Anatomy. 6th ed. Philadelphia: WB Saunders; 1989. p. 484–584.   2. Psillakis JM, Appiani E, de la Plaza R. Color atlas of aesthetic surgery of the abdomen. New York: Thieme; 1991.   3. Craig SB, Faller MS, Puckett CL. In search of the ideal female umbilicus. Plast Reconstr Surg. 2000;105:389.   4. Dubou R, Ousterhout D. Placement of the umbilicus in an abdominoplasty. Plast Reconstr Surg. 1978;61(2): 291–3.   5. Matarasso A. Abdominoplasty. Plast Surg Tech. 1995; 4:303.

31   6. Gray SW, Skandalakis JE, McClusky DA. Atlas of surgical anatomy for general surgeons. Baltimore: Williams and Wilkins; 1985. p. 342–9.   7. Peter LW, Roger W, Lawrence HB. Gray’s anatomy. 37th ed. UK: Churchhill Livingstone; 1989. p. 599–602.   8. Huger WE. The anatomic rationale for abdominal lipectomy. Am J Surg. 1979;45(9):612–7.   9. Skandalakis JE, Skandalakis PN, Skandalakis LJ. Surgical anatomy and technique. New York: Hamilton; 1999. p. 123–55. 10. Delvin B, Kingsnorth AN. The management of abdominal hernias. 2nd ed. London: Arnold; 1999. p. 211–30. 11. Grevious MA. Structural and functional anatomy of the abdominal wall. Clin Plast Surg. 2006;33(2):169–79. 12. Ahluwalia HS, Burger JP, Quinn TH. Operat Tech Gen Surg. 2004;6(3):147–55.

4

History of Classifications of Adiposity Excess Melvin A. Shiffman

4.1 Introduction Fat accumulation is classified in order to visualize areas of fat deformity that can be treated surgically. There are a variety of regions of the body that may accumulate excess amounts of fat, some of which are hereditary with a genetic defect. The gluteal, thigh, buttocks, and abdominal areas are the areas of frequent complaint from patients as areas of excess fat accumulation.

4.2 History Vague [1] measured circumferences (CFD) at the nape of the neck, sacrum, and the four proximal attachments of the extremities comparing male and female. An index of masculine differentiation (IMD) (Table 4.1) was established using the average fat in each area. Obesities were called gynoid and hypergynoid that consisted of localization of fat on the lower part of the body and android and hyperandroid that had localization of fat on the upper part of the body. The android obesity leads to metabolic disturbances. Ashwell et al. [2] used a photographic method for classifying female fat distribution (FD). The recommended measure, the FD score, was a simple ratio of waist and thigh diameters obtained from standard sideview somatype photographs. FD score = 26 log10 × waist diameter thigh diameter M. A. Shiffman  17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

The photographic method requires special facilities and is therefore not available to all who wish to classify FD. Circumferential measurements have been successfully used to derive equations for the estimation of body fatness [3, 4]. Grazer and Klingbeil [5] classified fat accumulation taking into consideration major anatomic components in and around the hip and thigh areas that contribute to body configuration (Table 4.2) (Fig. 4.1). The method of correction of the deformity was also included. Ashwell et  al. [6] used photographs to assess the patients as being either central, peripheral, or intermediate (Fig. 4.2) that was quicker and more reliable than the assessment of body outline drawings [7], X-rays [8], or skin fold thickness [9]. FD in women was classified by Kalkhoff et al. [10] on the basis of the ratio of the waist to hip circum­ ference. Shaer [11] produced a simplified classification of gluteal and thigh deformities (Fig. 4.3). This classification was used to plan surgical procedures. The lateral gluteal recess is a normal depression that may be visually aggravated by the accumulation of fat in the anterior superior iliac spine, iliac crest, and the trochanteric area. The deformities illustrated in Fig. 4.1 were treated by the author by augmentation of area one, fat removal in areas two, three, four, six, and seven, and skin excision in areas three, four, and six. At the present time, liposuction is the preferred method of fat removal and depressions can be treated with fat transfer. Skin excision is usually not necessary if superficial liposuction is performed that stimulates skin retraction. Ashwell et al. [12] classified the FD from anthropomorphic findings and could distinguish only those with

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M. A. Shiffman

Table 4.1  Classification of masculine differentiation on the basis of the index of masculine differentiation (IMD) scale IMD scale Group > + 15 +15

Hyperandroid

0

Android

−15 −45

Intermediate

60

Gynoid

−75 3,400 U daily) (both Grade 1A)

− Surgery patients who received appropriate VTE prophylaxis within 24 h prior to surgery to 24 h after surgery

− Other advances in perioperative care

− High-risk general surgery patients with multiple risk factors: recommend pharmacologic methods (i.e., LDUH tid or LMWH > 3,400 U daily) combined with the use of GCS and/or IPC (Grade 1C+) − Selected high-risk general surgery patients, including those who have undergone major cancer surgery: suggest posthospital discharge prophylaxis with LMWH (Grade 2A)

Trends that may increase dvt risk in general surgery patients: − Performance of more extensive operative procedures in older and sicker patients − Use of preoperative chemotherapy − Shorter lengths of stay in the hospital, leading to shorter durations of prophylaxis Excerpted from the 7th ACCP Conference on antithrombotic and thrombolytic therapy. Abdominal surgery was considered as a part of general surgery recommendations LDUH low-dose unfractionated heparin; LMWH low-molecular-weight heparin; GCS graduated compression stockings; IPC intermittent pneumatic compression a

b

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Fig. 24.5  Preoperative marking

Incisions are performed along the preoperative drawing and an “en-bloc” resection of skin and subcutaneous tissue is carried out. The umbilicus is resected in a triangular shape, with the base placed superiorly, isolating and preserving its stalk, which is left attached to the abdominal fascia.

P. Persichetti et al.

The lateral flaps are elevated through sharp dissection in a prefascial plane in order to mobilize the flaps sparing the lateral musculocutaneous perforators, and being careful not to impair the vascular supply (Huger’s zone III). Use of conventional electric cutting current is discouraged, given the increased risk of seroma associated with this procedure, as observed in other sites [17]. Ultrasound devices or new electrocautery devices with limited thermal damage can be a valid alternative. Plication of the rectus sheath is then performed; in most cases it is vertical and sometimes vertical and horizontal depending on the myoaponeurotic laxity (Fig. 24.6). Reinforcement of the abdominal muscolo-aponeurotic layer may imply medial advancement of muscolofascial flaps from the oblique muscles of both sides. In these cases, the fascia is incised along the anterior axillary lines and the muscles are split, preserving the underlying intercostal vessels, allowing medial advancement of the flaps. The oblique muscles are fixed medially with bilateral paramedian plications, which are performed in addition to the medial one. Plications are carried out with an inverted nonabsorbable suture such as Prolene 1–0. In case of recurrent abdominal incisional or inguinal hernias, a Prolene mesh is placed in a preperitoneal position. Sometimes the mesh is applied onto the deep rectus muscle fascia, because of peritoneal impairment caused by previous surgery (Fig. 24.7). The umbilicus, previously cut out in a triangular shape, with a superior base, is fixed to the aponeurosis.

Fig. 24.6  After “en bloc” dermolipectomy. (a) Before plication of rectus and oblique muscle fascia. (b) After plication

24  “Anchor-Line” Abdominoplasty: A Comprehensive Approach to Abdominal Wall Reconstruction

a

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b

Fig. 24.7  (a) Epigastric incisional hernia. (b) Suprapubic incisional hernia

The lateral dermoadipose flaps are advanced and approximated medially and two oblique incisions are carried out in the midline, in the umbilicus anatomical position. A “Y”-shaped recipient site results, and the navel is sutured into it. A very natural umbilicus shape is obtained. Two suction drains are always placed, one in a supraumbilical position and the other in a lower position, beneath the umbilicus. Before advancing the abdominal flaps and starting the sutures, the operating table is flexed 30° to release tension on the sutures. Subcutaneous approximation is attained with absorbable polyglycolic acid sutures, followed by a running subcuticular nylon suture. The abdomen is padded with a cotton–wool bandage. An elastic pressure dressing is applied all over the area. Patients stay in bed for 48 h postoperatively, wearing elastic stockings till they are ambulated for thromboembolic prophylaxis. They are carefully instructed to mobilize their lower extremities in bed under a nurse’s supervision and antibiotics (cephalosporins) are administered until drains are removed. A full blood count is requested the day after surgery. Postoperative temporary ileus is frequent and patients are nil by mouth till bowel canalization is ascertained. A girdle is worn for 1.5 months; the first 2 weeks it is worn night and day. The “anchor-line” abdominoplasty is often associated with other extraperitoneal or intraperitoneal operations,

mainly, inguinal hernioplasty or cholecystectomy. The association with other surgeries must take into account the higher risk of postoperative complications, which depend on the type of combined operations. Whenever the umbilicus is lost during previous surgery, a neo-omphaloplasty is performed, marking a 2 cm diameter circle at the new navel site. An equatorial incision is then performed obtaining two flaps. The lower flap is defatted and sutured to the underlying fascia. The wound heals by secondary intention, yielding a very natural umbilical scar.

24.6 Complications Early complications observed following an anchorline abdominoplasty are considered as minor when they do not require surgical revision: suture abscess/ granuloma, minor wound dehiscence, minor skin slough can be treated with local dressings to obtain healing by secondary intention. Innovative wound care, with active dressings, is available to assist in the healing process and provide excellent exudate management. Seroma formation following abdominoplasty has a statistically higher incidence in overweight or obese patients [18]. Quilting sutures have been shown to decrease the rate of seromas in a recently published

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study. In a retrospective study, Kim et  al. [19] concluded that liposuction of the flanks in concert with abdominoplasty does not increase the risk of seroma formation. Seroma is easily assessed with ultrasound and is generally treated with syringe aspiration and elastic pressure dressing in the out-patient clinic. The main early major complications, following an anchor-line abdominoplasty, are skin necrosis and loss of the umbilicus. Skin necrosis generally occurs at the crossing of the vertical and horizontal incisions. Once the necrotic area is well-demarcated, surgical debridement is performed and, depending on the extent of the defect, reconstruction is attained through local flap advancement or skin grafting. New undermining of the

a1

b1

Fig. 24.8  (a1,2) Preoperative view. (b1,2) Three months postoperatively

abdominal flaps allows further medial advancement, which generally results in a longer horizontal scar. Loss of umbilicus requires neo-omphaloplasty, as previously described. Postoperative hematoma can be a major complication in the days following surgery and its early recognition is extremely important. On clinical examination, the amount of blood drained, local swelling and ecchymosis as well as symptoms of anemia reveal an ongoing blood collection. Ultrasonographic examination is an effective method for early recognition of such postoperative hematomas, and it should be carried out as soon as clinical symptoms appear. Haematoma surgical

a2

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24  “Anchor-Line” Abdominoplasty: A Comprehensive Approach to Abdominal Wall Reconstruction

evacuation is mandatory, as well as identification and sealing of bleeders. Blood transfusion is requested based on the haemoglobin level. Infection can be a severe complication, especially if caused by multiresistant bacteria and if a mesh was placed. A sample should always be sent for microbiological examination to select specific antibiotics. In severe cases, local debridement is necessary; vacuum therapy offers a valid option but in the most severe cases, mesh removal is necessary. The most devastating early complication of abdominoplasty is pulmonary embolus, which seems to be related to the severity of plication of the rectus fascia, which can cause intraabdominal hypertension [20– 22]. The increased intraabdominal pressure causes stasis of the venous circulation and predisposes to deep venous thrombosis (DVT). However, deep vein thrombophlebitis and pulmonary embolus seem to be rare complications. Long-term complications include scar asymmetry, hypertrophic scarring, umbilical malposition, elevation of the pubic escutcheon, painful neuromas, and dog-ears [23]. Surgical revision depends on the patient’s preferences and severity of the defect. Comorbid factors play a significant role. Patients who smoke or have diabetes, hypertension, or asthma have significantly higher complication rates. Postoperative anemia is to be expected in patients with malabsorption following bariatric surgery. Obesity is yet another wellknown risk factor for wound complications in abdominoplasty. Obesity at the time of abdominoplasty has a profound influence on the wound complication rate following surgery, regardless of any previous weight reduction surgery [24]. In a recent study, the largest series of local and systemic complication rates was reported and compared with those of previously published abdominoplasty surveys [25]. This study underlined that, despite more extensive abdominal contouring techniques and the association of liposuction, the local and systemic complication rates coincided with previously published data (Fig. 24.8).

24.7 Conclusions In the vast majority of patients who are candidates for an abdominoplasty and present with supraumbilical

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median or paramedian scars, especially in case of concomitant intraabdominal procedures, an anchor-line abdominoplasty should always be considered.

References   1. Persichetti P, Simone P, Scuderi N. Anchor-line abdominoplasty: a comprehensive approach to abdominal wall reconstruction and body contouring. Plast Reconstr Surg. 2005; 116(1):289–94.   2. Weinhold S. Bauchdeckenplastik. Zentralbl Für Gynäk. 1909;38:1332.   3. Dufourmentel C, Mouly R. Chirurgie plastique. Paris: Flammarion; 1959. p. 381–9.   4. Galtier M. Obésité de la paroi abdominale. Presse Méd. 1962;70:135–6.   5. Castañares S, Goethel JA. Abdominal lipectomy: a modification in technique. Plast Reconstr Surg. 1967;40(4):378–83.   6. Barraya L, Dezeuze J. Chirurgie abdominale, réparation pariétales et dermolipectomies. Nouvel ombilic. Mem Acad Chir (Paris). 1967;93(15):473–9.   7. Dellon AL. Fleur-de-lis abdominoplasty. Aesthetic Plast Surg. 1985;9(1):27–32.   8. Regnault P. Abdominoplasty by the “W” technique. Plast Reconstr Surg. 1975;55(3):265–74.   9. Grundy SM, Brewer HB Jr, Cleeman JI, Smith SC Jr, Lenfant C. American Heart Association, National Heart, Lung, and Blood Institute. Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/ American Heart Association conference on scientific issues related to definition. Circulation. 2004;109(3):433–8. 10. Persichetti P, Simone P, Langella M, Marangi GF, Carusi C. Digital photography in plastic surgery: how to achieve reasonable standardization outside a photographic studio. Aesthetic Plast Surg. 2007;31(2):194–200. 11. Cardoso de Castro C, Salema R, Atias P, Aboudib JH Jr. T abdominoplasty to remove multiple scars from the abdomen. Ann Plast Surg. 1984;12(4):369–73. 12. de Castro CC, Costa Aboudib JH Jr, Salema R, Gradel J, Braga L. How to deal with abdominoplasty in an abdomen with a scar. Aesthetic Plast Surg. 1993;17(1):67–71. 13. Matarasso A. Liposuction as an adjunct to a full abdominoplasty revisited. Plast Reconstr Surg. 2000;106(5):1197–202. 14. Dillerud E. Abdominoplasty combined with liposuction (letter). Ann Plast Surg. 1991;27(2):182–6. 15. Huger WE Jr. The anatomical rationale for abdominal lipectomy. Am Surg. 1979;45(9):612–7. 16. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004;126(3 Suppl):338–400S. 17. Porter KA, O’Connor S, Rimm E, Lopez M. Electrocautery as a factor in seroma formation following mastectomy. Am J Surg. 1998;176(1):8–11. 18. Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture prevent seroma in abdominoplasty?. Plast Reconstr Surg. 2007;119(3):1060–4; discussion 1065–6.

248 19. Kim J, Stevenson TR. Abdominoplasty, liposuction of the flanks, and obesity: analyzing risk factors for seroma formation. Plast Reconstr Surg. 2006;117(3):773–9; discussion 780–1. 20. Schein M, Wittmann DH, Aprahamian CC, Condon RE. The abdominal compartment syndrome: the physiological and clinical consequences of elevated intraabdominal pressure. J Am Coll Surg. 1995;180(6):745–53. 21. Ivatury RR, Diebel L, Porter JM, Simon RJ. Intraabdominal hypertension and the abdominal compartment syndrome. Surg Clin North Am. 1997;77(4):783–800. 22. Sugrue M. Intra-abdominal pressure: time for clinical practice guidelines? Intensive Care Med. 2002;28(4):389–91.

P. Persichetti et al. 23. Chaouat M, Levan P, Lalanne B, Buisson T, Nicolau P, Mimoun M. Abdominal dermolipectomies: early postoperative complications and long-term unfavorable results. Plast Reconstr Surg. 2000;106(7):1614–8; discussion 1619–23. 24. Rogliani M, Silvi E, Labardi L, Maggiulli F, Cervelli V. Obese and nonobese patients: complications of abdominoplasty. Ann Plast Surg. 2006;57(3):336–8. 25. Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. Plast Reconstr Surg. 2006;117(6):1797–808.

Circular Lipectomy with Lateral ­ Thigh–Buttock Lift

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Héctor J. Morales Gracia

25.1 Introduction Patients with body contour deformities are among the challenges that plastic surgeons most frequently face. These body contour deformities vary from patient to patient in number, intensity, and anatomical location depending on racial and genetic factors, and these are worsened with overweight and even more with obesity. These patients usually have tried different weightreduction methods, including diets, reductive massages, amphetamines, exercise, etc. Nevertheless, the majority do not succeed and they fall into a vicious cycle that only increases the problem. Those who succeed in losing weight end up with skin and soft tissue laxity that creates problems. Some of these patients believe that liposuction is magical, thinking that it will solve all their contour deformities. Therefore, it is vital that plastic surgeons inform their patients about the limitations of liposuction, the risks of a radical liposuction, and the need for an appropriate surgery. Most patients present a number of body contour deformities that cannot be corrected in one single surgical stage. Some will require three or more surgical stages. For these reasons, I decided to create a treatment program that combines several body contour techniques without increasing the surgical risk. With this program, it is possible to change the patient’s silhouette (body contour), helping them to recover their self-esteem and break the vicious obesity cycle [1].

H. J. Morales Gracia Belisario Domínguez 2501, Colonia Obispado, Monterrey, Nuevo León, CP 64060, México e-mail: [email protected]

The obesity and morbid obesity rate has increased all over the world in the last decade, and so has the bariatric surgery and consequently, the number of postbariatric or massive weight loss patients who successfully have lost weight and recurred (needed, asked for) to plastic surgery. Initially in post-bariatric plastic surgery, the procedures were merely paniculectomies, cutting out the skin excess, careless of the resultant scar placing, ignoring the body aesthetic units and symmetry, without improving body contouring and shaping and yet the patients were satisfied. There was no experience in this kind of patients, but later, different plastic surgeons started to create new procedures and sometimes modified preexistent procedures to improve them, observing all the principles of the aesthetic plastic surgery, placing the scars following the aesthetic units of the body, getting the best possible symmetry, shape, and volume to obtain a nice silhouette. The post-bariatric surgery patient is a much more difficult patient than the moderately overweight patient in order to get an aesthetic result. To perform the surgery, they must be weight stable; that can be achieved in approximately between 12 and 18 months after bariatric surgery. They must also be in good nutritional shape. When they come to the plastic surgeon, some of them have lost a lot of the fat tissue; in this case, the skin and subcutaneous tissue are very thin and the fixation mechanisms of the connective tissues to the muscular fascia have excessive laxity, which makes it easy to evaluate the amount of skin resection using the pinch manoeuvre, and easy to control bleeding, but without fat it is almost impossible to get a nice female body shape and in a couple of months, the tissues that were tightened get loose, the tissues lose elasticity and due to elasticity loss, have excessive laxity. That is why we often see cases of circular lipectomies in post-bariatric patients with bad located asymmetrical scars with a complete

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_25, © Springer-Verlag Berlin Heidelberg 2010

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lack of female silhouette, no volume at the gluteal area and some with residual skin excess in the abdomen. The asymmetrical and/or misplaced scars could be due to either bad planning or displacement of the scar because the fixation sutures did not hold the tissues that were extremely lax and weak and could be even worse if there is still residual weight on the legs or buttocks. That is why in this case, we must plan properly following the aesthetic units of the body and place as many fixation sutures as possible and we must team up with the bariatric surgeons and nutritional assistance staff to assure patient’s weight and nutritional stability prior to cosmetic surgery in order to succeed. One of the advantages of the stable post-bariatric patient is that the skin becomes very thin so they usually tend to form less conspicuous, almost invisible scars.

H. J. M. Gracia

25.2 Objectives with Circular Lipectomy There are several objectives that we seek to achieve with this Circular Lipectomy: 1. To lift, and to improve the shape, size, and skin texture of the gluteus, making them look round and youthful (Fig. 25.1). 2. To lift the lateral thigh, eliminating cellulite by tightening the skin (Fig. 25.2). 3. To eliminate redundant flank tissue (Fig. 25.3). 4. To lessen the amount and size of (and sometimes eliminate) the middle and lower back adipose cutaneous folds, therefore reducing waist size (Fig. 25.4).

Fig. 25.1  The lift corrects the ptosis and improves the shape, size, and skin texture of the gluteus, making then appear round and youthful

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Fig. 25.2  The lift improves the silhouette and eliminates cellulite by tightening the skin of the lateral thigh

5. To reduce the redundant skin and fat of the abdomen and to tighten the rectus abdominis and external oblique muscles when needed, thus improving the abdomen and waist shape (Fig. 25.5). 6. To break the vicious cycle of obesity. 7. To leave a single circular scar that can be hidden with a thong and that may be planned and placed according to the patient’s dressing habits and of course respecting the aesthetic units of the body (Fig. 25.6).

25.3 Indications This surgery is indicated in thin, normal, and little overweight patients with loose and redundant skin and subcutaneous tissue and even in patients with moderate obesity and obesity (Fig. 25.7). It can also be performed only to lift the buttocks to improve their size, shape and eliminate cellulite without doing the abdominoplasty (Fig. 25.8). The author frequently combines this surgery with breast surgery, either mastopexy or

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Fig. 25.3  Circular lipectomy eliminates redundant flank tissue

breast augmentation, but can also be combined with brachioplasty if needed. In postbariatric patients, numbering the areas to be corrected and making a surgical plan is mandatory in order to reduce the number of surgical stages within safety limits.

25.4 Pre-Operative Markings For pre-operative markings, the patient stands while the trochanteric area that needs liposuction is outlined. The supragluteal and lateral supragluteal areas (flanks) that will be resected are marked starting with the lower

marking line at the posterior midline, 3–5 cm above the intergluteal crease. A convex line lightly ascendant is traced until it reaches the gluteal midline and then extends caudally following the line of the inferior edge of the lateral supragluteal fat pad (love handles) until it reaches the upper edge of the lateral gluteal recess. The contralateral side is marked in the same way, forming a seagull–wing shape line (Fig. 25.9). The upper marking line is marked at the midline, 2 or 3 cm above the expected or desired suture line. It starts at the midline, usually 5–7 cm above the inferior edge of the resection with lightly ascending curved line extended laterally just over the lateral supragluteal fat deposit (flanks).

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Fig. 25.4  Circular lipectomy lessens the amount and size (sometimes eliminates) of the middle and lower back adipose cutaneous fonds

It is important to consider that the further an incision is from the midline, the more lax the subcutaneous tissue and its superficial fascia system are [2]. The expected suture line at the lateral aspect of the flanks will be located 5–7 cm below the upper limit of resection. Once both lines are marked, the vertical distance of midline is 5–7 cm and of the lateral aspect of the flanks is 14–25 cm (Fig. 25.9). The pinching maneuver on the flank facilitates marking on the thin patients [3]. The abdominoplasty is then marked conventionally. A horizontal line of 10–12 cm, located just above the pubic hairline, is traced, extended laterally, and following an ascending line parallel to the inguinal crease. The upper margin is a curved line with its upper end located above the umbilicus (at the lowest), depending on the case, and extended laterally until it meets the inferior margin line. The posterior and anterior marking lines are then joined in the most convenient way for each case.

25.5 Surgical Technique An intravenous line is set, and the anaesthesiologist administers light intravenous sedation with 50 mg/kg of mydazolam, 1 mg/kg of fentanest, 1 g of cephalotine

every 6 h, 50 mg of ranitidine every 12 h, and 5,000 U of subcutaneous heparin. The epidural catheter is introduced in a lateral decubitus position at the L2–3 level and in cases in which breast surgery will also be performed, a second epidural catheter is introduced at T6–7 level. A Foley catheter is set and the patient is made prone. The surgery starts with the trochanteric dry liposuction of the deep fat. If liposuction is not needed, the cannula is used to undermine and free the trochanteric area to facilitate the lift using a 4-mm cannula through a small, oblique 7 mm incision located at the inferior posterior edge of the trochanteric markings, being careful not to damage or compromise the integrity of the superficial fascia system and subcutaneous tissue of the upper edge of the lateral thigh flap because they are going to be used for closure. The resection of the supragluteal and lateral supragluteal tissue starts dividing (cut the flap in two) (Fig. 25.10) the flap at the posterior midline to facilitate the undermining and the resection, then the incision is made on or following the superior or upper marking line and then the incision of the lower or on the lower or inferior marking line is made both starting from medial to lateral. The whole thickness of the subcutaneous tissue is resected, exposing the fascia thoracolumbalis in the mid lower back

254 Fig. 25.5  The abdomen and waist shape are nicely improved

H. J. M. Gracia

25  Circular Lipectomy with Lateral ­Thigh–Buttock Lift Fig. 25.6  The Scar is placed at the limits of the body’s aesthetic units and can be hidden by a thong

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Fig. 25.7  Circular lipectomy in a 35-year-old obese patient who refused bariatric surgery has significantly improved buttocks and abdomen

area and laterally, the aponeurosis of the latissimus dorsi and external oblique muscles [4]. The caudal limit of the undermining is just to the level of the inferior line of the markings. Once the undermining and resection are completed, the lower flap is manually pulled up to confirm that the resection has been

adequate and to establish the vector of the lifting at several points and marking them the way we like it (Fig. 25.11). In moderately obese patients, it is difficult to establish, by using the pinch maneuver, the amount of tissue to be resected; a partial resection is made to facilitate the undermining and also to establish the

25  Circular Lipectomy with Lateral ­Thigh–Buttock Lift

Fig. 25.8  The size, shape, uneven aspects, and cellulite of the buttocks are totally corrected by the lift

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H. J. M. Gracia UPPER ANTERIOR AND POSTERIOR MARKING LINES

LOWER ANTERIOR AND POSTERIOR MARKING LINES

HORIZONTAL SUPRA PUBIC MARKING LINE

TROCHANTERIC AREA (SADDLE BAGS)

OBLIQUE PARANGUINAL ASCENDING MARKING LINE

LATERAL SUPRA GLUTEAL AREA OR FLANK (LOVE HANDLES)

RESULTANT SCAR

IDEAL SILHOUETTE LINE

UPPER MARKING LINE LOWER MARKING LINE

INTER GLUTEAL CREASE

GLUTEAL MIDLINE

LATERAL GLUTEAL RECESS

TROCHANTERIC LIPOSUCTION INCISION

Fig. 25.9  Pre-operative markings are done immediately before surgery with the patient standing

definitive level of the resection. In most patients, the tissue resection is greater than the initial marking because the flap displacement increases once the tissue is resected, facilitating an overlapping maneuver of the upper over the lower flap allowing a more precise, complementary resection. This is especially important at the flanks because an insufficient resection will not correct the cellulite or the contour deformities. When the resection is excessive, the wound closure will be difficult and the tension on the suture may result in dehiscence, or widening of the scar. Once the resection is completed, a combined maneuver is performed that shifts the upper and lower flaps to define and mark the traction axis of the lateral thigh and gluteal lift (Fig. 25.11). The gluteal flap is pulled up over the fascia thoracolumbalis, the aponeurosis of the latissimus dorsi, and external oblique muscles to mark traction and fixation suture line (Fig. 25.12). The wound closure starts with zero monofilament Prolene sutures, to fix mid line, taking enough subcutaneous tissue, with its superficial fascial system, at mid line on the inferior flap and then enough tissue of the aponeurosis of the fascia thoracolumbalis at the midline. As many of these sutures (every cm) as necessary are placed on each side following the traction-fixation suture line in order to pull up the flap

and reduce tension on the subcutaneous and sub dermal sutures, favouring better scar quality. A 2.5-mm external diameter perforated tube is placed as suction drainage. The subcutaneous tissue is sutured with zero Prolene, taking enough subcutaneous tissue, with its superficial fascia system, on both flaps and then taking some of the aponeurosis of the underlying muscles. Ten to twelve of these sutures are paced on each side. The subdermal layer is then closed with 3–0 Monocryl inverted sutures and there is no need for intradermal suture. The posterior suturing is finished leaving a dog ear on each side before moving the patient to the supine position (Fig. 25.13). The abdominoplasty begins with the skin resection as marked. The rectus abdominis muscle is plicated (Fig. 25.14) as is the external oblique muscle when needed. The wound is closed in two layers and suction drainages are left. At the end of the surgery, the patients wear a compressive girdle with shoulder straps to suspend the buttocks during ambulation. The patients spend one night at the clinic and receive autologous blood if needed [5, 6]. They start walking the next morning and are discharged at noon. They are examined on the sixth post-operative day when the drains and umbilicus stitches are removed. Examination is continued weekly for the first month, and then monthly for a year [1].

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Fig. 25.10  Cutting the supragluteal flap in two at the midline facilitates the undermining and resection

25.6 Complications Over the past 10 years, circular lipectomy has been performed with lateral thigh and buttock lift in over 100 patients. No major complications have occurred. All the patients had a fast recovery, beginning

ambulation the morning after the surgery, wearing the compressive girdle with gluteal suspension. Some patients indicated pain in the lumbar area, but it did not prevent them from walking. It was easier for the most obese patients to walk because of their decrease in weight and reduced circumference, due to the

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Fig. 25.12  Gluteal flap pull up maneuver over the fascia thoracolumbalis and muscles to mark traction and fixation suture line

Fig. 25.11  Overlapping maneuver allows a more precise complementary resection

elimination of excess skin and fat folds. Their heart rate and blood pressure decreased after surgery. The body contour deformities involved were corrected in all the patients, with very good aesthetic results. The average fat volume obtained by liposuction was 400 g.

The resected tissue weight varied from 1.3 to 15 kg with an average of 3.6 kg Twentynine patients had abdominal seroma. In ten patients, the seroma extended to the flank (or it was isolate formed at the flank and back) and six patients presented seroma leakage through the wound at the posterior midline. This problem was spontaneously corrected during the first 3–4 weeks. Seroma leakage through the wound has been prevented by placing thin suction drain tubes on the back. There were two cases of partial dehiscence, one was 7 cm-long and the other was 5 cm-long. One of the dehiscence cases was on the flank – site of maximum tension – and the other was in the supragluteal area. There were three cases of micro-dehiscence at the posterior midline,

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Fig. 25.13  Posterior suture end laterally leaving dogears

resulting from difficulty in suturing the tip of the upper flap and /or favoured by posterior seroma draining through. Therefore, the incision design was changed to eliminate the tip of the seagull-wing flap (Fig. 25.9) and place posterior drains. In the last 60 cases, there has been no complication other than few abdominal seroma. Excellent results were achieved on non-obese patients who had thin torsos, producing an ideal silhouette (Figs. 25.15 and 25.16). In the moderately obese patients, the correction was also very good, significantly improving the silhouette at the waist, the gluteus, and lateral thigh. The ideal silhouette was not obtained in patients with other body contour deformities that were left untreated, such as the internal thighs, the upper back, the trunk, and the arms. The resulting scar was located at the limits of the aesthetic units and could be covered by thongs and bikinis in most of the cases. In six patients, the scar could not be covered by  a thong, requiring normal underwear or bikinis,

Fig. 25.14  Rectus abdominis muscle plication significantly improves the abdominal silhouette

because of scar widening or asymmetry. Four patients presented unilateral widening of the scar at the flanks, caused by dehiscence in one case but in absence of skin dehiscence, in the remaining three cases (Fig.  25.17). In four patients, the scar was high, two presented asymmetry of the supragluteal scar. The wide scars at the flanks that were not preceded by dehiscence were probably due to technical failure because this area of maximum tension requires meticulous suturing. It is also possible that liposuction of the neighbouring area compromised the integrity of the superficial fascial system, producing subcutaneous dehiscence. I found that the scars were less conspicuous in non-obese patients than in obese patients. In all

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Fig. 25.15  Excellent results in non-obese patients with thin torso

the cases, the results were greater than patient’s expectations. During the first 2 months, the gluteal shape and projection on the lateral view is very poor and the buttocks look flat, but around the fourth month, the area becomes round and youthful (Fig. 25.18). The results were consistently good.

25.7 Discussion The circular lipectomy with lateral thigh and buttock lift is based on previous experiences of several

surgeons, [2, 3, 7–17]. The circular lipectomy of Gonzàlez Ulloa was designed to eliminate the redundant skin and fat tissues of the abdomen, flanks, and lower back, but it did not improve the lateral thighs and buttocks contour or lift them either. The resultant scar was higher than that left by the author’s procedure, requiring compensation triangles that left vertical scars. Liposuction [7, 13, 14], together with the body contour surgery techniques of Baroudi, advanced the treatment of body contour deformities [6, 10–12]. The different combinations proposed by Baroudi have similar incisions, but the posterior ones are lower and the ones of the abdomen are different [6]. Lockwood used

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Fig. 25.16  Ideal silhouette is obtained with circular lipectomy in mild overweight patients

incisions on the lower body lift that are similar to those we use, but lower and with different design and marking of the area of resection [17]. His results are outstanding but require several stages. Also, he does not perform this procedure on moderately obese patients. With the circular lipectomy, it is possible to achieve several objectives in one stage: 1. The gluteus is lifted and its size and shape is improved. 2. The lateral thigh is lifted, improving the contour and tightening the skin, eliminating cellulite.

3. The number and size of adipose cutaneous folds of the lower and middle back are decreased, improving the waist silhouette. 4. Redundant flank tissue is eliminated. 5. Excessive abdominal skin and fat are eliminated. 6. The rectus abdominis muscle is plicated, improving the waistline and abdominal silhouette. 7. The circumferences of the abdomen, waist, hips, and thighs are significantly decreased. 8. The only scar left can be placed according to the patient’s dressing habits and can be covered by a thong in most cases [1].

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Fig. 25.17  Scar widening at the flank in the absence of dehiscence

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c

b

a

c

Fig. 25.18  (a) Flat gluteal shape and projection at 1 month after surgery. (b) Three months after surgery with buttocks starting to appear better. (c) One year after surgery with round and youthful buttocks

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References   1. Baroudi R, Keppke EM, Tozzi-Neto F. Abdominoplasty. Plast Reconstr Surg. 1974;54(2):161–8.   2. Baroudi R. Body sculpturing. Clin Plast Surg. 1984; 11(3):419–43.   3. Baroudi R. Lipolysis combined with conventional Surgery. In: Hetter GP, editor. Lipolysis: the theory and practice of blunt suction lipectomy. Boston: Little Brown; 1984.   4. Baroudi R. Body contouring surgery. Clin Plast Surg. 1989; 16(21):263–77.   5. Gonzalez Ulloa M. Circular lipectomy with transposition of the umbilicus and aponeurolytic technique. Cirugìa 1959; 27:394–409.   6. González Ulloa M. Belt lipectomy. Br J Plast Surg. 1960; 13:179–86.   7. Illouz YG. Illouz`s technique of body contouring by liposis. Clin Plast Surg. 1984;11(3):409–17.   8. Illouz YG. Surgical remodeling of the silhouette by aspiration liposis or selective lipectomy. Aesthetic Plast Surg. 1985;9(1):7–21.

H. J. M. Gracia   9. Illouz YG, De Villers YT. Body sculpturing by lipoplasty. New York: Churchill Livingstone; 1989. 10. Couch N, Laks H, Pilon RN. Autotransfusion in three variations. Arch Surg. 1974;108(1):121–2. 11. Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg. 1988;82(2):299–304. 12. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991; 87(6):1009–18. 13. Lockwood TE. Transverse flank-thigh-buttock lift with superficial fascial suspension. Plast Reconstr Surg. 1991; 87(6):1019–27. 14. Lockwood T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6):1123–5. 15. Morales Gracia HJ. Circular lipectomy with lateral thighbuttock lift. Aesthetic Plast Surg. 2003;27(1):50–7. 16. Newman MM, Hamstra R, Block M. Use of banked autologous blood and elective surgery. J Am Med Assoc. 1971; 218(6):861–3. 17. Testut L, Jacobs O. Tratado de anatomía topográfica. Barcelona: Salvat Editores SA; 1952.

Prevention and Management of Abdominoplasty Complications

26

Melvin A. Shiffman

26.1 Introduction Complications following abdominoplasty can occur at any time with any patient despite adequate surgical technique and patient care. These problems may cause patient discomfort, delay recovery, require further surgery, or threaten the patient’s survival. The surgeon should be aware of the possible complications, their prevention, their timely diagnosis, and their treatment. The possible risks and complications must be discussed with the patient prior to surgery.

26.2 Complications 26.2.1 Asymmetry If care is not taken in the initial marking prior to surgery, asymmetry may result. The midline should be marked above the umbilicus and in the area of the pubis. If there is a very fatty abdominal wall, the midline at the level of the pubis can be located either by visualizing the anterior junction of the vulva or carefully spreading the pubic hair to find the direction of the hairs that diverge to each side at the midline. The transverse lower abdominal incision line should be marked preoperatively so that the distance from the midline is equal on each side. The height of the ends of the lateral extensions should be equidistant from some measurable point superiorly or inferiorly, such as the

M. A. Shiffman 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

anterior superior tubercle or the level of the top of the ilium. The amount of skin excised is determined by firm traction on the skin flap at an equidistant point on each side from the midline of the flap. This will prevent excessive tension on one side of the flap compared to the other. Care must be taken to center the umbilicus to prevent asymmetry involving the umbilicus. Excessive fat or skin can be surgically excised to correct asymmetry. Fat can also be liposuctioned in areas of excess.

26.2.2 Bleeding (Bruising, Hematoma, Exsanguination) The presence of bruising following any surgical procedure is accepted as a known consequence of the procedure [1–3]. When a swelling filled with blood appears in the abdominal wall shortly after surgery, the surgeon must make a decision as to careful observation or some form of drainage. When a hematoma first appears, the clot can be aspirated only with great difficulty. Over time (a few days), the fibrin precipitates and the remaining fluid can be more easily aspirated with a needle. If the hematoma is not aspirated, the serosanguinous fluid in the pocket will slowly become typical serous fluid and thus a pseudocyst. When the hematoma is increasing in size, surgery should be seriously considered to ligate the bleeder surgically by exploring the wound and emptying the clot. Mohammad [3] reported a 9% incidence of hematoma. Bleeding from the wound is easier to monitor than hidden bleeding. Compression dressings, bed rest, and ice packs sometimes will control the bleeding. If there

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is persistent bleeding, surgical exploration is essential. The wound is opened, any hematoma evacuated, and the bleeder(s) ligated or electrocoagulated. The wound may be closed with or without drainage but it is safer with catheter or penrose drainage. The presence of orthostatic hypotension should be a warning that there may be inadequate fluid replacement or excessive blood loss. Fluid should be replaced if the hypotensive episodes persist. If there is no prolonged response, then there is probably excessive blood loss even if there is no apparent bleeding from the wound or expanding hematoma. Immediate Hemoglobin (Hgb) and Hematocrit (HCT) should be obtained and if there is a significant drop from the preoperative studies, then replacement of fluids should be rapid with volume expanders such as Hespan or albumin. A 20% drop in Hgb or HCT is reason enough to consider blood replacement since these studies do not equilibrate for 24–48 h. Admission to a hospital emergency room may be necessary to monitor the patient over a period of time in order to determine if blood replacement is necessary.

26.2.3 Dehiscence Dehiscence following abdominoplasty usually occurs at the tightest point of the abdominal incision closure. This point is the center of the flap at the attachment in the region of the pubis. The area darkens and necrosis occurs followed by disruption of the closure, sometimes with the wound pulling apart. The tight closure elongates the vessels resulting in spasm and clotting of the vessels, which is followed by necrosis and disruption of the wound. Usually the wound does not pull far apart because the sutures lateral to the disrupted area hold the wound together [1, 4]. Other contributory causes include smoking, poorly controlled diabetes mellitus, underlying hematoma or seroma, and too much activity by the patient. Many surgeons close the wound tightly with the patient bent tilting the chest and legs toward each other. The surgeon then expects the patient to remain in that position for several weeks even while walking around. Compliance with these instructions is usually poor since it is virtually impossible to maintain this position for any length of time, especially if the patient has a history of back problems.

M. A. Shiffman

Treatment for dehiscence should be conservative allowing the wound to slowly slough the necrotic tissue and the wound should heal by secondary intention if the wound cannot be sutured closed because of excessive tension. The necrotic tissue can be debrided at appropriate intervals of time. Usually the scar will contract sufficiently to form a slightly widened scar that can be revised if necessary (if the patient is dissatisfied with the appearance).

26.2.4 Dog-Ears The closure of the transverse lower abdominal wound is started with a suture in the midline to properly position the new umbilicus. The wound should then be closed starting laterally on each side to give a flattened appearance to the most lateral regions of the wound. If there is excessive fatty tissue in the region where dog­ ears usually form, this tissue should be excised prior to the closure. Many times, small dogears will resolve within 3 months without treatment. When there are persistent dogears for more than 3 months, these can be excised under local anesthesia, usually in an elliptical form. Very large dogears and fullness in the area can be treated by liposuction as well as excision.

26.2.5 Edema, Persistent When edema is persistent, over 3 months, and does not respond to conservative measures such as compression, liposuction with tumescent solution should be considered. Too much liposuction may result in damage to the skin or indentations. Therefore, the liposuction should be conservative. At the same time, there should be a determination as to whether there is persistent edema or just too much residual fat.

26.2.6 Infection, Sepsis Wound infection is a known consequence of any clean surgery, occurring in 1% of patients in an outpatient or office surgical center and 3% in a hospital. It is not

26  Prevention and Management of Abdominoplasty Complications

unusual for slight erythema to occur around the sutures without actual significant infection. If significant wound erythema occurs while the patient is on antibiotics, the dosage may be increased or the antibiotic changed. The wound should be watched very carefully for progression of the infection that may require intravenous antibiotics that can be given as an outpatient of in the hospital. Infections not responding to antibiotics may require consultation with an infectious disease specialist and may indicate early necrotizing fasciitis or may evolve into toxic shock syndrome that can be fatal. Complete blood count (CBC) should be obtained as well as wound, where possible, and blood cultures [1]. Uncontrolled infection can be life threatening if sepsis occurs. This may be indicated by fever, elevated white count, and lethargy. Prompt treatment with appropriate intravenous antibiotics is essential.

26.2.7 Necrosis Necrosis is more likely to occur if the patient is a smoker, if concomitant abdominal liposuction is performed, or if there has been prior extensive liposuction to the abdominal wall. Smokers may say they will stop smoking but there are some who will continue to smoke despite all the admonitions. There is nothing that can be done if the patient does not stop smoking completely. The necrosis will progress to its fullest extent, not only in the lower abdomen, but also at times in the periumbilical area and upper abdomen [1, 2, 4]. Poorly controlled diabetes mellitus, very tight wound closure, underlying hematoma or seroma, and infection may contribute to the cause and extent of the necrosis. If the patient has a prior transverse upper abdominal scar (i.e., cholecystectomy, gastrectomy, splenectomy), the triangle formed by the scar, the midline, and the tightly pulled abdominal skin flap is susceptible to necrosis unless enough space is left between the old scar and the transverse closure line to allow vascularity to the triangle. It is helpful to place less tension on the flap closure so that stretching the vessels and thromboses are not added to the problem. Sometimes, the use of a different type of resection may be necessary to prevent necrosis. This usually means the addition of a vertical midline scar [5]. The best treatment is observation with debridement as needed and allowing the wound to heal by secondary

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intention. Placing skin grafts in a granulating abdominal wound will shorten the healing time but will not allow the wound to contract enough to decrease the extent of scarring. It is surprising how small the scar can be after complete healing and contraction even if the whole lower abdominal wall has been involved with necrosis. Scar revision is usually necessary for wide or irregular scars.

26.2.8 Necrotizing Fasciitis Necrotizing fasciitis is a result of infection from Streptococcus or mixed infection, frequently with anaerobic organisms. The infection results in thrombosis of the subcutaneous vessels, including vessels entering the fascia and underlying muscles. The tissues become necrotic and require debridement as well as proper antibiotics. Cultures of the tissues may reveal the offending organism(s). The wound should then be allowed to granulate and can be skin grafted when all the necrotic tissue has been removed and granulations are present.

26.2.9 Need for Further Surgery There are a variety of reasons for further surgery being necessary following abdominoplasty. These include asymmetry, irregularities, dogears, necrosis, inadequate skin resection, significant scar (hypertrophic or keloid), umbilical stenosis, or excessive fat requiring liposuction. If a patient has excessive fat prior to the abdominoplasty and the fat is not liposuctioned at the same procedure, the patient should be informed about the probable future need for liposuction before surgery.

26.2.10 Perforation of Intraabdominal Viscus It is possible to perforate the bowel when repairing an umbilical hernia or ventral hernia at the same time as performing the abdominoplasty by not opening the hernia sac to observe for attached bowel or placing the

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sutures superficially only in well-exposed fascia. Closing the midline fascia in a patient with a very loose abdominal wall may require sutures at the lateral edge of the rectus. This is an area consisting only of fascia and peritoneum millimeters in depth where suturing can readily perforate into the abdominal cavity. It might be more appropriate to consider lateral sutures in the external oblique aponeurosis first before central repair so that the central sutures may not need to be placed so far laterally. Any patient complaining of more postoperative abdominal pain than the usual patient or persistent severe pain should be observed very carefully and at appropriate short intervals of time to rule out perforation of a viscus. Abdominal X-ray series may be indicated and possibly, observation in the hospital. If a perforation is diagnosed, immediate surgical intervention is indicated. Preoperative antibiotics should be started. The abdomen should be carefully explored for possible multiple perforations and any observed bowel perforations should be closed after thorough irrigation of the abdominal cavity. Early intervention may prevent a severe infectious process.

M. A. Shiffman

26.2.13 Scarring (Widened, Thickened, Hypertrophic, Keloid) Wide scars are frequent following abdominoplasty because of the need for a tight closure to get a flat abdomen. When the skin loosens after 6 months, it is possible to resect the scar in order to make it thinner [2]. Certain individuals are prone to get ­hypertrophic scars although this is unpredictable. Hypertrophic scars may resolve without treatment. Keloid scars occur in 15% of blacks, Asiatics, and Hispanics. There are a variety of treatments available, usually used in combination. Recurrence of keloids is common.

26.2.14 Sensory Loss

Patients should be forewarned that weight gain after abdominoplasty could result in recurrent fatty abdomen with panniculus that might require another surgical procedure. Pregnancy after abdominoplasty is a risk for causing loose skin, stretching the muscles and the midline, and striae. This may result in the need for repeat abdominoplasty.

Loss of sensation in the abdominal wall is more common when liposuction is performed at the same time as abdominoplasty. This sensory change is usually temporary and resolves without treatment. Injury to the lateral femoral cutaneous nerve has been reported [1, 6]. This can result in permanent sensory loss along the anterior, lateral, and posterior thigh. It is possible to explore and reanastamose a transected nerve, if the nerve ends can be found and a large section of the nerve has not been removed. This type of surgery must be performed in a timely manner in order to have any success. Usually the sensory loss is not in areas that will interfere with normal activity and patients may become used to the sensory loss over a long period of time.

26.2.12 Recurrent Protrusion of Abdominal Wall

26.2.15 Seroma

Some patients have very lax abdominal wall muscles and there is a tendency for recurrent protrusion after a seemingly adequate fascial repair. This can be improved with repeat closure of the abdominal wall fascia in the midline with the combination of lateral wall (external oblique aponeurosis) tightening. This repair can also be performed for the patient who has recurrent protrusion from loosened or disrupted sutures.

The use of drains following abdominoplasty usually prevents the accumulation of blood but may not prevent seroma formation. The large flap with an empty space extending from xyphoid to pubis is readily filled with serous fluid with patient movement that results in the rubbing together of raw tissues. If there is a palpable fluid collection, this can be aspirated and compressed to allow the tissues to seal. If aspiration does

26.2.11 Recurrent Panniculus

26  Prevention and Management of Abdominoplasty Complications

not resolve the problem, injecting room air to fill the cavity after fluid aspiration will almost always result in sealing the cavity. Introduction of air may have to be repeated if there is a larger cavity. This method is less traumatic than excision of the pseudocyst [1–3, 7, 8].

26.2.16 Skin Overhanging Scar If enough skin is not resected in abdominoplasty or the transverse lower abdominal scar becomes adherent to the underlying fascia, there may be a visible overlap of the skin over the scar. This may require revision by resecting the excess skin and/or freeing up the skin scar attachment to the deeper tissue.

26.2.17 Thromboembolism Patients who undergo surgery are at risk for venous thromboembolic complications. This is especially critical in the cosmetic surgery patient who, having an elective procedure, would not expect to have the morbidity or mortality associated with thromboembolic disease. The cosmetic surgeon must be aware of the possibility of thromboembolism in every patient and should take a careful history to disclose predisposing risk factors. The surgeon should also be aware of the clinical manifestations of pulmonary embolus in order to make a timely diagnosis.

26.3 Risk Factors Minor surgery 30 min and patients under 40 years on oral contraceptives are in the moderate risk category [9]. High risk category would be major surgery in patients over 40 years of age with recent history of deep-vein thrombosis or pulmonary embolism, extensive pelvic of abdominal surgery for malignancy, and major orthopedic surgery of the lower extremities.

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Predisposing risk factors include age over 50 years, malignancy, obesity, prior history of thromboembolism, varicose veins, recent operative procedures, and thrombophilia. These risks are further modified by duration and type of anesthesia, preoperative and postoperative immobilization, level of hydration, and the presence of sepsis [10]. Medical problems associated with increased risk include acute myocardial infarction, stroke, and immobilization [11]. Estrogen therapy and pregnancy are common risk factors while uncommon factors include lupus anticoagulant, nephrotic syndrome, inflammatory bowel disease, polycythemia vera, persistent thrombocytosis, paroxysmal nocturnal hemoglobinuria, and inherited factors such as antithrombin III deficiency, protein C deficiency, protein S deficiency, plasminogen activator deficiency, elevated plasminogen activator inhibitor, and homocystinuria [12]. Superficial calf vein thrombosis, proximal deepvein thrombosis, and fatal pulmonary embolus increase in incidence as the risk category increases from low to high.

26.4 Clinical Manifestations Superficial thrombophlebitis (an inflamed vein) appears 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) and/or tenderness of the calf on palpation is 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 findings of pleural effusion or lung consolidation; and (3) sudden apprehension, chest discomfort, and dyspnea with findings of cor pulmonale and systemic hypotension. The symptoms occasionally consist of fever, arrhythmias, or refractory congestive heart failure.

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26.5 Diagnosis Deep-vein thrombosis is best diagnosed with duplex ultrasonography, which combines pulsed gated Doppler evaluation of blood flow with real-time ultrasound imaging. Other diagnostic tests include X-ray venography, radionucleide venography, radioisotope-labeled fibrinogen, ultrasonography, and impedance plethysmography. Liquid crystal thermography detects increases in skin temperature and is a useful adjunct to ultrasonography or impedance plethysmography. Ventilation–perfusion (VP scan) lung scan is a safe, sensitive means of diagnosing pulmonary embolism. Isotope pulmonary perfusion scan (Q scan) is more specific with inclusion of the isotope ventilation scan (V scan). The definitive diagnosis can be made by pulmonary arteriography but VP scan can give a high degree of certainty. Arterial blood gas typically shows reduction in PaO2 and PaCO2, while electrocardiogram will show tachycardia but is best used for ruling out myocardial infarction. Chest X-ray may show basilar atelectasis, infiltrates, pleural effusion, or cardiac dilatation.

26.6 Prophylactic Treatment Low-risk general surgical patients may be treated with graduated compression stockings applied during surgery, early ambulation, and adequate hydration [13]. Keeping the knees flexed on pillows during surgery and avoiding local compression on any areas of the legs are helpful. All patients are treated the same if there are any low risk factors. The type of surgery does not matter as long as general anesthesia or intravenous sedation is given. Compression stockings (20– 30  mm support hose is adequate) are applied in the operating room and ambulation is begun when the patient is awake and capable of ambulating with assistance. When the patient is ambulating on a regular basis during the day, the compression stockings can be removed. For moderate risk patients, low-dose heparin (5,000 units 2  h before surgery and then every 8–12  h until ambulatory), low molecular weight heparin (LMWH), dextran, or aspirin is recommended. Alternatively, graduated compression stockings or intermittent pneumatic compression started during surgery, used continuously

M. A. Shiffman

until ambulatory, or a combination of both is recommended [10]. All high risk patients should be treated with lowdose heparin or LMWH, and combined pharmacologic and mechanical methods. Dextran can result in cardiac overload and high dose aspirin (1,000–1,500  mg/day) has limited efficacy in preventing deep-vein thrombosis. In cosmetic surgery, the use of aspirin or heparin may result in postoperative bleeding. The best prophylaxis for low risk cosmetic surgery patients would appear to be mechanical methods, including knee compression stockings and early ambulation. For low risk patients, the knees should be slightly flexed and extremity compression avoided [14].

26.6.1 Hereditary Hypercoagulable States Patients with a family history of thrombosis, earlyonset or recurring thrombosis, thrombosis at unusual sites, or warfarin-induced skin necrosis should be evaluated for possible underlying inherited hypercoagulable disorders. Antithrombin III (AT-III) is a heparin cofactor that allows heparin to inactivate primarily factor IIa but also factors IXa, Xa, XIa, and XIIa [15]. A deficiency in AT-III predisposes to thrombosis by allowing uncontrolled activity of many of the coagulation factors. Endothelial surfaces have receptors called thrombomodulin that function as anticoagulants because of the ability to neutralize thrombin. The thrombin– thrombomodulin complex activates protein C, a vitamin K-dependent factor that is facilitated by protein S, another vitamin K-dependent factor. Activated proteins C and S metabolize activated factors V and VIII that results in downregulating the coagulation system. Patients with protein C deficiency may have recurrent episodes of superficial thrombophlebitis as well as thromboembolism [16]. Patients with protein S deficiency experience more arterial thromboembolism including stroke [17]. Deficiency in protein C or S may present as neonatal purpura fulminans in the newborn or skin necrosis in adults treated with warfarin, a drug known to cause a sudden fall in protein C or S. Venous thromboembolism occurs in one out of every thousand people with activated protein C resistance

26  Prevention and Management of Abdominoplasty Complications

(APC-R) responsible for up to 64% of the cases. APC-R is due to a single point mutation in the FV gene for clotting factor V. This mutated FV may be referred to as factor V Leiden (FVL), FV:Q506 allele, or APC-gene and is less efficiently degraded by APC. A hypercoagulable state results from impairment of the inactivation of factor V by activated protein C. This creates a lifelong increased risk of thrombosis and thromboembolism. Within the intact vessel, thrombin binds to thrombomodulin on the endothelial cell acting as an anticoagulant bay activating the protein C system. Activated protein C (APC), potentiated by cofactor protein S, downregulates the activity of the coagulation system (limits clot formation) by cleaving and inhibiting factors V (FV) and VIII [18–20]. APC testing can be performed with DNA genotyping. This can differentiate acquired from inherited APC-R. Approximately 10% of patients with APC-R phenotype lack the FV mutation (genotype) and the diagnosis of APC-R in these patients will be missed [21]. The combination of phenotype and genotype information aids in establishing prophylactic and therapeutic guidelines. Asymptomatic patients with APC-R who have never had a thromboembolic event, as well as their family members, should receive counseling regarding the implications of the diagnosis and information ­concerning the signs and symptoms of venous Thromboembolism [22]. Short-term prophylaxis with heparin should be considered when there are high risk circumstances encountered such as immobilization, surgery, trauma, or obstetrical procedures. After a thrombotic event, these patients need extended anticoagulation, balancing the risk of bleeding against the risk of recurrence when therapy is discontinued. Empirical treatment is for at least 1 year after two episodes of thromboembolism and life-long treatment after three episodes [23].

26.6.2 Toxic Shock Syndrome Toxic shock syndrome has been reported in breast augmentation [24–26]. The syndrome is caused by the exotoxins (superantigens) secreted with infection from Staphylococcus aureus and group A Streptococci [27]. Knowledge of the criteria for diagnosis is important in

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order to treat this potentially fatal disease. These include [27]: 1. Fever (>102°) 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 CPK) (c)  Mucous membrane (conjunctiva, oropharynx) (d)  Renal (BUN or creatinine >2 times normal) (e) Hepatic (bilirubin, SGOT, SGPT >2 times normal) (f)  Hematologic (platelets 1.5 cm) or amount of deflation in the massive weight loss patient determines the amount and the location of liposuction. The inner elbow should be evaluated as a

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separate sub-unit for liposuction; as should the axillary area and upper lateral thorax. This should be done with a pinch test to predetermine the exact area and relative volume of liposuction. In the massive weight loss patient, an upper extremity without full deflation would be ideal for this limited procedure as the amount of liposuction and skin excision can be tailored to the appearance of the entire arm, avoiding a skeletonized upper arm with large forearms. Skin quality and quantity should be evaluated. Skin quality in the nonmassive weight loss patient should be relatively normal with adequate tone and intact contractile properties. The massive weight loss patient may have stigmata of permanent skin damage with striae and thinning of the upper arm skin. In this circumstance, a limited procedure should be avoided, as early recurrence of the deformity would be predictable. Skin excess should be located in the proximal third of the upper arm, which is the focal point of the excisional area. The vertical limit of the excision is 3–5 cm from the axilla to the upper arm.

32.4 Markings Patients are marked in the upright position with the anterior and posterior limits of the axillary incision marked in the axillary skin crease with the arm at the side of the patient, as this is the position of the arm at repose. By limiting the incision to these points, the incision is hidden within the axilla. The arm is then abducted to 90° and the two points are connected in the axillary fold, delineating the final position of the scar and most medial incision. Using medial traction on the upper medial arm skin, the amount of skin excision is marked in an elliptical fashion. This usually measures 3–5 cm in vertical distance at the most central point. The areas of liposuction are marked within the medial arm, elbow, and axilla with the arm in the abducted position. The bicipital groove is marked as the most anterior point of arm liposuction. The medial elbow is marked separately, as this will be an area to be suctioned with standard liposuction. The axilla should be marked as a separate sub-unit to blend the upper arm and axilla to contour the bra strap area.

A. P. Trussler and R. J. Rohrich

32.5 Procedure The procedure is performed with the patient in the supine position under general anesthesia. The limited incision medial brachioplasty can be performed as a single procedure or combined with other contouring procedures. The arms are prepped into the operative field with the peripheral intravenous (IV) preferably, but not absolutely in the lower extremity, and the hands and forearms covered with a surgical stockinette. The arm is supported by an assistant while the areas for liposuction are infiltrated using a superwet technique with a solution of 1 L of lactated Ringers, 30 mL of 1% Lidocaine and 1 ampule of 1:1,000 epinephrine. The arm is accessed via a 1 cm radial incision in the elbow. A separate incision in the lateral chest may be required if axillary liposuction is to be performed. Approximately 200–500 mL of lipoaspirate is retrieved from the both the arm and axilla, depending on the amount of lipodystrophy present. Ultrasonic-assisted liposuction (UAL) is utilized in the arm and axilla using long radial strokes. The UAL settings are 50% in a nonpulsed mode. The middle fat layer is targeted with a ­3.7–4.6-mm liposuction cannula. The end point for UAL in all areas is time and decreased stroke resistance. UAL is then followed by standard liposuction using exaggerated long strokes to prevent contour deformities. Superficial standard liposuction is performed at the elbow with a 3.0–3.7-mm Lambros cannula. UAL is not recommended around the medial elbow secondary to the close proximity of the ulnar nerve. After completion of the liposuction portion of the procedure, an incision is made in the medial axillary skin fold previously marked in the patient. This is carried to the subcutaneous layer of the inner arm to preserve the underlying structures, including lymphatics and nerves. The liposuction plane will be visualized and the skin is undermined after the lateral incision is made and connected to form an elliptical area of resection. A deeper plane is excised posteriorly to aid in the final contour of the incision. The medial incision is undermined for 1 cm in the subcutaneous plane to assist the closure. After irrigation of the incision with antibiotic irrigation and confirmation of hemostasis, the closure is approximated,

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with staples anteriorly and posteriorly advancing any excess centrally. Pleating in the incision should be kept to a minimum. If pleating occurs, it may be addressed with a vertical wedge excision to remove the excess redundancy. The closure is performed in a layered fashion with 3–0 Vicryl® suture (Ethicon, Inc. Somerville, NJ) interrupted sutures in the deep dermis, 4–0 PDS® suture (Ethicon, Inc. Somerville, NJ) running subcuticular suture, and the skin reapproximated and dressed with Dermabond® (Ethicon, Inc. Somerville, NJ). The liposuction ports are closed with a single 5–0 fast-absorbing suture. No drains are used in this procedure.

32.6 Postoperative Care The limited incision medial brachioplasty can be performed as an isolated procedure or combined with other body contouring procedures. It can be performed as an outpatient procedure, but should be performed in an approved, accredited operating room environment. Antibiotics are administered perioperatively and continued for 3 days postoperatively. The patient is placed in a long arm surgical garment after the operation. This provides compression to the areas of liposuction; which is maintained for 3 weeks. Topifoam® (Lysonix, Inc. Carpenteria, CA) is placed under the garment onto the areas of liposuction and is maintained for 48 h. The patient may shower 2 days after the procedure when the Topifoam® (Lysonix, Inc. Carpenteria, CA) is removed. The use of Dermabond® (Ethicon, Inc. Somerville, NJ) reduces the amount of wound drainage and enables early showering. Patient activity is not limited after surgery with early ambulation encouraged, though abduction of the arms is limited to less than 90° for 3 weeks postoperatively.

32.7 Modifications A vertical dart may be incorporated into the limited incision medial brachioplasty if the area of excess

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includes focal horizontal excess combined with vertical excess. This maneuver refines the outcome as it may eliminate central pleating in the incision, though it adds a “T” incision to the procedure. A “pursestring” closure has been described to eliminate the “T” incision [9]. This converts the crescent excision pattern to that of an oval. The redundancy and pleating though may be excessive and revision procedures may be necessary to smooth the contour of the scar. The areas of liposuction may be modified to address the focal areas of lipodystrophy within the sub-units of the upper-extremity: elbow, upper arm, and axilla/ lateral chest wall.

32.8 Complications The complication rate in the limited incision medial brachioplasty is decreased secondary to the short incision and superficial excision plane. Wound infections and small areas of incision dehiscence are the most common complications. These are usually treated conservatively with oral antibiotics and local wound care; and do not necessitate reoperation. Lymphoceles have rarely occurred postoperatively and usually can be opened, marsupialized, and packed with gauze in the office setting. These usually resolve shortly after opening the cavity. Nerve injury, hypertrophic scarring, major wound complications and lymphedema have not been observed with this procedure.

32.9 Conclusions The limited incision medial brachioplasty can be applied to a diverse, select patient population with excellent results and limited morbidity (Figs. 32.1 and 32.2). This procedure is a continuum of the current refinements in upper extremity contouring surgery, and highlights the importance of careful preoperative analysis and categorization, with safe, reliable surgical procedures.

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A. P. Trussler and R. J. Rohrich

Fig. 32.1  Left: Preoperative 45-year-old female with diffuse upper arm lipodystrophy, limited skin excess, and excellent fascial support. Right: One year postoperative after UAL of the upper arm with a limited incision brachioplasty

Fig. 32.2  Left: 38-year-old with diffuse though limited upper arm lipodystrophy with moderate skin excess and moderate fascial support. Right: One year postoperative after UAL of the upper arm with a limited incision brachioplasty

32  Limited Incision Medial Brachioplasty

References   1. Trussler AP, Rohrich RJ. Limited incision medial brachioplasty: technical refinements in upper arm contouring. Plast Reconstr Surg. 2008;121(1):305–7.   2. Correa-Iturraspe M, Fernandez JC. Dermolipectomia braquial. Prensa Med Argent. 1954;41(34):2432–6.   3. Pollock WJ, Virnelli FR, Ryan RF. Axillary hidradenitis suppurativa: a simple and effective surgical technique. Plast Reconstr Surg. 1972;49(1):22–7.   4. Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006; 118(1): 237–46.

325   5. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):545.   6. Pinto E, Erazo PJ, Matsuda CA, Regazzini DV, Burgos DS, Acosta HAP, do Amaral AG. Brachioplasty technique with the use of molds. Plast Reconstr Surg. 2000;105(5):1854.   7. Knoetgen J III, Moran SL. Long-term outcomes and ­complications associated with brachioplasty: a retrospective and cadaveric study. Plast Reconstr Surg. 2006;117(7): 2219–23.   8. Pascal JF, Le Louarn C. Brachioplasty. Aesthetic Plast Surg. 2005;29(5):423–9.   9. Reed LS, Hyman JB. Minimal incision brachioplasty: refining transaxillary arm rejuvenation. Aesthet Surg J. 2007; 27(4):443–1.

Augmentation Brachioplasty with Cohesive Silicone Gel Implants

33

Gal Moreira Dini and Lydia Massako Ferreria

33.1 Introduction Acquired and congenital body contour deformities may lead to low self-esteem and negative self-image. The use of fat transplants harvested from the abdomen and buttocks became a common practice among surgeons after the work of Lexer [1] was published. However, complications such as high reabsorption rate of fat, chronic drainage, calcification, and presence of a visible scar at the donor site had discouraged its use. The use of alloplastic materials in the repair of body contour deformities has been the subject of research for centuries. Different substances have been injected percutaneously such as paraffin, and more recently, in the beginning of the 1960s, liquid silicone. Complications resulting from the use of paraffin and silicone include the presence of nodules and embolism. Prosthesis implantation was the next step in the evolution of methods. The first authors to describe a prosthesis implantation technique for breast augmentation were Cronin and Gerow [2]. Various types of prostheses have been devised since that time [3–6]. Presently, implants of various shapes and sizes, and of different outer shell and filler materials are available in the market. There are smooth and textured silicone shell prostheses, polyurethane-coated implants, and double- or triple-lumen implants. With regard to the filler material, there are implants filled with saline solution, natural oils, and silicone gel. In the 1980s, there was an intense debate about the eventual association between the risk of systemic

G. M. Dini (*) Department of Plastic Surgery, Universidade Federale de São Paulo, Escola Paulista de Medicina, São Paulo, Brazil e-mail: [email protected]

diseases, such as cancer and autoimmune diseases, and silicone implants. The lack of scientific evidence on the safety of these implants raised concerns among the general public, resulting in a large number of lawsuits. Later, several studies have proved the absence of risks associated with implants [7–9] other than those normally involved in any surgical procedure. Capsule contracture is the most common complication related to silicone implants. The literature shows that there is a decreased incidence of capsule contracture when the implant is protected by muscles, probably because of the constant massaging action of the muscle on the implant [10]. The search for a better body contour has motivated persons to exercise regularly to increase muscle mass in the arms and legs. In a study performed by the author on ten adult female cadavers, in the Division of Anatomy at the Federal University of São Paulo (UNIFESP-EPM), Brazil (unpublished data), it was verified that the average size of the short head of the biceps was 20 cm in length, 3 cm in width, and 1.7 cm in height. Based on these measurements, an implant consisting of a silicone elastomer envelope filled with silicone gel (similar to that used in breast prostheses) was designed to enhance the appearance of the biceps muscle.

33.2 Surgical Technique The procedure is performed under local anesthesia (axillary brachial plexus block) and sedation (midazolam). Both arms are extended at 90° to the trunk and maintained in this position during the entire surgical procedure. The outline of the biceps muscle is traced on the skin. A 3-cm incision is made through the skin and subcutaneous tissue in the axilla, exposing the fascia of

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the biceps brachii muscle. The fascia is opened (Figs. 33.1 and 33.2), and a tunnel is created into the short head of the biceps muscle (Fig. 33.3) with a Langenbeck

retractor. Hemostasis is verified using a 4-mm rigid endoscope (Fig. 33.4) and the silicone implant is inserted (Fig. 33.5). The aponeurosis is closed with a

Fig. 33.1  Visualization of the fascia of the biceps brachii muscle

Fig. 33.4  Verification of hemostasis using a video endoscope

Fig. 33.2  Opening of fascia of the biceps brachii muscle

Fig. 33.3  Evulsion of the short head of the biceps muscle

Fig. 33.5  Insertion of the silicone implant

Fig. 33.6  Wound closure

33  Augmentation Brachioplasty with Cohesive Silicone Gel Implants

2–0 absorbable suture, and the skin with a 4–0 absorbable suture (Fig. 33.6). At this point, liposuction of the posterior arm is performed. A small amount of skin may be resected for a better aesthetic result.

33.3 Discussion The anatomy of this region favors the surgical approach since there are no vascular or nerve structures in the incision or dissection path nor under or over the muscle that may be damaged by the compression exerted by the implant. This technique may be used in selected cases of hypoplasia of the biceps brachii muscle, either associated or not associated with a low degree of flaccidity of the posterior upper arm [11]. The volume

increase in the anterior upper arm stretches the skin of the posterior upper arm (Figs. 33.7–33.8). The use of instruments for image enhancement that offer a direct visualization of the detached planes allows precise dissection and safe hemostasis [12, 13]. The elastic property of the fascia covering the muscle allows easy placement of the implant. Standard implants are fusiform in shape since asymmetrical implants that were tried first had a tendency to roll laterally. No postoperative complications, such as edema of the forearm and relevant pain, have been reported. Patients are able to return to their normal activities in less than a week. Patients who underwent this surgical procedure reported improvement in quality of life when assessed with appropriate tools (Rosenberg’s self-esteem scale/ UNIFESP-EPM and Short Form-36 health survey questionnaire (Brazilian versions)) [14]. Improvements in

a

b

Fig. 33.7  (a) Preoperative. (b) Postoperative

a

Fig. 33.8  (a) Preoperative. (b) Postoperative

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b

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self-esteem, vitality, role emotional, social functioning, and mental health have been observed after treatment.

33.4 Conclusions This technique can be an important addition to the therapeutic arsenal of the plastic surgeon.

References   1. Lexer E. Freie Fettransplantation. Dtsch Wochenschr. 1910;36:640.   2. Cronin T, Gerow F. Augmentation mammaplasty-a new “natural feel” prosthesis. In: Transactions of the Third International Congress of Plastic Surgeons. Amsterdam: Excerpta Medica; 1964. p. 41–9.   3. Bartels RJ, O’Malley JE, Douglas WM, Wilson RG. An unusual use of the Cronin breast prosthesis. Case report. Plast Recosntr Surg. 1969;44(5):500.   4. Glicenstein J. “Advantages” and inconveniences. Apropos of breast implants. Ann Chir Plast Esthet. 1992;37(4):353–5.   5. Montellano L. Calf augmentation. Ann Plast Surg. 1991; 27(5):429–38.

G. M. Dini and L. M. Ferreria   6. Vergara R, Marcos M. Intramuscular gluteal implants. Aesthetic Plast Surg. 1996;20(3):259–62.   7. Berner I, Gaubitz M, Jackisch C, Pfeiderer B. Comparative examination of complaints of patients with breast cancer with and without silicone implants. Eur J Obstet Gynecol Reprod Biol. 2002;102(1):61–6.   8. Brown SL, Duggirala HJ, Pennello G. An association of silicone-gel breast implant rupture and fibromyalgia. Curr Rheumatol Rep. 2002;4(4):193–298.   9. Cash TF, Duel LA, Perkins LL. Women’s paychosocial outcomes of breast augmentation with silicone gel-filled implants: a 2-year prospective study. Plast Recosntr Surg. 2002;109(6):2112–21. 10. Lemperle G, Kostka K. Calf augmentation with new solid silicone implants. Aesthetic Plast Surg. 1993;17(3): 233–7. 11. Dini GM, Ferreria LM. Augmentation brachioplasty. Plast Reconstr Surg. 2006;117(6):2109–11. 12. Beer GM, Kompatscher P. Endoscopic plastic surgery: the endoscopic evaluation of implants after breast augmentation. Aesthetic Plast Surg. 1995;19(4):353–9. 13. Price CI, Eaves FF III, Nahai F, Jones G, Bostwick J III. Endoscopic transaxillary supbectoral breast augmentation. Plast Reconstr Surg. 1994;94(5):612–9. 14. Ciconelli RM, Soarez PC, Kowalski CC, Ferraz MB. The Brazilian Portuguese version of the Work Productivity and Activity impairmentL General Health (WPAI-GH) Questionaire. Sao Paulo Med J. 2006;124(6):325–32.

Long-Term Outcomes and Complications After Brachioplasty

34

James Knoetgen III

34.1 Introduction

34.2 Technique

Brachioplasty has traditionally been an unpopular procedure in plastic surgery because of the poor scarring and complications. Because of the increased popularity of bariatric surgery in recent years, plastic surgeons are caring for more massive weight loss patients, and as a result, upper arm contouring has become increasingly popular. Brachioplasty is an upper arm contouring procedure which includes skin excision from the upper arm and was first described 75 years ago [1]. Since that description, there have been a large number of technique papers in the plastic surgery literature [2–18]. American Society of Plastic Surgery (ASPS) data reveal that the popularity of brachioplasty has increased dramatically in recent years. There was a 4,059% increase in the number of brachioplasties performed between 2000 and 2008 [19]. A variety of procedures have been described to treat the upper arms, covering the spectrum from liposuction to large upper arm skin excisions which extend onto the lateral torso. Traditional brachioplasty results in a long longitudinal scar extending from the axilla to the elbow. This scarring is typically displeasing, which limited the popularity of this procedure and encouraged the use of upper arm liposuction and the development of limited incision or mini-brachioplasty techniques. The introduction of upper arm pathology classification systems has significantly helped the plastic surgeon in selecting the appropriate procedure for the patient with upper arm contouring needs.

Prior to choosing the appropriate brachioplasty procedure for the patient, the plastic surgeon must first accurately classify the type and degree of upper arm pathology. While there have been many advances and evolutions in brachioplasty surgical technique, perhaps the most significant contribution to brachioplasty surgery in recent years has been the development of upper arm classification systems [20, 21]. Appelt et al. [20] classify upper arm pathology by the amount of excess skin and fat, and location of skin excess. Their classification system can be summarized as follows:

J. Knoetgen III Private Practice, 20296, Bakersfield, CA, 93390-0296, USA e-mail: [email protected]

Type I: excess upper arm fat with good skin tone Type II: moderate skin laxity with minimal excess fat Type II A: proximal upper arm skin redundancy only Type II B: skin redundancy of entire upper arm Type II C: skin redundancy extends onto lateral chest wall Type III: lipodystrophy and redundant skin of the arm The authors proposed a treatment algorithm for determining the best procedure for each type of upper arm pathology. Regardless of which classification system is used, it is important for the plastic surgeon to determine the amount of lipodystrophy of the upper arm, the amount and location of excess skin, and the quality of the skin before planning surgery. Liposuction alone can be successful in patients with upper arm lipodystrophy, minimal or no redundant skin, and good skin quality. Many surgeons advocate ultrasound-assisted liposuction to improve skin retraction [22]. Arms with mild-to-moderate skin excess and lipodystrophy may respond to a limited incision or mini-brachioplasty technique with or without the use

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of adjuvant liposuction. Patients with significant skin excess and/or poor skin quality require a full brachioplasty. If skin excess extends onto the trunk, as is often seen in the massive weight loss patient, an extended brachioplasty is often required. Complication and revision rates are included in the preoperative discussions with brachioplasty patients when informed consent is obtained. The risks, benefits, alternatives, hopeful outcomes, and potential complications of brachioplasty are thoroughly explained in detail prior to surgery. As with all plastic surgery techniques, proper patient selection is vital. The plastic surgeon must establish that the patient has realistic expectations, and expected outcomes should be explained to the patient in detail. The standard brachioplasty technique focuses on the removal of skin and subcutaneous fat from the upper medial arm. While the details of brachioplasty techniques vary among surgeons, the majority of surgeons attempt to place the scar in the brachial sulcus. It is thought that this location will best hide the brachioplasty scar, which is often lengthy and unattractive, especially in the massive weight loss patient. Some surgeons have suggested placing the incision in a more posterior location [16, 17]. The resultant scar may be less visible. Markings are performed with the patient upright, elbow flexed at 90°, and the shoulder abducted at 90°. The bicipital groove is marked, and the planned skin excision is marked around the bicipital groove. For a full brachioplasty, the skin excision generally extends from the axilla to the elbow. If skin laxity extends into the axilla or onto the trunk, excision can be extended to these areas. It is always safer to underresect skin rather than overresect, and several techniques are helpful in accomplishing this. The intraoperative use of Pitanguy forceps is very helpful in making decisions about the amount of skin to be resected. Alternatively, as the surgeon elevates the flap of upper arm skin to be resected, the flap can be divided in several places with interval incisions to ensure an appropriate amount of skin resection. It is advisable to approximate wound edges immediately after skin resection with surgical staples or towel clips to facilitate wound closure. It is prudent to interrupt a scar that crosses the axilla with a Z or W plasty to prevent a contracture. Skin excision rarely extends past the elbow. Liposuction is sometimes combined with the skin excision, and when performed, should be limited to superficial and medium-depth fat. Likewise, it is imperative to keep surgical dissection

J. Knoetgen III

superficial to avoid injury to deeper structures. Injury to the medial antebrachial cutaneous nerve (MACN) was reported in 5% in one series [23] and can result in long-term paresthesia. The superficial fascia of the arm is then sutured to the clavipectoral fascia. The wound is closed in layers with absorbable suture over a closedsuction drain. Sterile dressings and a compressive wrap are applied. A variety of limited incision or mini-brachioplasties have been described [18, 22]. Trussler and Rohrich describe a technique for patients with moderate amounts of proximal third upper arm skin excess and moderate upper extremity and axillary lipodystrophy. The authors emphasize the importance of systematic preoperative evaluation and categorization of the deformity before planning the procedure. A vertical scar is placed in the axillary sulcus and debulking of the arm is performed with ultrasound-assisted liposuction. While limited incision brachioplasties cannot replace the standard brachioplasty, if performed in the right patient population, it can minimize patient morbidity and recovery. Postoperatively, compressive garments or wraps are helpful in treating edema and ecchymosis. Careful postoperative care is important to assess for seromas, hematomas, nerve injury, poor scarring, and other complications.

34.3 Complications Complications cited in the literature include poor ­scarring, edema, wound infection or suture abscess, lymphocele, wound dehiscence, distal seroma, under resection, and paresthesias/dysesthesias secondary to nerve injury. Despite these reports, there are few peer reviewed long-term brachioplasty outcome studies, so complications and complication rates are poorly understood. Gusenoff et al. [24] reported a prospective study of 101 patients who underwent brachioplasty. All patients were massive weight loss patients and 96% had concomitant body contouring procedures. They report a brachioplasty complication rate of 36% and a total revision rate of 4%. Arm liposuction, in addition to brachioplasty, was noted to increase complications. Knoetgen and Moran [23] reported a retrospective review of 40 patients and a cadaveric study of brachioplasty anatomy. Seventy six percent were massive

34  Long-Term Outcomes and Complications After Brachioplasty

weight loss patients. The overall complication rate was 25%. Complications noted were seroma (10% of  patients), hypertrophic scarring (10%), cellulitis (7.5%), wound dehiscence (7.5%), subcutaneous abscess (2.5%), and nerve injury (5%). Patients with nerve injury had symptoms which persisted beyond 1 year. Surgical revisions were performed in 12.5% of patients, and included skin resections as well as liposuction alone. A cadaveric study was performed to study upper arm anatomy in relation to the typical brachioplasty excision, particularly the course of the nerves. The courses of the MACN and the medial brachial cutaneous nerve (MBCN) were studied. The MACN and MBCN were present in all ten cadaver specimens. The course of the MACN was variable after exiting the deep fascia, but tended to run in close proximity to the intramuscular septum (Fig. 34.1). The average distance at which the nerve penetrated the deep fascia was variable, but averaged 15 cm proximal to the medial epicondyle (range 8–21 cm). The nerve did divide into an anterior and posterior branch after exiting the deep fascia. The posterior branch consistently terminated in branches at the level of the medial epicondyle, while the anterior branch coursed more distal to supply portions of the anterior proximal forearm. The nerve did not consistently run with the basilic vein, and in three specimens, the nerve was found greater than 5 cm anterior to the basilic vein within the mid arm. Anatomic dissections noted that the MACN becomes a superficial structure at an average distance of 15 cm proximal to the medial epicondyle, and is therefore, at risk of injury during brachioplasty surgery. At the point

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Fig. 34.2  The MACN, adjacent to the basilic vein, travels superficial to the deep brachial fascia of the upper arm where it is at risk of injury during brachioplasty

where the MACN exited the deep fascia, it was considered a superficial structure, and thus, at risk during brachioplasty procedures when the superior skin incision is placed near the intermuscular septum (Fig. 34.2). The MBCN consistently ran posterior to the basilic vein and was encountered during the inferior portion of the skin resection in all cadavers. The nerve passed medial and posterior to the ulnar nerve at the mid portion of the forearm giving terminal braches at the level of the medial epicondyle. This structure would be at risk in incisions centered more posterior to the medial intermuscular septum. The important conclusion from this study is that both nerves run superficial to the deep fascia, which strongly supports the assertion that brachioplasty dissections should be performed as superficially as possible.

34.4 Discussion

Fig. 34.1  Medial upper arm. Forceps point to the medial antebrachial cutaneous nerve (MACN) as it pierces the deep brachial fascia to become a superficial structure in the upper arm

The frequency of brachioplasty procedures continues to rise. However, despite this increase, there are few studies which have attempted to examine the complication rates associated with this procedure. Previous reports in the literature have sited complications such as poor scarring, edema, wound infection or suture abscess, lymphocele, wound dehiscence, distal seroma, and under resection. Because of the historical unpopularity of brachioplasty, some authors have suggested liposuction of the upper extremity alone as an alternative to brachioplasty [25]. This technique can be effective in patients with minimal or no excess skin and

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with good skin quality. Others have suggested that the use of short scar or mini-brachioplasty to minimize scarring; suggesting the incidence of hypertrophic or unsightly scarring is high in this patient population. Patients with lipodystrophy and moderate skin excess may benefit from a combination of liposuction and a limited incision brachioplasty. While brachioplasty techniques vary among surgeons, several basic tenets should be followed to minimize complications while maximizing aesthetic results. These tenets include: (1) Careful preoperative classification of upper arm pathology and an algorithmic approach to surgical planning, (2) appropriate, yet conservative, skin resection with the intraoperative use of Pitanguy forceps or other technique to control the degree of skin resection, (3) judicious use of liposuction when combined with brachioplasty and perhaps the use of ultrasound-assisted liposuction to improve skin retraction, (4) the use of a z-plasty when crossing the axilla, (5) superficial dissection and liposuction to avoid injury to deep structures such as nerves, (6) suturing of the superficial fascia to the clavipectoral fascia and a layered wound closure over closed-suction drains, and (7) light compressive dressings postoperatively for at least 7 days. To improve scarring, treatment with early silicone gel sheeting in patients with a history of poor scaring or at the first sign of hypertrophic scarring or keloid is helpful. Perhaps the most distressing complication associated with brachioplasty is nerve injury. Injury to the MACN has been reported most frequently in relation to cubital tunnel surgery, where the nerve is often injured as the terminal branches pass anterior to the medial epicondyle. Injury to the nerve in this location may lead to the development of painful neuromas [26, 27]. The anatomy of the MACN has been described in several papers [26–29]. The MACN arises from the brachial plexus, emerges from the axilla, travels medial to the brachial artery, and lies adjacent to the basilic vein, but its course with the basilic vein is variable. The nerve pierces the deep fascia to become subcutaneous in the distal or midbrachium. The nerve then divides into an anterior and posterior branch at an average distance of 14.5 cm from the medial epicondyle. However, no specific anatomic landmark has been consistently attributed to the location at which the nerve pierces the deep fascia to become a superficial structure. Therefore, the MACN is consistently present in the deep plane of dissection for the standard brachioplasty

J. Knoetgen III

technique. Thus, it may be potentially injured during skin and fat resection. If injured, the patient is at risk of developing dysesthesia, and possibly a complex regional pain syndrome. While injury to other major structures (i.e., ulnar, median nerves) has not been reported in the literature, complications such as these are theoretically possible during brachioplasty. These structures are deep upper arm structures that exist beneath the brachial fascia, and if a brachioplasty technique penetrates the deep fascia, especially in the area of the intermuscular septum, injury to median and ulnar nerves is a possibility. The posterior brachioplasty approach could still potentially injure one of the posterior crossing branches of the MACN. Subcutaneous crossing branches of the posterior branch of the MACN near the elbow have been described by Lowe et al. [27]. Injury to the posterior branch can result in a painful neuroma and paresthesia of the elbow pad. In addition, with more posterior dissections, surgeons must be aware of the course of the MBCN running posterior to the ulnar nerve and basilic vein. Regardless of which brachioplasty technique a surgeon chooses, the course of the MACN should be understood and considered during design of the skin resection. It is advisable to preserve a cuff of at least 1 cm of fat on the deep (brachial) fascia of the upper arm to help prevent the possibility of nerve injury during dissection. This technique would also prevent injury to deeper structures, such as the median and ulnar nerves.

34.5 Conclusions Upper arm contouring has evolved from one surgical procedure to a variety of procedures which can treat a wide variety of upper arm pathologies. Brachioplasty has become increasingly popular, especially in the massive weight loss population. Accurate preoperative evaluation is imperative before establishing a surgical plan. Informed consent, emphasizing potential complications and revisions, must be discussed with patients preoperatively. Surgical procedures should be based on the patient’s specific anatomic abnormality. While arms with lipodystrophy, minimal excess skin, and good skin quality can be treated with liposuction alone, patients with significant amounts of excess skin and

34  Long-Term Outcomes and Complications After Brachioplasty

poor quality skin require skin excisions which may extend onto the torso. Regardless of which surgical technique is used, dissections should be superficial to avoid injury to deeper structures such as nerves and lymphatics. While brachioplasty can be performed with a low incidence of major complications, patient and surgeon should be aware of the possible risks associated with this procedure. Excellent aesthetic results and minimal morbidity can be accomplished with careful preoperative analysis and safe procedures.

References   1. Thorek M. Esthetic surgery of pendulous breast, abdomen and arms in the female. Ill Med J. 1930;58:48.   2. Correa-Iturraspe M, Fernandez JC. Dermolipectomia braquial. Prensa Med Argent. 1954;41(34):2432–6.   3. Lewis JR. Atlas of aesthetic surgery. Boston: Little Brown; 1973.   4. McCraw LH Jr. Surgical rehabilitation after massive weight reduction: case report. Plast Reconstr Surg. 1974;53(3): 349–52.   5. Baroudi R. Dermatolipectomy of the upper arm. Clin Plast Surg. 1975;2(4):485.   6. Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect and inner side of the arm and elbow dermosenescence. Clin Plast Surg. 1975;2(3):477–83.   7. Guerrerosantos J. Brachioplasty. Aesthetic Plast Surg. 1979; 3:1.   8. Juri J, Juri C, Elias JC. Arm dermoplipectomy with a quadrangular flap and T closure. Plast Reconstr Surg. 1979; 64(4):521–5.   9. Borges AF. W-plastic dermolipectomy to correct bat-wing deformity. Ann Plast Surg. 1982;9(6):498–501. 10. Regnault P. Brachioplasty, axilloplasty, and pre-axilloplasty. Aesthetic Plast Surg. 1983;7(1):31–6. 11. Goddio AS. A new technique for brachioplasty. Plast Reconstr Surg. 1989;84(1):85–91. 12. Vogt PA, Baroudi R. Mastery of plastic and reconstructive surgery. Boston: Little Brown; 1994.

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13. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(4):912–20. 14. de Souza Pinto EB, Erazo PJ, Matsuda CA, Regazzini DV, Burgos DS, Acosta HA, do Amaral AG. Brachioplasty technique with the use of molds. Plast Reconstr Surg. 2000; 105(5):1854–60. 15. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):545–51. 16. Strauch B, Greenspun D, Levine J, Baum T. A technique of brachioplasty. Plast Reconstr Surg. 2004;113(3):1044–8. 17. Aly A, Soliman S, Cram A. Brachioplasty in the massive weight loss patient. Clin Plast Surg. 2008;35(1):141–7. 18. Abramson DL. Minibrachioplasty: minimizing scars while maximizing results. Plast Reconstr Surg. 2004;114(6):1631–4. 19. http://www.plasticsurgery.org/Media/stats/2008-cosmeticreconstructive-plastic-surgery-minimally-invasive-statistics. pdf. Accessed 1 Feb 2009. 20. Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006; 118(1):237–46. 21. El Khatib HA. Classification of brachial ptosis: strategy for treatment. Plast Reconstr Surg. 2007;119(4):1337–42. 22. Trussler AP, Rohrich RJ. Limited incision medical brachioplasty: technical refinements in upper arm contouring. Plast Reconstr Surg. 2008;121(1):305–7. 23. Knoetgen J III, Moran SL. Long-term outcomes and complications associated with brachioplasty: a retrospective review and cadaveric study. Plast Reconstr Surg. 2006;117(7): 2219–23. 24. Gusenoff JA, Coon D, Rubin JP. Brachioplasty and concomitant procedures after massive weight loss: a statistical analysis from a prospective registry. Plast Reconstr Surg. 2008;122(2):595–603. 25. Gilliland MD, Lyos AT. CAST liposuction: an alternative to brachioplasty. Aesthetic Plast Surg. 1997;21(6):398–402. 26. Dellon AL, MacKinnon SE. Injury to the medial antebrachial cutaneous nerve during cubital tunnel surgery. J Hand Surg Br. 1985;10(1):33–6. 27. Lowe JB, Maggi SP, MacKinnon SE. The position of crossing branches of the medial antebrachial cutaneous nerve during cubital tunnel surgery in humans. Plast Reconstr Surg. 2004;114(3):692–6. 28. Masear VR, Meyer RD, Pichora DR. Surgical anatomy of the medial antebrachial cutaneous nerve. J Hand Surg Am. 1989;14(2 Pt 1):267–71. 29. Race CM, Saldana MJ. Anatomic course of the medial cutaneous nerves of the arm. J Hand Surg Am. 1991;16(1): 48–52.

Lymphoscintigraphy: Evaluation of the Lymphatic System

35

Cristina Hachul Moreno, Aline Rodrigues Bragatto, Américo Helene, Carlos Alberto Malheiros, and Henrique Jorge Guedes Neto

35.1 Introduction The lymphatic system can be studied by various methods, invasive or noninvasive. Among the invasive ­methods, conventional lymphography consists of the injection of a radioopaque contrast into the previously dissected and cannulated lymphatic vessel, providing images of the anatomy of the lymphatic vessels and lymph nodes, but without much information as to their function [1–3]. Computerized tomography and magnetic resonance also provide anatomical visualization, in a noninvasive manner, but also leave much to be desired as to the functional part; they show details of the size and architecture of lymph nodes, but do not provide the dynamic study of the lymphatic vessels [4]. Lymphoscintigraphy was introduced as a diagnostic tool in 1953 by Sherman and Ter-Pergossian, who did experimental studies on rabbits, injecting colloidal radioactive gold into their paws and parametrium, enabling them to evaluate the regional lymphatic and lymph node passages. In 1955, Hultborn, Larsson, and Ragnhult utilized the same radiopharmaceutical, colloidal gold, but this time in vivo in five lower limbs, measuring the radiation with a counter at different sites, evaluating the time of appearance of the radioactivity. Sage and Gozun described the same technique in normal dogs,

C. H. Moreno (*) Rua Vergueiro, 1353 cj 407, Paraiso, CEP 04101-000, São Paulo, Brazil e-mail: [email protected]

concluding in 1958 that the described method was capable of graphically demonstrating the lymphatic vessels and lymph nodes, serving as a pilot for other physiological studies and evaluations of some diseases. Interest in lymphoscintigraphy led to the perfecting of the same, which occurred with the improvements in the images obtained on the scintigram and with the better distribution of the size of the particles utilized, facilitating their removal from the tissues studied, confirmed by Seiki et al. in 1968 by means of the analysis of the clearance rate of albumin marked with iodine 131, showing that it could be used as a lymphatic flux indicator under normal conditions. In 1965, Harper et al. published studies with technetium-99m, revealing the versatile characteristics of this radiopharmaceutical, indicating it as their radioisotope of choice because of its favorable physical conditions of a very low rate of deposition in tissues and rapid urinary excretion, as compared to colloidal gold. In 1982, Henze et al. after the publishing of various papers, which studied the best substance to mark technetium-99m, utilized dextran instead of the previously used agents, which presented limitations due to a low migration from the injection site and the unknown effect of phagocytosis to remove marked particles. Dextran, a polysaccharide utilized as a substitute for plasma, whose drainage from the interstices occurs only through lymphatic capillaries, presented excellent stability when marked with technetium-99m and began to be used in the lymphoscitigraphic exams. Lymphoscintigraphy studies the lymphatic system by making use of radioactive agents injected in the

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interstices, which are absorbed and transported in the lymphatic circulation, establishing images of the anatomy and functional analyses. This occurs because the transport of macromolecules, coupled with the radioactive compound, depends on their absorption, which in turn reveals details of the flow, the accumulation in lymph nodes, and other parameters. It presents elevated sensitivity and specificity in the study of lymphatic vessels, making it the exam of choice for the evaluation of the same [2, 6]. The radiopharmaceuticals utilized in the exam present variations, and many studies describe the search for the ideal agent for the performance of lymphoscintigraphy. Even so, all of them, when compared with the contrast used in lymphography, present low rates of direct damage to the lymphatic system and systemic complications, thus demonstrating superiority in relation to the lymphographic exam [6, 7] The lymphoscintigraphic study is of rapid execution. It is noninvasive and well tolerated by the patients, even the pediatric ones, and can be considered the exam of choice for lymphatic drainage evaluation [8]. As it is easily performed, it has a fundamental role in the follow-up in therapeutic, medicinal, and surgical interventions in the treatment of lower-limb edemas [1, 3, 6, 8–11]. The diagnosis of lymphatic alterations can be observed with an accuracy rate of approximately 93%. It also permits one to distinguish purely venous edema of the lymphedema and can analyze anatomical abnormalities in the lymphatic system, such as lymphoceles or lymphangiectases with reflux [1].

35.2 Technique The exam consists of the subcutaneous administration of a radiopharmaceutical in the first interdigital space of both lower limbs, or both upper limbs each of which receives 3mCi of human albumin marked with technetium-99m (99mTc-SAH) serum, in a volume of 0.2 mL. The images were acquired in the Elsint Apex SP-6 gamma chamber of a detector equipped with a lowenergy and high-resolution collimator, scanning from the thorax to the feet. These images were made at 15, 30, 60, and 180 min after the injection of the radiopharmaceutical, with the patient in frontal incidence.

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The images of the foot, leg, and thigh on both sides, or hand, elbow and axillary region on both side stored in a digital file or on radiological film, were evaluated by doctors in the Department of Nuclear Medicine. The interpretation of the images involved the evaluation of the injection sites, number and size of the lymphatic vessels, lymph node chains, presence of collateral vessels or dermal reflux, crossover uptake by lymph nodes, and the evaluation of hepatic uptake. The following were considered abnormalities: • Impermeability of the lymphatic passages • Delay in the drainage of the radiopharmaceutical • Progression asymmetry in the lymph between limbs (temporal and qualitative) • Nonidentification of inguinal, or pelvic, lymph nodes, (or a small number of the same) in lower limbs and nonidentification of axilar lymphnodes, (or a small number of the same) in upper limbs • Presence of dermal reflux, lymphorrhagia or lymphorrhea • Predominant drainage by collateral lymphatic channels Normal lymphoscintigraphy: Image at 15, 30, 60, and 180 min. Normal lymphoscintigraphy presents symmetrical uptake in the larger lymph nodes, at the same speed, but with lymphoceles identified in the distal part of the thighs (Figs. 35.1–35.3). Altered lymphoscintigraphy: 1. Discrete deficit in lymphatic drainage in the right lower limb, noting the smaller uptake in the right inguinal lymph nodes, as compared to the left lower limb lymph nodes at 30 and 60 min (Fig. 35.4). 2. Moderate deficit, with smaller uptake in the right lower limb inguinal lymph nodes at 15, 30, and 60 min (Fig. 35.5). 3. Accentuated deficit in lymphatic drainage in the left lower limb, in addition to the visualization of lymphoceles in the distal part of the right and left thighs (Figs. 35.6–35.7).

35.3 Discussion It is not a simple task to make a differential clinical diagnosis of lymphedemas, mainly in their initial phase. In this way, advances in the study of lymphatic vessels have permitted earlier and more precise

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Fig. 35.1  Normal lymphoscintigraphy: Image at 15, 30, 60, and 180 min

Fig. 35.2  Normal lymphoscintigraphy presents symmetrical uptake in the larger lymph nodes, at the same speed, but with lymphoceles identified in the distal part of the thighs

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Fig. 35.3  Discrete deficit in lymphatic drainage in the right lower limb, noting the smaller uptake in the right inguinal lymph nodes, as compared to the left lower limb lymph nodes at 30 and 60 min

diagnoses [12]. Lymphography permits an adequate anatomical analysis of lymphatic vessels and lymph nodes, with little information as to the functional

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dynamics of the lymphatic system. It is difficult to execute and it is believed that the contrast used can destroy some lymphatic vessels during the performance [3]. The computerized tomography and the nuclear magnetic resonance also provide adequate information about the anatomy of the lymphatic vessels in the study of lower limb edemas. Furthermore, they provide information about differential diagnoses in relation to hematomas, cysts, and associated diseases, which justify the occurrence of the edema, however the dynamic analysis of lymphatic drainage is precarious [3, 4]. Lymphoscintigraphy is a very slightly invasive exam and is well tolerated even by pediatric patients. It is technically easy to perform, making use of the infiltration of a radiopharmaceutical into the interdigital spaces of both feet or hands. The drainage of the radiopharmaceutical by the lymphatic vessels is studied by means of imaging exams done at determined times, and the analysis of these evaluates the lymphatic drainage in an adequate manner. In most clinical situations, this technique permits a rapidly analyzed diagnosis, with results in as little as 3 h [1–3, 8, 13]. The effective use of lymphoscintigraphy requires an adequate knowledge of physiopathology and of the influence of technical parameters, such as the adequate selection of a radiopharmaceutical, image capturing time and physical activity of the patient following the injection of the radioactive product [13]. The analysis of the interpretation of the captured images following the injection of the radiopharmaceutical follows a specific study standard to determine the final result as altered or normal, by means of the analysis of the images surrounding the injection site of the radiopharmaceutical, the number and size of lymphatic vessels, the lymph node chains (number and distribution), the presence of collateral vessels or dermal reflux, crossed filling of larger lymph nodes (crossover), and hepatic uptake [1, 13, 14]. There are controversies in the literature as to the best manner to interpret the findings of the lymphoscintigraphy, as each author employs his or her own technique, different radioisotopes and different image acquisition times and curve plotting, making use or not of physical exercise. This analysis determines the transport of lymph, as well as identifying its anatomy. For example, the appearance of the radiopharmaceutical in

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Fig. 35.4  Moderate deficit, with smaller uptake in the right lower limb inguinal lymph nodes at 15, 30, and 60 min

the larger lymph nodes, combined with a decrease in the number of smaller lymph node chains, in relation to the expected anatomy, provides the information of a reduced lymphatic transport, always related to the contrast injection time [1, 13]. There is already a consensus in the literature on the normal and abnormal lymphoscintigraphical standards for the lower limbs, which included some cases of

upper limbs, the study of which was mainly developed in our midst by Neto in 2002 [15], concluding normal and abnormal qualitative lymphoscintigraphic standards for the arm and forearm, evaluating the lymphatic vessels, visualization of the lymph nodes, dermal reflux, collateral circulation and axillary uptake in patients with lymphedema following the surgical treatment for breast cancer.

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Fig. 35.5  Accentuated deficit in lymphatic drainage in the left lower limb, in addition to the visualization of lymphoceles in the distal part of the right and left thighs

This visual interpretation of the radiopharmaceutical uptake, associated with the estimated time of appearance of the colloid in the regional lymph nodes, provided information on the normal or abnormal ­lymphatic drainage, with a specificity of 100% and a

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sensitivity of 92% in the studies of Gloviczki et al. in 1989 [1], which analyzed 190 lymphoscintigraphies. Therefore, the peripheral lymphatic vessels can now be visualized as easily as the arteries and veins. The determining factor is lymphoscintigraphy, which allows for a rapid evaluation, and can be utilized before and after clinical and surgical treatments, in the follow-up of patients with lymphedema and lipedema, as a diagnostic complement to the physical exam and to evaluate the efficacy of drugs, surgical procedures, and complementary methods for the treatment of lymphatic drainage [2, 4, 9, 10, 16–19]. Perez [20] studied the effect of sequential intermittent pneumatic compression on the lymphedema of the lower limbs using lymphoscintigraphic evaluation with dextran marked with technetium, arriving at conclusions compatible with the literature of effective reduction in the circumference of the limbs studied, albeit without alteration in the transport of the radioisotope, by means of quantitative and qualitative lymphoscintigraphic analyses. Said method presents elevated rates of sensitivity and specificity when compared with lymphography or computerized tomography, among others, being the exam of choice for the evaluation of lymphatic drainage [14]. This is an exam that is habitually performed on patients to be submitted to thighplasties or brachioplasties. Depending on the outcome of the exam preoperatively, the patient is authorized or not to have the surgical procedure. Hence, the preoperative analysis is of significant importance, because if it demonstrates an alteration, the patient must then be evaluated by a vascular surgeon, followed by a joint decision to define or not the surgical conduct, once again demonstrating multidisciplinary treatment. In the same way, the postoperative follow-up is also fundamental in the identification of clinical alterations and the definition of the adequate treatment [21]. The decision to perform this exam postoperatively has the purpose of enabling the evaluation the lymphatic drainage following the surgical procedure and to study if this procedure alters it or not. A study was performed by the authors and it was observed from the case results that the surgical procedure determines alteration in the lymphatic drainage in a statistically significant manner, but no major clinical signs, such as

35  Lymphoscintigraphy: Evaluation of the Lymphatic System Fig. 35.6  Normal lymphoscintigraphy of upper limbs

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Fig. 35.7  Accentuated defict in lymphatic drainage in both arms, with lymphocele in both elbows, and collateral lymphatic channels on the left forearm

lymphedema, have been observed in the outpatient follow-up [21]. The edema present in the postoperative period underwent a gradual reduction, becoming minimal or absent in this period of 6 months, leading us to believe this was the best moment in the postoperative for lymphoscintigraphic analysis. Other studies are underway along the same research lines, analyzing lymphatic drainage following other surgical procedures, such as liposuction, for example, in the ex-obese or others. In the same way, the effect of the brachioplasty on lymphatic drainage of the upper limbs can be studied, with the knowledge that the lymphoscintigraphic exam is the gold standard and that the

ex-obese have an increasing prevalence, according to the world literature.

References   1. Gloviczki P, Calcagno D, Schirger A, Pairolero PC, Cherry Kj, Hallett JW, Wahner HW. Noninvasive evaluation of the swollen extremity: experiences with 190 lymphoscintigraphic examinations. J Vasc Surg. 1989;9(5):683–9; discussion 690.   2. Cestari SC, Petri V, Castiglioni ML, Lederman H. Linfedemas dos membros inferiores: estudo linfocintilográfico. Rev Assoc Med Brasil. 1994;40(2):93–100.

35  Lymphoscintigraphy: Evaluation of the Lymphatic System   3. Khan O, Maharaj P, Rampaul R, Archibald A, Naipaul R, Loutan N. Lymphoscintigraphic evaluation of chronic lower limb edema. West Indian Med J. 2003;52(2):136–9.   4. Williams WH, Witte CL, Witte MH, McNeill GC. Radionuclide lymphangioscintigraphy in the evalua­­tion  of peripheral lymphedema. Clin Nucl Med. 2000;25(6): 451–64.   5. Sherman AI, Ter-Pogossian M. Lymph-node concentration of radioactive colloidal gold following interstitial injection. Cancer 1953;6(6):1238–40.   6. Hung JC, Wiseman GA, Wahner HW, Mullan BP, Taggart TR, Dunn WL. Filtered technetium-99m-sulfur colloid evaluated for lymphoscintigraphy. J Nucl Med. 1995;36(10): 1895–901.   7. Wahl RL, Liebert M, Wilson BS, Petry NA. Radiolabeled antibodies, albumin and antimony sulfide colloid: comparison as lymphoscintigraphic agents. Int J Rad Appl Instrum B. 1998;15:243–50.   8. Bellini C, Arioni C, Mazzella M, Campisi C, Taddei G, Boccardo F, Serra G. Lymphoscintigraphic evaluation of congenital lymphedema of the newborn. Clin Nucl Med. 2002;27(5):383–4.   9. Yeh SD, Morse MJ, Grando R, Kleinert EL, Whitmore WF Jr. Lymphoscintigraphic studies of lymphatic drainage from the testes. Clin Nucl Med.1986;11(12):823–7. 10. Richards TB, McBiles M, Collins PS. An easy method for diagnosis of lymphedema. Ann Vasc Surg.1990;4(3): 255–59. 11. Ercocen AR, Yilmaz S, Can Z, Berk F, Kir M, Yenidunya S, Edali N, Ozbek MR. The effects of tissue expansion on skin lymph flow and lymphatics: an experimental study in rabbits. Scand J Plast Reconstr Surg Hand Surg. 1998; 32(4):353–8. 12. Guedes Neto HJ. Diagnóstico e tratamento de linfedema periférico. Rev Cir Vasc Angiol. 1996;12:62–5.

345 13. Szuba A, Shin WS, Strauss HW, Rockson S. The third circulation: radionuclide lymphoscintigraphy in the evaluation of lymphedema. J Nucl Med. 2003;44:43–57. 14. Ter SE, Alavi A, Kim CK, Merli G. Lymphoscintigraphy. A reliable test for the diagnosis of lymphedema. Clin Nucl Med. 1993;18(8):646–54. 15. Guedes Neto HJ. Estudo linfocintilográfico qualitativo dos membros superiores de pacientes com linfedema secundário a tratamento cirúrgico para câncer de mama. Tese (Doutorado). São Paulo: Faculdade de Ciências Médicas da Santa Casa de São Paulo; 2002. 16. Brautigam P, Vanscheidt W, Foldi E, Krause T, Moser E. The importance of the subfascial lymphatics in the diagnoses of the limb edema: investigations with semiquantitative lymphoscintigraphy. Angiology 1993;44(6):464–70. 17. Bilancini S, Lucchi M, Tucci S, Eleuteri P. Functional lymphatic alterations in patients suffering from lipedema. Angiology 1995;46(4):333–9. 18. Howarth DM. Increased lymphoscintigraphic flow pattern in the lower extremity under evaluation for lymphedema. Mayo Clin Proc. 1997;72(5):423–9. 19. Bourgeois P, Leduc O, Leduc A. Imaging techniques in the management and prevention of posttherapeutic upper limb edemas. Cancer 1998;83(12 suppl American):2805–13. 20. Perez MCJ. Compressão pneumática intermitente seqüencial no linfedema dos membros inferiores:avaliação linfocintilográfica com Dextran marcado com tecnécio 99m. Tese (Doutorado). São Paulo, UNIFESP; 1997. 21. Moreno CH, Guedes Neto HJ, Junior AH, Malheiros CA. Thighplasty after bariatric surgery: evaluation of lymphatic drainage in lower extremities. Obes Surg. 2008; 18(9): 1160–4.

Medial Thigh Lift and Declive: Inner Thigh Lift Without Using Colle’s Fascia1

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Daniele Spirito

36.1 Introduction The medial thigh aesthetic deformity frequently presents a challenging problem to the plastic surgeon. Skin laxity in the medial thigh area is the earliest sign of aging in the thighs and is one of the first signs of ptosis of the body. The skin of the medial thigh area is thin, and therefore, not elastic resulting in early relaxation with age, and does not respond well to liposuction due to poor retraction. By the age of 40 years in most patients, actual or potential laxity of the medial thigh tissue can lead to disappointing result after liposuction alone. Laxity of the medial thigh area may occur at an early age in patients with a history of obesity during childhood or early adulthood or in patients with the familial trait of thin, lax skin. The classic medial thigh lift has been plagued with persistent problems, such as inferior migration and widening of the scar, lateral traction deformity of the vulva, and early recurrence of the ptosis. In an attempt to limit untoward results, the medial thigh lift was modified to allow anchoring of the inferior skin flap to the tough, inelastic deep layer of the superficial fascia of the perineum. More long-lasting and effective results were achieved while applying Colles’ fascia as the central anchor for the medial thigh lift. This procedure decreased the risk of complications being

1

commonly associated with the classic skin-suspension medial thigh lift. Since the fascial anchoring technique for medial thigh lift was originally described in 1987 by Lockwood [1] (Fig. 36.1), numerous technical refinements have been developed to provide enhanced safety, predictability, and aesthetic. The surgical principles of the medial thigh lift have evolved to allow a more accurate patient selection, individualized operative planning, and standardized surgical techniques. Significant actual or potential laxity of the medial thigh tissue remains the standard indication for medial thigh lift today. Liposuction of the moderate to severe fat deposits of the medial thighs often leads to skin relaxation, especially after the age of 35. Moderate to severe skin laxity requires thigh lifting along with liposuction of any medial thigh fat deposits. In less severe cases of skin laxity, a more limited medial thigh lift may provide optimal thigh contours and skin tightening with improved aging potential in the region. The medial thigh lift design has changed significantly in the last 10 years due to a better understanding

 pecial acknowledgment to Ted Lockwood† and Ricardo S Baroudi for the studies on the “anchoring system” and on the “adhesion sutures,” respectively

D. Spirito Via delle Baleniere, 107/b, 00121, Rome-Ostia, Italy e-mail: [email protected]

Fig. 36.1  Ted Lockwood

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of thigh aesthetic deformities. The majority of the skin laxity in this area occurs at the juncture of the anterior and medial thighs; the standard surgical resection pattern has rotated anteriorly allowing the entire procedure to be performed in the supine position. Lockwood basically reinvented the lower body lift by redefining the nature of suspension of the deeper tissue of the abdomen and flank. The lower body lift extends the tummy tuck incision completely around the lower torso. This allows resuspension of the lateral and anterior thighs along with the traditional tummy tuck improvements. The concept has been expanded upon to include additional lifts such as those of the inner thigh (medial thigh lift). The traditional lower body lift targeted the upper thighs as well as the buttocks and abdomen. For the large volume weight loss patient, this operation is ideal to remove the redundant skin that frequently “hangs” around the lower torso. This type of operation requires 5–8 h “all at once” and postoperative supervision is strongly advised. An accurate reconstruction of the inguino-crural fold can really improve and stabilize the contour of the inner thigh surface. The anchorage of the medial thigh skin to a deep and strong structure, i.e., the superficial perineal fascia, allows a correction that is anatomically better. The perineal fascia, described for the first time in 1811 by Colles [2], defines and anchors the inguino-crural fold. Unfortunately, it was not successful in all cases. It works well reducing the scar broadness, and avoids external genitalia distortion and scar descent when no excess skin resection is removed. Tension in the suture should not exist. These problems may become evident a few months after surgery; if these procedures are not followed, patients complain about these. The patient should be made aware that the final result is restricted to the upper third of the thigh only. Patients regularly take the skin of the upper thigh in both hands and stretch/pull the skin upwards, and ask the surgeon to obtain a similar result to this. Presently, there is no surgical technique available that can yield this result except for: (a) The Vertical Dermo Cruro Lipectomy is the technique referred to as “DECLIVE” (in Italian language: DErmo Cruro LIpectomia VErticale which in Latin means something that moves downward) technique, scar migration can be avoided so we can lift tightly. (b) The “adhesion sutures of Baroudi” improves the results.

D. Spirito

The Declive technique represents a contribution to the dynamics of the thigh lift. With a “sacrifice of skin” of a triangular portion of the perivulvar area, a “vertical scar” is achieved that will stop its displacement downward. The routine use of the Baroudi’s (Fig. 36.2) sutures to avoid the “dead space” is useful in the thigh lift because of this morphodynamic area. The incision should not extend into the posterior buttock fold.

36.2 Marking Preoperative markings are made in standing position with the knees apart. The extent of medial thigh fat deposits is marked and an estimate of the amount of skin redundancy is determined (Fig. 36.3). The actual skin resection has become more conservative over the years, averaging 5–7 cm of stretched skin at the anterior medial corner of the thigh. The Declive technique plus the adhesion sutures provide an additional lift. More conservative resection has decreased wound complications from over resection while still providing consistent contour improvements. Initially the patient is placed in the lithotomy position, and the natural perineal crease is marked as it extends into the posterior infrabuttocks crease. Traction on medial thigh tissue is placed at different points along the natural perineal crease to mark the point at which traction will not affect the position of the vaginal labia. Usually this corresponds to the origin of the gracilis muscle.

36.3 Technique After anesthesia is established, a foley catheter is inserted, and the patient remains in the frog-leg position, with the hips flexed 20–30°. Stockinettes are placed to the knees, so the thighs can be repositioned during the surgery. The excision of the redundant tissue and the subsequent repair is performed with the knees shoulder-width apart (rather than semi-frog leg) to avoid undercorrection. The thigh can be abducted for exposure as needed. Initial deep liposuction with epinephrine solution is followed by skin-only incision along superior resection line. Posteriorly, the perineal thigh crease incision should not extend into the buttocks fold as Lockwood suggested. Anteriorly, the incision will leave the crease

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Fig. 36.2  Baroudi 1989

Fig. 36.3  Marking of declive

at the origin of the adductor longus muscle (pubic tubercle) and extend vertically along the lateral border of the mons pubis after the excision of the triangular of the skin of the Declive technique. A more youthful narrowed pubic hair pattern should be selected. After skin incision, undermining of the inferior flap posterior to the pubic tubercle is performed superficial to the adductor muscle fascia. This direct undermining usually extend 4–6 cm beyond the planned line of resection. Cannulas undermining more distally may be helpful for laxity problems extending to the knee. Anterior to the pubic tubercle, care is taken to leave the soft tissue bundle coursing between the mons pubis, and the femoral triangle preserves the external pudendal blood and lymphatic vessels, reducing the risk of lymphatic complications. Blunt dissections through this soft tissue bundle at the mons pubic exposes Scarpa’s fascia or muscular fascia, either of which was used for anchoring of the thigh flap in the pubic region according to Lockwood’s technique. Once flap undermining is completed, the Colles’ fascia roll is identified. It is very important not to overdissect

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this fascia because, like all superficial fasciae, it tends to be somewhat vague and indistinct on gross examination. Attempts to overly define this fascia will lead to disruption of the connections between Colles’ fascia and the periosteum of the ischio-pubic ramous. Digital dissection using a dry gauze sponge most reliably preserves Colles’ fascial anatomy. Push superiorly, the adductor muscles until the tendinous muscle origins are seen and the bony ischio-pubic ramus is palpated at the fingertip. Retracting the skin and the superficial fat of the vulva medially will expose the Colles’ fascial roll at the deepest and most lateral aspect of the vulvar soft tissues. Scarpa’s fascia is used as the anchor anteriorly and the buttock-fold SFS is used as the anchor posteriorly. Blunt dissection throughout the soft tissue bundle at the mons pubis exposes Scarpa’s fascia or muscular fascia, either of which can be used for anchoring of the thigh flap in the pubic region. Failure to do this will lead to unaesthetic widening of the mons pubic. Skin is repaired with 3–0 nylon subdermal sutures and interrupted 3–0 absorbable monofilament skin suture. “Good” dressings are applied. Anchoring sutures into Colles’ fascia are not needed because of the vertical manner of the Declive. In addition, Scarpa’s fascia is used as the anchor anteriorly and the buttock-fold SPS posteriorly. Baroudi sutures are used for the total area undermined. They consist of isolated absorbable material that fixates two dissected cutaneous or noncutaneous surfaces during the surgery. The extension of the “dead space” is reduced when the sutures are applied with up to 2 cm distance between them. Drains are generally not used; there is no space to introduce them after the adhesion stitches. Of course, the “good” dressing (for a week) is important.

D. Spirito

presence, location, and severity of excess skin and fat in the thigh. Based on the degree of excess skin and fat, liposuction alone, a transverse medial thigh incision, or a vertical medial thigh incision (Declive) should be made to correct the deformity. Care must be taken to preserve the soft tissue between the mons pubis and the femoral triangle to prevent postoperative lymphedema. To prevent recurrence of thigh ptosis, the Declive technique plus the adhesion sutures is the solution. In medicine and surgery, the subcutaneous tissue and superficial tissue have always been secondary and the subject was always left to interested anatomists and dermatologists. They were mainly interested in using the external tissue of the hernia in the groin area as described by Camper and Scarpa. The subcutaneous tissue was always considered an “appendage” when considering diseases of the layers of the skin. The anatomist Sterzi [3] (Fig. 36.4) was the first to discover the structure and function of this organ and its systematic distribution throughout the body (with few exceptions) a subcutaneous layer subdivided as follows: 1. A superficial layer of skin comprised fibrous septi vertically arranged between the superficial layer, deep layer, and fat deposits 2. A thin superficial layer where the fibrous septi are apparent on both sides 3. A deep layer of fibrous septi that present in a disorderly manner, vertical, connected, and held together by the superficial layer and fat deposits 4. A deep layer of muscle tissue Sterzi categorized his observations: 1.  Different regions of the body 2.  Individual differences (obese/thin)

36.4 Complications Complications include delayed would healing (3%), scar widening (0.5%), transient lymphocele (0.3%), and pubic hair dislocation (31%). No infection in spite of the area because we suggest to the patients to wash with betadine soap very often, and never scar migration.

36.5 Discussion Aesthetic rejuvenation of the thigh begins with complete history and physical examination to determine the

Fig. 36.4  Giuseppe Sterzi 1876–1919

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3.  Sexual differences 4.  Age difference His description in 1910 was extremely detailed and there still exists today (rare in real life) a text with reference to the subcutaneous tissue. Nevertheless, the argument over the years has never sparked much interest. Even in the eighties and nineties the majority of surgeons were not even aware that the area existed. This was also included in Bibbia’s text/book called Anglo-Saxon Grey’s Anatomy. With Mitz and Perone’s publication [4] on the superficial layers of the skin named SMAS (superficial musculo aponeurotic system) by them, the superficial tissue became the leading protagonist of facial plastic surgery. They then followed the work of Stuzin et  al. [5], Jost and Levet [6], Hamra [7], and others (Table 36.1). It was Micheli-Pellegrini [8] who contributed to history the work of the incredible Sterzi. It was Spirito (Fig. 36.5) in 1980–5 who had the insight

Table 36.1  Contributors to the medial thigh lift Lewis 1957 reported an operation in which he treated medial thigh excess, due to massive weight loss with a combine one stage vertical and horizontal skin excision Pitanguy 1964 used a buttock fold and a medial thigh incision only Baroudi 1989 described a flanc excision to slim and tighten the hip flank area Lockwood 1987 and 1991 (new concept) anchors the deep closure to SFS Spirito 1995 sacrifices the skin of the perivulvar area and anchors with not absorbable stitches directly on derma (Declive technique) Spirito 2007 introduce the adhesion stitches of Baroudi to Declive to improve the results

Fig. 36.6  Declive procedure. Left: preoperative with markings. Right: postoperative

Fig. 36.5  Daniele Spirito

to underline the importance of the layers of the skin with an article titled “Il lifting, da Skoog a Jost.” Markmann followed by Lockwood published their works on the system of the superficial layers of the body as well as articles defining the fat and adhesion zones. This revolutionized the technique of liposuction and by using the new surgery techniques studied by Sattler et al. [9], was more careful in not destroying the superficial layers of the skin. Lockwood also published his studies on abdominoplasty and lifting of the middle leg region and the superficial skin layers.

352 Fig. 36.7  Declive procedure. (a) Preoperative patient. (b) Marking declive and abdominoplasty. (c) Postoperative

D. Spirito

a

b

c

Nava et al. [10] reported his studies on the superficial system in the breast region that is so important in reconstruction.

36.6 Conclusions The vertical dermo cruro lipectomy (Declive) is the only technique to guarantee against the possibility of scar migration. The result goes from good to excellent, but always with satisfaction (Figs. 36.6 and 36.7).

  5. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3): 441–9.   6. Jost G, Levet Y. Parotid fascia and face lifting: a critical evaluation of the SMAS concept. Plast Reconstr Surg. 1984; 74(1):42–51.   7. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992;90(1):1–13.   8. Micheli-Pellegrini V. Surgical anatomy and dynamics on face lifts. Facial Plast Surg. 1992;8(1):1–10.   9. Sattler G, Sommer B, Bergfeld D, Sattler S. Tumescent liposuction in Germany: history and new trends and techniques. Dermatol Surg. 1999;25(3):221–3. 10. Nava M, Quattrone P, Riggio E. Focus on the breast fascial system: a new approach for inframammary fold reconstruction. Plast Reconstr Surg. 1998;102(4):1034–45.

References   1. Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg. 1988;82(2):299–304.   2. Colles A. A treatise on surgical anatomy. Dublin: Gilbert & Hodges; 1811.   3. Sterzi G. Il tessuto Sottocutaneo (Tela Subcutanea). Florence: Niccolai; 1910.   4. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;58(1):80–8.

Further Reading   1. Aston SJ. Buttocks and thighs. In: Rees TD, editor. Aesthetic plastic surgery. Philadelphia: WB Saunders; 1980. p. 1039–66.   2. Baroudi R. Body sculpturing. Clin Plast Surg. 1984;11(3): 419–43.   3. Baroudi R, Carvalho CGS. Lifting of the inner third of the thigh; an analysis of immediate and mediate results. Cir

36  Medial Thigh Lift and Declive: Inner Thigh Lift Without Using Colle’s Fascia1 Plast Iber Lat Am. 1981;7:275; abstracted in Plast Reconstr Surg. 1981;74:160.   4. Baroudi R. Thigh lift and buttock lift. In: Courtiss EH, editor. Aesthetic surgery: trouble how to avoid it and how to treat it. St Louis: CV Mosby; 1978. p. 223–31.   5. Baroudi R, Moraes M. Philosophy, technical principles, selection and indication in body contour surgery. Aesthetic Plast Surg. 1991;15(1):1–18.   6. Baroudi R. Body contour surgery. Clin Plast Surg. 1989; 16(2):263–77.   7. Baroudi R. Flankplasty. In: Hetter GP, editor. Lipoplasty: the theory and practice of blunt suction lipectomy. Boston: Little Brown; 1990. p. 399–416.   8. Baroudi R, Ferreira CAA. Seroma: how to avoid it and how to solve it. Aesthet Surg J. 1998;18:439–41.   9. Baroudi R., De Almeida FR. Adhesion stitches to avoid and to treat seroma. In: Eisenmann-Klein M, Neuhann-Lornz C, editors. Innovations in plastic and aesthetic surgery. New York: Springer; 2008. 10. Clemente C. Gray’s anatomy of the human body. 30th ed. Philadelphia: Lea & Febiger; 1985. 11. Ducourtioux JL. Technique et indications des dermolipectomies crurales. Ann Chir Plast. 1972;17(3):204–11. 12. Farina R, Baroudi R, Golcman B, De Castro O. Lipodistrofia pelvi-crural tipo calcas de montaria. Hospital (Rio J). 1960; 57:717–22. 13. Farina R, Baroudi R, Golcman B, De Castro O. Ridingtrousers like type of pelvicrural lidpodystrophy (trochanteris lipomatosis). Br J Plast Surg. 1960;13:174–8. 14. Hodgkinson DJ. Medial thighplasty, prevention of scar migration, and labial flattening. Aesthetic Plast Surg. 1989; 13(2):111–4. 15. Hoffman S, Simon BE. Experiences with the Pitanguy method of correction of trochanteric lipodystrophy. Plast Reconstr Surg. 1975;55(5):551–8. 16. Illouz YJ, Dradour JC. Combined procedures: the thighs and the buttocks. In: Illouz YG, de Villers,YT, editors. Body contouring by lipoplasty. New York: Churchill Livingstone; 1989. p. 340–52. 17. Leitner DW, Sherwood RC. Inguinal lymphocele as a complication of thighplasty. Plast Reconstr Surg. 1983;72(6): 878–81. 18. Lewis JR. Surgery of the hips, buttocks and thighs. In: Goldwin RM, editor. Long term results in plastic and reconstructive surgery. Boston: Little Brown; 1980. p. 784–9. 19. Lewis JR Jr. Correction of ptosis of the thigh. The thigh lift. Plast Reconstr Surg. 1966;37(6):494–8. 20. Lewis JR Jr. The thigh lift. J Int Coll Surg. 1957;27(3): 330–4. 21. Lockwood TE. Medial thighplasty. In: Hetter GP, editor. Lipoplasty: the theory and practice of blunt suction lipectomy. Boston: Little Brown; 1990. p. 375–83.

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22. Lockwood TE. Superficial Fascial System (SFS) of the trunk and the extremities. A new concept. Plast Reconstr Surg. 1991;87(6):1009–18. 23. Lockwood TE. Transverse flank, thigh, buttock lift with superficial fascial suspension. Plast Reconstr Surg. 1991; 87(6):1019–27. 24. Lockwood TE. Lower body lift and medial thigh lift. In: Aly A, editor. Body contouring after massive weight loss. St. Louis: Quality Medical Publishing; 2006. 25. Loeb R. Narrowing of the mons pubis during thigh lift. Ann Plast Surg. 1979;2:290. 26. Pitanguy I. Aesthetic plastic surgery of head and body. New York: Springer; 1981. p. 129–53. 27. Pitanguy I. Aesthetic plastic surgery of the upper and lower limbs. Aesthetic Plast Surg. 1980;4:363–72. 28. Pitanguy I. Technique for trunk and thigh reductions. In: Huston J, editor. Transactions of the fifth international congress of plastic surgeons. Melbourne: Butterworths; 1971. p. 1204–10. 29. Pitman GH. Liposuction and aesthetic surgery. St Louis: Quality Medical Publishing; 1993. 30. Planas J. The “Crural Meloplasty” for lifting of the thigh. Clin Plast Surg. 1975;2(3):495. 31. Posse RP. Chirurgia esthetica. Cited In Pitanguy I (Ed), Aesthetic plastic surgery of the upper and lower limbs. Aesthetic Plast Surg. 1980;4:363–72. 32. Salmon M. Arteries of the skin. Paris: Masson & Cie; 1936. (First English Edition edited by Taylor GI, Tempest MN. Translated by Hueston P, Cuthbertson A, Tempest MN, New York: Churchill Livingstone; 1988). 33. Schulz RC, Feinberg LA. Medial thigh lift. Ann Plast Surg. 1979;2:404–10. 34. Shaer WD. Gluteal and thigh reduction: reclassification, critical review and improved technique for primary collection. Aesthetic Plast Surg. 1984;8(3):165–72. 35. Shaer WD. Gluteal and thigh reduction: reclassification, critical review and improved technique for primary correction. Aesthetic Plast Surg. 1984;8(3):165–72. 36. Spirito D. The medial thigh lift and the declive. 14th Congress Isaps. Sao Paulo Brazil: 1997. 37. Spirito D. The medial thigh lift and the DE.C.LI.VE. Aesthetic Plast Surg. 1998;22(4):298–300. 38. Spirito D. The declive and adhesion stiches according with Baroudi. 56th Italian Congress of Plastic and Reconstructive Surgery, 2007. 39. Vilain R, Dardour JC. Aesthetic surgery of the medial thigh. Ann Plast Surg. 1986;17(3):176–83. 40. Vilain R, Dardour JC. Aesthetic surgery of medial thigh. Ann Plast Surg. 1986;17(3):176–83. 41. Zook EG. The massive weight loss patient. Clin Plast Surg. 1975;2(3):457–66.

Spiral Lift: Medial and Lateral Thigh Lift with Buttock Lift and Augmentation

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Sadri O. Sozer, Francisco J. Agullo, and Humberto Palladino

37.1 Introduction Developments in surgical techniques allow safe and efficient surgical correction of contour deformities [1]. The trunk, buttocks, and thighs represent areas of increased patient interest and surgical technique modification. Consequently, familiarity with the presentation and effective treatment of these contour alterations has become increasingly important [2, 3]. Patients with a “pear” or “guitar” shaped body contour deformity comprising lipodystrophy and excess skin in the thighs, buttock, and waist, with abdominal sparing, are not frequently encountered, but represent a surgical challenge. These patients often present with additional trochanteric lipodystrophy and ptosis of the buttocks. This condition may consist of pure fat deposits or excess skin with or without fat accumulation. The development of these contour alterations can be accredited to the lack of exercise, body weight variations, and genetics. These deformities are very difficult to correct with diet and exercise alone. Liposuction can offer an improvement in select cases, but is usually insufficient, and overaggressive liposuction of the thighs can result in complications. Traditionally, these patients have been treated with a combination of liposuction, flankplasty, belt lipectomies, lower body lifts, and/or medial thigh lifts. Baroudi described an upper inner

S. O. Sozer (*) Department of Surgery, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA e-mail: [email protected]

thigh lift and flankplasty with optional lipoplasty as an alternative method for performing a medial, anterior, and lateral thigh lift at the same time [4]. This “extended flankplasty,” along with some modifications accompanied by a buttock lift and autologous augmentation with a dermal fat flap [5], is a good option for the deformities described. This “spiral lift” can be accomplished with a single spiral incision easily concealed by underwear resulting in the removal of excess tissue as well as reconfiguration of a natural silhouette (Fig. 37.1) [6].

37.2 Technique 37.2.1 Preoperative Markings Preoperative markings are a crucial component to a successful surgery and to achieving desired results. Patients are marked preoperatively in standing and prone positions (Fig. 37.2). The thigh is abducted while the patient is in prone position in order to assess lateral mobility and extent of lateral resection. Symmetry of the incisions is later evaluated with the patient standing. A line is drawn starting at the lateral portion of the inferior gluteal fold, extending medially to the upper inner thigh, proceeding interiorly and anteriorly through the pudendal region, moving along the inguinal line through the anterior iliac spine to the posterior iliac crest, above the buttocks, and to the sacrum. At the sacrum, the line from the contralateral side is joined forming a V. The pinch method is utilized to estimate

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Fig. 37.1  Tissue excised extends from the inner inside crease of the buttocks, along the inguinal crease and anterior iliac spine, spiraling above the buttocks and meeting the contralateral incision at the sacrum

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b

c

Fig. 37.2  Preoperative markings. Tissue to be excised is marked in red ink, the dermal fat flaps are marked in dark blue ink, and areas of liposuction marked with blue concentric circles

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a

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Fig. 37.3  (a) Creation of an autologous buttock augmentation flap. Tissue to be excised is in purple and the deepithelialized flaps in red. The flap is dissected down to the fascia at an oblique angle undermining the inferior border, rotated caudally 180° into the pocket, and anchored to the fascia with suture. The

remaining buttock skin is pulled to cover the flap. (b) Dissection of the buttock flap with a consistent pedicle including muscle fibers from gluteus muscle to achieve better mobility without blood supply compromise. (c) Development of the gluteal pocket to accommodate the rotated flap

the amount of possible skin resection. The areas of liposuction are marked in the traditional manner, with emphasis on the sacrum, supragluteal area, trochanteric region, and anterior and medial thighs. A dermal fat flap originating in the medial half of the supragluteal tissue marked for excision is designed (Figs. 37.2 and 37.3). The size of the flap is individualized according to the patient’s buttocks contour and desired augmentation.

37.3 Surgical Technique The patient is placed in the prone position under general anesthesia with legs abducted to expose the medial thigh and to maximize lateral resection. Traditional deep and superficial liposuction of the marked areas is performed after the subcutaneous tissue is infiltrated with tumescent solution consisting of 1 L of Hartmann

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solution with 1 mg of epinephrine and 10 mL of 1% lidocaine. The wedge excision of the inferior gluteal fold and  posterior portion of the medial thigh is accomplished and left for completion once the patient is rotated to the supine position. Skin and subcutaneous tissue are excised down to the gluteus maximus fascia and ­connective tissue of the ischial tuberosity. The inferior edge of the wedge excision is then anchored in  a cephalad and medial direction to the periosteal connective tissue surrounding the ischial tuberosity and gluteus maximus fascia with 2–0 polydioxanone (PDS). The objective is to lift the posterior thigh and shorten and elevate the inferior gluteal fold. The skin and subcutaneous tissues are then closed in layers. The marked supragluteal and flank wedges of skin are resected down to the fascia and the gluteal flaps are deepithelialized (Fig. 37.3). The inferior border of the flap is dissected at an oblique angle so that the base of the flap lies more inferior to allow for greater caudal mobility. The superior, medial, and lateral borders are dissected in a plane perpendicular to the underlying fascia including some muscle fibers from the gluteus maximus into the pedicle of the flap (Fig. 37.3). A pocket is then created for insertion of the flap by undermining the buttock skin and subcutaneous tissue caudally in the plane above the fascia, extending it to a sufficient length to reach the inferior gluteal crease (Fig. 37.3). The superior aspect of the flap is then detached in an intramuscular plane inferiorly until the flap can be rotated caudally 180° into the pocket and anchored to the fascia with polyglactin 910 (3/0 Vicryl) suture. The remaining buttock skin is then pulled superiorly over the flap and a drain is placed in each side. The lateral thigh is undermined inferiorly deep to the superficial fascial system using a Lockwood retractor. The superficial fascial system is then approximated with polyglactin 910 (0 Vicryl), and the skin and subcutaneous tissue are closed in a layered fashion. At this point, the patient is turned to the supine position with the legs abducted to expose the medial thighs. Liposuction is performed where necessary as previously described. Thereafter, resection of a crescent of redundant skin and fat at the superior medial

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thigh spiraling from the flank toward the infragluteal fold is made, thereby joining the previous flank and infragluteal excision sites. The Lockwood retractor is used for limited undermining of the anterior and lateral thigh in an inferior fashion deep to the superficial fascial system. The medial thigh is not undermined. The inferior margin of the incision is then suspended superiorly from the superficial fascial system to the superficial perineal (Colles’) fascia medially, inguinal ligament anteriorly, and periosteum of the anterior superior iliac spine laterally with PDS. The superior and inferior edges are then approximated in a layered fashion with subdermic running absorbable polyglactin 910 (3/0 Vicryl) and subcutaneous running absorbable poliglecaprone 25 (4/0 Monocryl).

37.4 Complications The procedure is performed at an outpatient surgery center under general anesthesia with 23-h postoperative observation. Operative time ranges from three and a half to four and a half hours. Total resection weight ranges from 2.3 to 3.7 kg (2.6 kg average), with an average volume of fat obtained by liposuction of 5,200 mL (5,000–7,000 mL). Mean operative blood loss is 220 mL (125–295 mL). Sequential compression devices and fractioned heparin are used for deep venous thrombosis prophylaxis before and after the procedure until the patient begins ambulation. Patients are continuously monitored during their stay, and intra and postoperative prophylactic antibiotics are used. Seroma and hematoma are usually prevented with meticulous surgical technique and drains, but if they occur, evacuation is required. Wound dehiscence or delayed wound healing are caused by technical errors in approximating the superficial fascial system or excessive tension during the closure. Visible scars are prevented by careful preoperative markings within the location of underwear. Inferior scar migration, labial separation, and early recurrence of ptosis are avoided by anchoring of the inferior skin flap to  the tough, inelastic deep layer of the superficial

37  Spiral Lift: Medial and Lateral Thigh Lift with Buttock Lift and Augmentation

perineal fascia medially, inguinal ligament superiorly, and periosteum of the anterior superior iliac spine laterally. In the authors’ experience with more than one hundred autoprosthesis buttock augmentations, there have been no instances of necrosis of the buttock dermal fat flap. Flap viability is corroborated by incising the most distal portion of the flap to check for adequate blood flow. Incorporating muscle in the superior undermined portion of the flap allows for a greater number of perforators to the flap.

37.5 Discussion Body contouring has continued to increase in popularity, as have the alternatives and procedures to address deformities. The trunk, buttocks, and thighs represent areas of increased patient interest and surgical technique modification. Consequently, familiarity with the presentation and effective treatment of these patients has become increasingly important [2, 3, 7]. The “pear” or “guitar” shaped body contour is an unaesthetic appearance that may cause much frustration for the patient and surgeon when encountered. The summation of deformities is very difficult to correct with diet and exercise alone. Liposuction can offer an improvement in patients that present with fat deposits without skin excess or laxity, but it is usually insufficient. More aggressive liposuction to correct these areas can result in untoward results and complications (Fig. 37.5). Traditionally, these patients have been treated with a combination of liposuction, flankplasty, belt lipectomies, lower body lifts, and/or medial thigh lifts [8–12]. Baroudi described an upper inner thigh lift and flankplasty with optional lipoplasty as an alternative method for performing a medial, anterior, and lateral thigh lift with a buttock lift [4, 7, 13]. Our modifications to the procedure include superficial fascial anchoring to the Colles’ fascia, inguinal ligament, and anterior superior iliac spine, aggressive liposuction, lateral and anterior thigh lift with

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undermining and high lateral tension, and a buttock lift with autoprosthesis augmentation using a dermal fat flap [5, 9, 10]. Anchoring of the inferior skin flap to the tough, inelastic deep layer of the superficial perineal fascia medially, inguinal ligament superiorly, and periosteum of the anterior superior iliac spine laterally has reduced inferior scar migration, labial separation, and early recurrence of ptosis [9]. The aggressive liposuction of the thigh is possible since it is done in combination with the circumferential thigh lift, thereby avoiding contour irregularities. The buttock lift is complemented with buttock augmentation to avoid a flattened buttocks contour after an aggressive resection of excess skin and subcutaneous tissue in the supragluteal region [5]. In contrast to gluteal flaps previously described [14–18], maximal projection of the buttocks is achieved at midlevel, which is aesthetically ideal [19]. By combining these techniques, the overall result is improved, since it not only relies on excision and lifting, but also includes a volumetric enhancement that leads to an improved and natural silhouette (Figs. 37.4–37.6).

37.6 Conclusions The spiral lift effectively addresses the “pear” or “guitar” shaped body contour deformity. The high satisfaction rate, the ease of concealing the incision with clothing, and the low complication rate suggest that this is a reliable and versatile technique. The procedure results in significant improved body contour and firmness of the skin in the medial and lateral thigh, trochanteric area, and gluteal region. The gluteal sulcus becomes less evident, the buttock mass is elevated, and the maximum projection is achieved at midlevel of the buttock. The scars are considered acceptable to the patients in respect to the procedure and easily concealed by a bikini-type bathing suit. The low complication rate, easily concealed scar, and high degree of contour correction contribute to a high patient and surgeon satisfaction rate.

360 Fig. 37.4  (a) Posterior and (b) Anterior preoperative and postoperative views after spiral lift. Note the improvement in the waist, buttock contour, and thigh circumference

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37  Spiral Lift: Medial and Lateral Thigh Lift with Buttock Lift and Augmentation Fig. 37.5  (a) Lateral and (b) three-quarter preoperative and postoperative views. Patient with previous overaggressive liposuction of lateral thighs with marked skin dimpling successfully corrected with the spiral lift

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362 Fig. 37.6  (a) Anterior, (b) lateral, and (c) posterior view of preoperative and postoperative photographs of a spiral lift

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37  Spiral Lift: Medial and Lateral Thigh Lift with Buttock Lift and Augmentation Fig. 37.6  (continued)

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References   1. Pitanguy I. Evaluation of body contouring surgery today: a 30-year perspective. Plast Reconstr Surg. 2000;105(4): 1499–514.   2. Aly A, Cram A, Heddens C. Truncal body contouring surgery in the massive weight loss patient. Clin Plast Surg. 2004; 31(4):611–24.   3. Cardenas-Camarena L. Various surgical techniques for improving body contour. Aesthetic Plast Surg. 2005;29(6): 446–55.   4. Baroudi R. Body contour surgery. Clin Plast Surg. 1989; 16(2):263–77.   5. Sozer SO, Agullo FJ, Wolf C. Autoprosthesis buttock augmentation during lower body lift. Aesthetic Plast Surg. 2005; 29(3):133–7.   6. Sozer SO, Agullo FJ, Palladino H. Spiral lift: medial and lateral thigh lift with buttock lift and augmentation. Aesthetic Plast Surg. 2008;32(1):120–5.   7. Baroudi R. Flankplasty: a specific treatment to improve body contouring. Ann Plast Surg. 1991;27(5): 404–20.   8. Farina R, Baroudi R, Golcman B, Castro O. Riding trouserslike type pelvicrural lypodystrophy. Br J Plast Surg. 1960; 13:174–8.   9. Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg. 1988;82(2):299–304.

10. Lockwood TE. Transverse flank-thigh-buttock lift with superficial fascial suspension. Plast Reconstr Surg. 1991; 87(6):1019–27. 11. Pitanguy I. Trochanteric lipodystrophy. Plast Reconstr Surg. 1964;34:280–6. 12. Schultz RC, Feinberg LA. Medial thigh lift. Ann Plast Surg. 1979;2(5):404–10. 13. Baroudi R. Contouring the hip and the abdomen. Clin Plast Surg. 1996;23(4):551–72. 14. Gonzalez M, Guerrerosantos J. Deep planed torso-abdominoplasty combined with buttocks pexy. Aesthetic Plast Surg. 1997;21(4):245–53. 15. Guerrerosantos J. Secondary hip-buttock-thigh plasty. Clin Plast Surg. 1984;11(3):491–503. 16. Pascal JF, Le Louarn C. Remodeling bodylift with high lateral tension. Aesthetic Plast Surg. 2002;26(3):223–30. 17. Pitanguy I. Surgical reduction of the abdomen, thighs and buttocks. Surg Clin North Am. 1971;51(2):479–89. 18. Regnault P, Daniel R. Secondary thigh-buttock deformities after classical techniques: prevention and treatment. Clin Plast Surg. 1984;11(3):505–16. 19. Cuenca-Guerra R, Lugo-Beltran I. Beautiful buttocks: characteristics and surgical techniques. Clin Past Surg. 2006; 33(3):321–32.

A Novel Treatment Option for Thigh Lymphoceles Complicating Medial Thigh Lifting Procedures

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Wayne K. Stadelmann

38.1 The Nature of Lymphatic Fluid Lymphatic fluid is a transudate derived from the ultrafiltration of blood across the endothelial layer of blood vessels. This fluid is devoid of cellular elements containing neither red blood cells nor platelets, yet it is rich in lymphocytes [1]. Lymph has high protein levels, but contains relatively small quantities of clotting factors [2]. The lack of platelets and clotting proteins predisposes cut lymphatic channels to leak and drain lymphatic fluid for hours to days after the channels are transected. Trying to seal transected lymphatics using electrocautery alone is relatively ineffective as the electrically induced thermal trauma cannot initiate a clotting cascade. Ideally, if lymphatic channels are cut, they should be sealed either with ligatures or hemoclips to prevent a postoperative leak from occurring. Most lymphatic channels are quite small and contain clear to yellow-tinged fluid, making their identification difficult intraoperatively. Once transected, lymph will flow passively into any adjoining potential space resulting in a sterile protein-rich fluid collection termed a lymphocele (Fig. 38.1). A lymphocele will enlarge until the pressure exerted by the accumulating lymphatic fluid equals the pressure exerted by the surrounding tissues. This is typically on the order of 10 mmHg pressure [1]. If the skin integrity over a lymphocele is violated, the flow of lymph will be externalized and lymphorrhea will occur (Fig. 38.2). Lymphatic fluid is a very good bacterial culture medium as it is protein-rich, has a high concentration of glucose, and is warm. Correspondingly,

Fig. 38.1  A well-established left groin lymphocele that is firm, protuberant, and uncomfortable for the patient

infections are always a concern with lymphoceles and the risk for infection becomes more acute with the development of lymphorrhea. Lymph production and lymph flow are dependent on blood flow, blood pressure, protein status, and muscle activity, and may range between 4 and 900 mL/kg/h [1]. Exercise will increase lymph production between 5 and 15 times above baseline levels. Lymphatic leaks are made more likely by several contributing factors such as prior radiation exposure to the lymphatic bed being operated upon, systemic steroid use, anticoagulation, infection, hematoma formation, and diuretic use [2].

38.2 Procedures at Risk for Groin Lymphocele Formation W. K. Stadelmann 248 Pleasant Street, Pillsbury Medical Office Building, Suite 201, Concord, NH 03301, USA e-mail: [email protected]

In the groin, oblique incisions place the lymphatic channels at risk for trauma, especially if the incisions

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is created which can subsequently passively fill with lymphatic fluid. With early ambulation and activity, the lymphocele may enlarge precipitously. Once formed, lymphoceles that fail to resolve spontaneously are notoriously difficult to treat and pose a constant threat of infection, as well as compromised patient satisfaction.

38.3 Treatment Options for Lymphoceles and Lymphorrhea The majority of lymphoceles will resolve spontaneously using external compression and extremity edema control. For refractory lymphatic fluid collections, numerous surgical as well as nonoperative methods have been used, all of which have a recurrence rate of up to 50% [6]. While not exhaustive in its scope, the following is a listing of the most commonly used treatments:

Fig. 38.2  Lymphorrhea originating from a lymphocele that has developed a sinus tract with the overlying skin. The risk of infection is elevated when the lymphatic collection communicates with the groin skin and native bacterial organisms

transverse the deep fascia above the femoral triangle. Any procedure performed in this area runs the risk of inadvertently damaging the underlying lymphatics. Lymphoceles have been reported with groin lymph node biopsies, vascular access for cardio-pulmonary bypass procedures, arterial revascularizations, saphenous vein manipulation and harvest, as well with medial thigh lift procedures [2–5]. Postoperative seroma formation has been documented in up to 19% of thigh lift procedures [5]. An early report of a lymphocele following an elective thigh lift was published in 1983 by Leitner and Sherwood [2]. Lymphoceles accompanying groin and pelvic lymphadenectomies have been reported to occur between 3 and 49% [2]. Medial thigh lift procedures often encroach upon the femoral triangle and even if the deep fascia is not violated, multiple small lymphatic channels may be transected. With a medial thigh lift operation, often a large potential space

1. Observation with leg elevation and edema control with compression garments and reduced physical activity has been shown to be successful in 70% of thigh lymphoceles [7]. Muscle activity is known to increase the production of lymphatic fluid from 5 to 15 times above baseline lymph production [8]. Therefore, by keeping the extremity at rest and providing edema control, lymph production and the associated increase in the lymphatic pressure head at the lymphocele can be minimized. Once a lymphocele has been well established, however, reducing the rate of lymph production may reduce the size of the fluid collection, but the potential space will persist only to fill time and time again. 2. Serial percutaneous aspirations and compression along with edema control. This method is potential curative when the lymphocele is young and the lining has not yet matured. Aspiration may also cause hemorrhage within the cavity, which may serve as an irritant promoting the formation of adhesions with subsequent obliteration of the potential space into which lymphatic fluid may accumulate. Aspirations may also introduce bacteria into the sterile fluid-filled space resulting in an abscess with the predictable consequences of loss of contour, depression of the local tissues, pain, fibrosis, and excessive scar formation.

38  A Novel Treatment Option for Thigh Lymphoceles Complicating Medial Thigh Lifting Procedures

3. Percutaneous aspiration and simultaneous instillation of sclerosing agents. Numerous agents have been used as sclerosants to attempt to cause an intense inflammatory response within the lining of the lymphocele and promote adhesions between the walls of the cavity. These agents have included talc, alcohols, bleomycin, tetracycline, ampicillin, doxycycline, and providone–iodine [9–13]. Success rates are variable and often multiple treatment sessions are needed. 4. Percutaneous placement of a closed system drainage catheters [14–16]. Drains can be used as a sole treatment option or in combination with sclerosants. Once again success rates are variable. 5. Operative approaches are mainly limited to direct exploration of the lymphocele with damaged lymphatic channel obliteration using ligatures. Visualizing the transected lymphatics is often very difficult, especially if the lymphocele lining is resected at the same time as the initial exploration. Surgical dogma has maintained that the lining of a lymphocele should be removed at the time of surgical exploration [2]. Direct physiological support for this practice is not well documented. The lining of a lymphocele is similar in texture to the fibrous capsule surrounding breast implants and lacks a true distinct epithelial lining. When a breast implant explantation is performed and a new implant is not inserted, a formal capsulectomy may not be performed and some residual capsule may be left behind. The capsule eventually is reabsorbed and obliterates. The same phenomenon occurs with a lymphocele lining, provided that the production of lymphatic fluid is stopped and the potential space incorporated by the lymphocele is obliterated. Additionally, and more importantly, the lining of the lymphocele directly overlays undamaged lymphatic channels as will be discussed below. If the lining is removed, these fine lymphatics may be transected and may then contribute to the high recurrence rates (up to 50%) traditionally seen with open operative treatment approaches [17]. 6. Operative treatment using muscle flaps such as the sartorius and rectus femoris muscles to obliterate the potential space occupied by the lymphocele [18–20]. This technique is particularly useful if the lining of the lymphocele has been removed and the resultant dead space cannot be obliterated using direct suturing. Muscle flaps do require more local dissection that can result in contour irregularity, which would not be desirable when dealing with a complication

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Fig. 38.3  A groin lymphocele that has been treated with a prior operative drainage, lining excision, and a rectus femoris flap. The lymphocele has recurred despite this relatively extensive operation. The lateral thigh is also depressed over the muscle donor site, which became more obvious when the patient was standing upright

resulting from a cosmetic procedure (Fig. 38.3). Muscle flaps are also associated with a small but real risk of bleeding and hematoma formation. 7. Operative treatment using lymphatic mapping and direct surgical ligation of leaking lymphatics. Several authors have written about using vital dyes to identify the leaking lymphatics that are responsible for the formation of lymphoceles [3, 5, 6, 16, 17]. The use of lymphatic mapping provides a relatively easy, safe, and effective method to identify and ligate leaking lymphatic channels. As described below, this technique has little associated morbidity.

38.4 Rational for Using Intraoperative Lymphatic Mapping with Blue Dye Lymphatic mapping using various dyes has been performed for many years [21]. While Patent Blue V and Evan’s blue have been used for lymphatic mapping, the dye most commonly used today is 1% isosulfan blue

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Fig. 38.4  Isosulfan blue dye has been used for sentinel lymph node mapping and harvesting for nearly 20 years. As seen here in a breast cancer case, the dye imparts a brilliant blue hue that is seen migrating away from the injection site through the dermal lymphatics. Isosulfan blue dye is relatively safe, but on rare occasions, it does create a mild powder blue-colored tattoo that may take over a year to resolve and may be permanent

[22]. Over the past two decades, isosulfan blue dye has emerged as a reliable, safe, and easy-to-use agent that has few side effects and an allergic reaction incidence of about 1% (Fig. 38.4) [23–27]. This dye is watersoluble, has a deep azure color, is selectively absorbed by lymphatic channels, has rapid transit time of about 10 cm/min, and has little extravasation beyond the lymphatic system making its use clean and precise [28]. Isosulfan blue is currently used for the sentinel node evaluation in patients with cutaneous malignancies such as melanoma, squamous cell carcinoma, Merkel cell carcinoma, as well as breast cancer and several other visceral malignancies [29–33]. Isosulfan blue dye has also been used before to assist in the intraoperative identification of leaking lymphatics for treating lymphoceles [3, 6, 16, 17]. Although the dye is not considered to be permanent, a prolonged blue hue at the injection site, especially in the lower extremities, back area, and the breast, has been reported. The possibility of permanent tattooing with the blue dye should, therefore, be discussed with the patient preoperatively.

38.5 Operative Technique for Treating Groin Lymphoceles Prior to treating a refractory groin lymphocele, no special imaging studies are needed in the absence of

W. K. Stadelmann

Fig. 38.5  In this patient, the groin lymphocele was secondary to an arterial bypass procedure. A preoperative duplex ultrasound scan was done to confirm that a pseudoaneurysm was not present

known trauma to the femoral area. If a firm mass exists, examination with a stethoscope should be performed to identify any bruits. A duplex ultrasound may be obtained if there is even the remote chance of a pseudoaneurysm or an arteriovenous fistula being present (Fig. 38.5). If these studies are positive, a vascular surgery consultation should be considered and/or contingency plans be made to deal with sudden arterial hemorrhage intraoperatively. Prior to prepping out the groin, 1% isosulfan blue dye is injected intradermally in the ankle area in four locations placed equidistantly around the extremity (Fig. 38.6). The rationale for this maneuver is to identify the cutaneous region corresponding to the leaking lymphatic. This is essentially a sentinel node mapping procedure done in reverse. With a lymphocele, the lymphatic vessels that are leaking need to be identified by the blue dye that is injected intradermally. The dermal drainage patterns cannot, however, be determined by random injection of blue dye. For example, the leaking lymphatic may drain a cutaneous distribution over the posterior leg. Blue dye injected into the anterior leg would not travel to the groin via the lymphatics that are damaged, and therefore, the leaking lymphatics would not stain blue and would defy detection. The blue dye should be injected in all four quadrants of the extremity, so that the draining blue dye will have the greatest likelihood of being transported to the lymphocele by the leaking lymphatic channel. After the dye is injected, the extremity is elevated and massaged to promote the more rapid transit of the dye

38  A Novel Treatment Option for Thigh Lymphoceles Complicating Medial Thigh Lifting Procedures

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a

b

Fig. 38.7  The typical lymphocele, if not infected, contains clear to yellow-tinged fluid under relatively low pressure. Here a large lymphocele is being drained prior to cavity exploration

Fig. 38.6  (a) Distal leg intradermal injections of the blue dye are done in at least four quadrants to capture any lymphatics that may be contributing to the lymphatic leak. The blue dye can be seen streaming through the dermal lymphatics toward the groin which is located to the left of the image. Point A represents the medial malleolus. (b) Another patient undergoing an extremity blue dye injection. Note the rapid uptake of the dye within the dermal lymphatics after the dye was injected intradermally

through the dermal lymphatics. The groin is then prepped and draped. Depending on the incision used to perform the medial thigh lift, an incision is made directly over the lymphocele. During the subcutaneous dissection, any blue staining lymphatics should be controlled with ligatures or hemoclips. Once the lymphocele is encountered, the anterior surface is incised and the contained fluid is evacuated (Fig. 38.7). The cavity lining is then carefully inspected for blue dye emerging from the offending lymphatic leak(s) (Fig. 38.8). The rate of dye emergence is dependent on the size of the lymphatic and also on the amount of time that has transpired since the time of injection. Often, the site of emergence is tiny and seems almost inconsequential (Fig. 38.9). Remembering that the patient is at rest with no active muscle contractions while anesthetized will help put the minimal flow volumes in perspective. Small leaks at rest can be much more voluminous when the patient

is ambulating and physically active. If no blue dye is seen, the injection site is massaged through the sterile drapes and the leg is elevated. Rarely is further injection of dye required, but this should be contemplated if absolutely no dye is seen to emerge after about 20–30 min. The leaking lymphatics may be multiple and a thorough search for any blue staining needs to be done to minimize any possible recurrence. At this time, the lining of the lymphocele may be seen to overlay multiple blue staining lymphatics that are beautifully demonstrated with this technique. These lymphatics are directly deep to the lining and are at risk for being transected if the lining is excised. This is the main reason why the lymphocele lining is not removed. The leaking lymphatics are now oversewn with figure-of-eight 4–0 monofilament absorbable sutures. The cessation of leaking blue dye provides immediate confirmation that the lymph leak has been successfully treated. Next, the lymphocele is closed by imbricating the lining with multiple layers of the figure-of-eight monofilament sutures. The lining of mature lymphoceles is quite tough and holds sutures very well (Fig. 38.10). This is the second reason to not resect the lining. If the lining is removed, the space created is lined by subcutaneous fat that does hold sutures well, especially if they are placed under tension. Usually the imbrication is done closing the cavity with multiple layers that completely obliterate the cavity, so completely that a drain is rarely used (Fig. 38.11).

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a

b

Fig. 38.9  An almost imperceptible leak causing a mere blush of blue dye to emerge. Despite waiting for almost 30 min, no other sites were seen to drain any blue fluid. The leaking lymphatic was oversewn and the capsule imbricated in multiple layers using a monofilament suture. No drain was used. An uncomplicated recovery followed with complete resolution of the lymphocele

a

Fig. 38.8  (a) In this patient, the lymphocele has been drained and fillet open after blue dye was injected into the ipsilateral distal extremity. Blue dye was seen to emerge immediately from two separate locations. Also, note the faint blue hue to the left of the superior leaking site. This represents subcapsular lymphatics that would be at risk for transection if the capsule was resected. (b) In this melanoma patient, the blue dye is seen traveling through the subcutaneous lymphatics. The blue dye is spectacular to observe

b

38.6 Postoperative Care The postoperative regimen is intended to reduce lymph production. By using compressive toe to thigh dressings, leg elevation, and relative extremity inactivity for 3–4 days postoperatively, the production of lymph is minimized. Exercise has been shown to increase the production of lymphatic fluid by as much as 5–15 times above baseline. Decreasing the production of lymph would seem to be a logical goal to minimize any pressure on the ligated lymphatics. Dry gauze dressings are placed over the incision every 12 h

Fig. 38.10  (a) A typical mature lymphocele. The lining is thick and fibrous and holds sutures extremely well. To the left near the army-navy retractor, the capsule has been transected and the surrounding fat can be seen. The fat is not able to hold sutures nearly as well and complete obliteration of the cavity is often difficult if the lining is resected. (b) Another lymphocele cavity with the thick capsule in situ

38  A Novel Treatment Option for Thigh Lymphoceles Complicating Medial Thigh Lifting Procedures Fig. 38.11  (a) The preoperative appearance of a 50-year-old woman with a groin lymphocele. (b) The same patient after the lymphocele was treated with lymphatic mapping, lymphatic ligation, and cavity obliteration with multiple layers using monofilament sutures. Full recovery was about 4 weeks postoperatively. The contour is normal and the scarring is quite acceptable

a

after the incision is wiped with a provolone iodine moistened gauze pad. Provolone iodine dressings are performed for 3–4 days postoperatively to reduce surface bacterial contamination. This regimen is admittedly empiric; however, it makes physiologic sense and has been associated with neither recurrent lymphoceles nor postoperative infections. After about 4 days, a gradual return to “normal” activity is allowed. I caution my patients to use common sense and refrain from working out or taking long walks for about 2 weeks. After this time, the repair should be healed well enough to allow resumption in the preoperative activity level.

38.7 Risks and Complications The main risks associated with the described technique are the ½% risk of blue dye associated anaphylactic reaction, blue staining of the skin at the injection site, bleeding, hematoma, infection, and the chance that the lymphocele may recur. I have performed over 25 lymphocele repair procedures with a 0% recurrence rate and no major bleeding or infectious complications. For the novice, the failure rate will likely be higher at first, especially if the surgeon is not familiar with sentinel node mapping techniques. It may prove prudent to refer the rare patient with this complication to a plastic surgeon who frequently does melanoma cases. It might also be a good idea to send along a copy of this chapter as well.

371

b

38.8 Conclusions A simple, safe, effective, and cosmetically acceptable method has been described to treat postoperative groin lymphoceles accompanying medial thigh lift procedures. This technique incorporates blue dye lymphatic mapping technology, direct visual identification and ligation of leaking lymphatics, maintenance of the lymphocele lining, and obliterating the lymphocele space with multiple layers of imbricating monofilament sutures. An empiric postoperative treatment regimen was also presented that is designed to minimize lymphatic flow and reduce surface colonization.

References   1. Eckert R, Randall D, editors. Animal physiology mechanisms and adaptations. 2nd ed. New York: WH Freeman; 1983. p. 579–80.   2. Leitner DW, Sherwood RC. Inguinal lymphocele as a complication of thighplasty. Plast Reconstr Surg. 1983;72(6): 878–81.   3. Stadelmann WK. Intra-operative lymphatic mapping to treat groin lymphorrhea complicating an elective medial thigh lift. Ann Plast Surg. 2002;48(2):205–8.   4. Lockwood TE. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6):1112–22.   5. Candiani P, Campiglio GL, Signorini M. Fascio-fascial suspension technique in medial thigh lifts. Aesthetic Plast Surg. 1995;19(2):137–40.   6. Stadelmann WK, Tobin GR. Successful treatment of 19 consecutive groin lymphoceles with the assistance of intraoperative lymphatic mapping. Plast Reconstr Surg. 2002;109(4): 1274–80.

372   7. Mori N. Clinical and experimental studies on the so-called lymphocyst which develops after radical hysterectomy in cancer of the uterine cervix. J Jpn Obstet Gynecol Soc. 1955; 2:178.   8. Guyton AC. Textbook of medical physiology. 5th ed. Philadelphia: Saunders; 1976. p. 370–3.   9. Cannon L, Walker AJ. Sclerotherapy of a wound lymphocele using tetracycline. Eur J Vasc Endovasc Surg. 1997;14(6): 505. 10. Seelig MH, Klingler PJ, Oldenburg WA. Treatment of postoperative cervical chylous lymphocele by percutaneous sclerosis with povidone-iodine. J Vasc Surg. 1998;27(6): 1148–51. 11. Zuckerman DA, Yaeger TD. Percutaneous ethanol sclerotherapy of postoperative lymphoceles. AJR Amer J Roentgenol. 1997;169(2):433–7. 12. Kerlan RK Jr, LaBerge JM, Gordon RL, Ring EJ. Bleomycin sclerosis of pelvic lymphoceles. J Vasc Interv Radiol. 1997; 8(5):885–7. 13. Folk JJ, Musa AG. Management of persistent lymphocele by sclerotherapy with doxycycline. Eur J Obstet Gynecol Reprod Biol. 1995;60(2):191–3. 14. Hoffman MS, Mark JE, Cavanagh D. A management scheme for postoperative lymphocysts. Gynecol Oncol. 1995;56(2): 262–5. 15. Kwaan JH, Bernstein JM, Connolly JE. Management of lymph fistula in the groin after arterial reconstruction. Arch Surg. 1979;114(12):1416–8. 16. Schanzer H, Skladany M. Treatment of lymphorrhea by early selective lymphatic ligation. Surgical Rounds. 1999: 542–5. 17. Weaver FA, Yellin AE. Management of postoperative lymphatic leaks by use of isosulfan blue. Letter to the editor. J Vasc Surg. 1991;14(4):566–7. 18. Goldstein JA, Janu P, Fields B. Rectus femoris flap repair of recalcitrant inguinal lymphoceles after heart transplantation. J Heart Lung Transplant. 1994;13(3):549–53. 19. Roberts JR, Walters GK, Zenilman ME, Jones CE. Groin lymphorrhea complicating revascularization involving the femoral vessels. Am J Surg. 1993;165(3):341–4. 20. Soots G, Mikati A, Warembourg H Jr, Watel A, Noblet D. Treatment of lymphorrhea with exposed or infected vascular prosthetic grafts in the groin using sartorious myoplasty. J Cardiovasc Surg (Torino). 1988;29(1):42–5. 21. Morton DL, Wen D-R, Wong JH, Economou JS, Cagle LA, Strom FK, Foshag LJ, Cochran AJ. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg. 1992;127(4):392–9.

W. K. Stadelmann 22. Reintgen DS, Rapaport DP, Tanabe KK, Ross MI. Lymphatic mapping and sentinel lymphadenectomy. In: Balch CM, editor. Cutaneous melanoma. 3rd ed. St. Louis: Quality Medical Publishing; 1998. p. 227–44. 23. Cimmino VM, Brown AC, Szocik JF, Pass HA, Moline S, De SK, Domino EF. Allergic reactions to isosulfan blue during sentinel node biopsy-a common event. Surgery 2001; 130(3):439–42. 24. Komenaka IK, Bauer VP, Schnabel FR, Horowitz E, Joseph KA, Ditkoff BA, El-Tamer MB. Allergic reactions to isosulfan blue dye in sentinel lymph node mapping. Breast J. 2005; 11(1):70–2. 25. Raut CP, Hunt KK, Akins JS, Daley MD, Ross MI, Singletary SE, Marshall GD Jr, et al. Incidence of anaphylactoid reactions to isosulfan blue dye during breast carcinoma lymphatic mapping in patients treated with preoperative prophylaxis. Cancer. 2005;104(4):692–9. 26. Montgomery LL, Thorne AC, Van Zee KJ, Fey J, Heerdt AS, Gemignani MN, Port E, Petrek J, Cody HS III, Borgen PI. Isosulfan blue dye reactions during sentinel lymph node mapping for breast cancer. Anesth Analg. 2002;95(2): 385–8. 27. Leong SPL, Donegan E, Heffernon W, Dean S, Katz JA. Adverse reactions to isosulfan blue during selective sentinel lymph node dissection in melanoma. Ann Surg Oncol. 2000; 7(5):361–6. 28. Nathanson SD, Nelson L, Karvelis KC. Rates of flow of 99m-labled human serum albumin from peripheral injection sites to sentinel lymph nodes. Ann Surg Oncol. 1996;3(4): 329–35. 29. Stadelmann WK, Javaheri S, Cruse CW, Reintgen DS. The use of sentinel lymphadenectomy in squamous cell carcinoma of the wrist. a case report. J Hand Surg Am. 1997;22(4):726–31. 30. Javaheri S, Cruse CW, Stadelmann WK, Reintgen DS. Sentinel node excision for the diagnosis of metastatic neuroendocrine carcinoma of the skin: a case report. Ann Plast Surg. 1997;39(3):299–302. 31. Messina JL, Reintgen DS, Cruse CW, Rappaport DP, Berman C, Fenske NA, Glass LF. Selective lymphadenectomy in patients with merkel cell (cutaneous neuroendocrine) carcinoma. Ann Surg Oncol. 1997;4(5):389–95. 32. Albertini JJ, Lyman GH, Cox C, Yeatman T, Balducci L, Ku N, Shivers S, et  al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA. 1996;276(22): 1818–22. 33. Reintgen DS, Albertini J, Miliotes G, Berman C, Cruse CW, Fenske N, Glass F, et al. The Accurate staging and modern day treatment of malignant melanoma. Cancer Res. 1995; 4:183–97.

Fat Augmentation of Buttocks and Legs

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Lina Valero de Pedroza

39.1 History Surgical techniques to enhance buttocks’ or calves’ volume have consisted of placement of silicone implants below the gluteus maximus muscle in the buttocks or over the internal gemellus muscle for calves. Those surgical techniques with placement of silicone implants were performed by the author; however, they were inconvenient because they had the following consequences: 1. Very painful within the twenty postoperative days. 2.  Very poor aesthetic results. 3. Permanent and/or long-term disabilities that consisted of persistent pain when in the sitting position or whenever wearing heels. Fat transfer was used by the author to obtain optimal aesthetic results, reduce the recovery period, reduce the side effects, and avoid physical or aesthetic complications. Extensively related uses of small quantities of fat tissue were described in the medical literature since 1893 to correct defects in soft tissues.

39.2 Technique 1. Fat retrieval is from any anatomical area below the neck that is good to retrieve fat tissue. There are major areas of concentration of volume such as the arms, back, abdomen, hips, knees, and buttocks.

L. Valero de Pedroza Clínica La Font, Carrera 16, No 86A–32, Bogotá, DC, Colombia e-mail: [email protected]

2. Tumescence with 1,000 mL saline containing 1 mL epinephrine is performed in any area used as a donor site. Five to ten minutes before harvesting are required to achieve maximum hemostasis and obtain clean tissue. 3. Liposuction is performed with a mixture of ultrasonic-assisted liposuction and traditional liposuction at low pressure with machine. The use of ultrasound-assisted liposuction was from September 1997 to the present time. From 1991 to 1997, machine suction was performed at low pressure. 4. The fat tissue graft is placed in sterile glass flasks that have been vapor sterilized. An amount of 1–3 L and more is kept sterile for about 15–25 min with no contact with air until decantation of the cells is done. 5. After the natural separation of the fat has occurred with the fat cells rising to the surface and the tumescent liquid on the bottom of the flasks, the harvested tissue is ready to be transferred to a sterile syringe. 6. For large volumes, a 60-mL syringe is used, and for small volumes, a 10-mL syringe is used to inject the graft.

39.3 Materials 1. Cannulas from 3 to 5 mm are used to harvest tissue. If tissue is retrieved with a 3-mm cannula, injection of the graft is performed with a 3-mm cannula. 2. Blunt cannulas to harvest and blunt cannulas to graft are used. 3. Suction machine at low pressure 350 mm Hg is used to preserve the integrity of the cells that could be disrupted under high vacuum pressure.

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L. Valero de Pedroza

4. Syringe suction is recommended for small amounts of fat tissue transplant. 5. Centrifugation of a small amount of fat tissue to be transplanted over the face and hands is recommended in order to obtain a more precise quality of graft free of liquid and avoid unnecessary edema. 6. No washing or exposing to the air is the main purpose in managing the graft to preserve its viability and preventing its contamination, as a priority.

39.4 Fat as a Tissue Filler Fat tissue has three of its characteristics that make it the ideal tissue filler: (1) It is composed of cells that have the property to be hypertrophic; (2) It is composed of cells able to grow in volume, and at the same time, it is a hyperplasic tissue; and (3) It has a large amount of cells, able to grow in volume (hyperplasic nature). These properties make it the ideal “Soufflé” to fill a depressed or deformed anatomical area.

a

39.5 Placement of the Fat Graft The nature of human anatomy places fat tissue under the skin surface and over the muscular structure. Intraperitonealy, it covers all the abdominal organs and structures and we find a large amount of fat cushion denominated “Epiplon.” The author sculpts the normal anatomy of the human body by reshaping and relocating fat tissue. The initial goals were based on enhancing the volume of buttocks, ankles, and calves for beautification. The graft was placed under the skin following the normal anatomic growth and existence of the fat tissue. The author has found fat of great help as a total body tissue filler to reconstruct body deformities from traumatic, congenital, or iatrogenic origin. It produces excellent results in cosmetic enhancement, is a long-term survival tissue, is well tolerated, and  has low risks if the graft is adequately manipulated (preventing its contamination and preserving the survival of its cells while harvesting it) (Figs. 39.1–39.4).

b

Fig. 39.1  (a) Preoperative 58-year-old female with aging process of the buttocks with wrinkles and loss of volume. (b) Eight months postoperative after 300 mL of fat transfer to each side

39  Fat Augmentation of Buttocks and Legs

a1

375

a2

Fig. 39.2  (a1, 2) Preoperative 28-year-old female requesting increased volume of buttocks. (b1, 2) One year following fat retrieval from abdomen, waist, and hips, and transfer of 300 mL of fat to each buttock

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b1

b2

Fig. 39.2  (continued)

39.6 Synopsis of Technique (a)  Materials 1.  3–5 mm cannulas 2.  Syringe suction 3.  Machine suction low pressure 4.  3–5 mm cannulas blunt for injection 5. Tumescence with 1,000 mL saline and 1 mg epinephrine 6.  Sterile glass 1,000 mL flasks

(b)  Donor site areas 1.  Arms 2.  Back 3.  Hips 4.  Abdomen 5.  Buttocks 6.  Knees (c)  Methods 1.  Traditional suction machine 2.  Syringe suction

39  Fat Augmentation of Buttocks and Legs Fig. 39.3  (a) Preoperative 27-year-old male with agenesis of gemellus muscle of the right leg. (b) Seven years after 350 mL fat graft over the agenetic musculature of the right leg

a

3.  Ultrasound-assisted liposuction 4. Centrifugation for small amounts of fat transplant tissue (for face and hands) (d)  Recipient areas 1.  Buttocks 2.  Hips 3.  Muscular atrophies in legs, arms, ankles (e)  Manipulation of the graft 1.  No washing 2. Natural decantation 15–25 min in the sterile glass flasks 3.  Storage for 30–45 min with no air contact 4. Direct liposuction from patients, to flasks, to sterile syringes, to patient again as a graft (f)  Amount of fat volume transplanted Area amount Each buttock 240–700 mL Each leg 150–400 mL

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b

Each ankle 120–280 mL Each hip 300–750 mL

39.7 Qualities of Fat Transplant 1.  It is an autologous tissue 2.  Hyperplasic tissue (large number of cells) 3. Each fat cell has an hypertrophic capacity to grow in volume (the “soufflé” effect) 4.  Normal to the touch 5.  No side effects if manipulated sterile 6.  Easy handling 7.  Long lasting – permanent in life 8.  No functional changes 9. It is a fat cells graft, not a fat (liquid) or oil i­njection

378 Fig. 39.4  (a1, 2) Preoperative 72-year-old male with “skinny” legs. (b1, 2) Two and one half years after 300 mL fat transfer to each calf and ankle

L. Valero de Pedroza

a1

a2

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39.8 Complications

39.9 Conclusions

In the author’s cases there were a few slight complications varying from skin vesicles from the skin tape, redness without injection, edema of the ankles for 20 days postoperatively, and one case of erysipelas occurred from trauma that was treated with penicillin and without losing the fat transplant volume injected over the legs.

The author recommends fat transfer to all patients for reconstructive and cosmetic purposes because of the clinical results and satisfaction of the patients, after a long term follow-up during the 16 years making use of this technique.

Lower Leg Augmentation with Combined Calf-Tibial Implant

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Afshin Farzadmehr and Robert A. Gutstein1

40.1 Introduction Augmentation of the calves has been performed for over 25 years. Patients seeking this procedure have underdeveloped lower legs that make them self-conscious and their calves are source of embarrassment. This is even more true when the underdevelopment or  atrophy is associated with asymmetry, congenital deformity (tibial torsion, pes planus, genu valgus) traumatic nerve injury or disease (polio). In some people exercise would not help in building the musculature in the calves. Calf augmentation with implant has been performed by placing a subfascial silicone implant from a transverse incision in the popliteal crease in a plane dissected between the gastrocnemius fascia and the muscle. Usually either medial and/or lateral gastrocnemius is augmented with the medial one being a larger size. In patients who have lower legs that are also thin from calf to the ankle, just performing the calf augmentation alone would exaggerate the deformity. In 2003, Gutstein [1] developed an implant to address the deficiency of contour of the lower leg and calves combined via an implant that would have a rodlike structure extending from the lenticular implant inferiorly. He had operated in over 40 patients successfully of varied ages with a variety of presenting conditions. The majority had generalized (congenital) hypoplasia and hypoplasia with tibial torsion. There were also patients with polio, direct trauma, club foot,

1

trauma with nerve damage, and burn scars. They all had one thing in common, which was either “I will not wear shorts” or “I will not wear short skirts.” Among these patients, there were those who had previous calf augmentation and wanted to exchange the medial implant with one with extended calf-tibial implant. It was noted that sufficient pliable tissue is necessary, but it was possible to achieve distention and safe implantation with extensive but mature scars present.

40.2 Implant The implant is a one piece, molded, soft, solid silicone structure with proximal portion similar to the Aiache lenticular implant and a rod extension from the inferomedial border of the gastrocnemius to just above medial malleolus (Fig. 40.1). The rod extension’ length varies from 12 to 20 cm depending on the length of patient’ leg. The rod portion is 2.5 cm wide and projects 1.3 cm feathering at the distal end. The proximal portion of the implant corresponds to Aiache 3, 4, 5 implant and the choice is based on the patient’s input regarding the bulk and definition of the calf and with consideration of tissue distensibility. During consultation, measurements of the lengths of the medial and lateral heads of the gastrocnemius, as well as the length between the inferior border of the medial belly of the gastrocnemius and the malleolus

Posthumously for Robert A Gutstein.

A. Farzadmehr (*) Plastic Surgery Center of Beverly Hills, 1125 South Beverly Drive, Suite 600, Los Angeles, CA 90035, USA e-mail: [email protected]

Fig. 40.1  Gutstein implant

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are taken. With these measurements, the implant can be ordered through Hanson Medical (US Patent no. USD478,988S). The implant is solid silicone with durometer of 4.5–5.0.

A. Farzadmehr and R. A. Gutstein

a

40.3 Technique Based on patient’s preference, this procedure could be performed under local, dissociative twilight, or general anesthesia. The patient is placed in prone position and the ankles elevated slightly. Local anesthesia is injected, usually 0.5% lidocaine with epinephrine into the incision line and as a field block for the calf and the medial leg. A 4-cm incision is marked at the popliteal crease 3 cm medial to the midline of the leg and 1 cm lateral to that point. The incision is carried through the superficial fascia to the thin fascial covering adherent to the gastrocnemius muscle. At this level, the subfascial pocket is made. A bridge is allowed to remain containing the lesser saphenous-sural nerve bundle if both heads of the muscle are to be augmented. The medial head is only augmented in cases of tibial torsion, especially in women. Blunt dissection is performed in this plane using blunt scissors, middle finger, and a flat cannula (which also instills Marcaine), and finally the long paddle or spade to the inferior border of gastrocnemius fascia. The long, straight, ribbon retractor with a hole drilled near each end is passed into the medial compartment to enter the subfascial plane of soleus. A piece of umbilical tape is passed through the proximal hole in the instrument and the tape is tied over the implant so that the implant tip is on the metal “sled.” The ribbon metal retractor sled is advanced to just above the medial malleolus. Palpation delineates the instrument and a vertical incision of 2 cm is made over it, 2 cm proximal to the malleolus. The incision is spread and the ribbon dissector exposed (Fig. 40.2). The tibialis posterior tendon should be posterior to this area and the greater saphenous vein anterior to the exit point. The hole in the distal end of the sled is helpful in retrieving it with a curved hemostat. The ribbon retractor is pulled through and the implant extension follows. The umbilical tape is removed, a slight distal dissection of the subfascial pocket is made, and the end of the implant is seated. Then, 4–0 nylon is used to approximate the fascia, 4–0 Vicryl is used to approximate the subcutaneous tissue, and the skin is closed with subcuticular 4–0 Prolene. If the lateral gastrocnemius compartment is to be augmented, an appropriate sized Aiache implant is positioned in the lateral subfascial pocket.

b

Fig. 40.2  The ribbon retractor is passed from the incision at the popliteal crease to the area 2 cm proximal to the medial malleolus

The popliteal incision is repaired with 4–0 nylon, 3–0 or 4–0 Vicryl, and 4–0 subcuticular Prolene. If the patient will not be available for suture removal in 10–14 days because of geographic consideration, 4–0 polydioxanone or Monocryl is used. Xeroform gauze, 4 × 4 gauze, paper tape, and 65-in. Ace wraps are used for dressing. The legs should be elevated as much as possible for the first 2 days, with limited ambulation. Ace wraps are continued for another week. Use of an elevated heel is helpful in the early postoperative period. Lower body exercises may commence in 4 weeks. Ancillary procedures such as liposuction of fat or AlloDerm grafting are useful at times to complete the contour correction at the knees or ankles. Over time and with experience, the leg extension rod has been made longer, feathering it to slide over the proximal slope of the malleolus, which eliminates any gap in contour. Also, a longer, 18-in. metal sled has been used in taller patients so that an intermediate incision is no longer necessary.

40.4 Discussion The patients who underwent this procedure to enhance the entire thin and/or curved medial lower leg have all  expressed great pleasure with their augmentation (Figs. 40.3–40.6). There have been no limitation of motion, no malposition, and no athletic restrictions.

40  Lower Leg Augmentation with Combined Calf-Tibial Implant Fig. 40.3  (Left) Preoperative. (Right) Postoperative

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384 Fig. 40.4  (Left) Preoperative. (Right) Postoperative

A. Farzadmehr and R. A. Gutstein

40  Lower Leg Augmentation with Combined Calf-Tibial Implant Fig. 40.5  (Left) Preoperative. (Right) Postoperative

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386 Fig. 40.6  (Left) Preoperative. (Right) Postoperative

Reference   1. Gutstein RA. Augmentation of the lower leg a new combined calf-tibial implant. Plast Reconstr Surg. 2006;117(3): 817-216

A. Farzadmehr and R. A. Gutstein

Part Liposuction

V

Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications

41

William W. Cimino

41.1 Introduction Safe and effective use of ultrasonic instrumentation for lipoplasty requires an understanding of both the technology and associated surgical methods that differ significantly in many ways from the basic tools and methods of suction-assisted lipoplasty. The basic physics and tissue interactions for ultrasound-assisted lipoplasty, the benefits of the proper use of this technology and complications associated with its improper use will be discussed.

41.2 Basic Physics Over the past decade and a half, there have been three distinct generations of ultrasonic instrumentation for lipoplasty introduced to the market. In each subse­ quent generation, there have been design changes that improved the safety, efficacy, and usability of the equipment. In the following section, the basic physics of ultrasonic instrumentation is explained and used to describe the differences in each of the three generations of ultrasonic instrumentation for lipoplasty. Firstgeneration ultrasonic instrumentation is represented by the SMEI Sculpture technology, second-generation by the Mentor Contour Genesis and Lysonix 2000/3000 technologies, and third-generation by the Sound Surgical VASER technology, respectively. Ultrasonic surgery is the use of metal probes ­vibrating at low ultrasonic frequencies (20–60 kHz) to

W. W. Cimino 578 W. Sagebrush Ct., Louisville, CO 80027, USA e-mail: [email protected]

achieve a desired surgical effect in tissues. The probe design, the frequency of vibration, and the surgical technique, all play a role. To be clear, it is the vibrating metal tip of the probe interacting with the tissue that is of concern; not sonic radiation or some other mysterious phenomenon. It is complex, but understandable. Ultrasonic surgical instruments are in common use as dental descalers (from the 1950s to 1960s), for phacoemulsification (from the 1960s to 1970s), for neurosurgery (from the mid 1970s), for laparoscopic surgery (from the 1980s to 1990s), and for lipoplasty. Firstgeneration ultrasonic lipoplasty devices arrived in the late 1980s and early 1990s, second-and third-generation devices in the mid 1990s and the early 2000s, respectively. The basic ultrasonic surgery system has an electronic generator that interacts with an ultrasonic handpiece. The ultrasonic handpiece has an ultrasonic motor, most often composed of PZT crystals that convert electrical energy into vibratory motion. The vibratory motion is passed to a probe that vibrates in resonance with the handpiece. The electronic circuits in the generator maintain the vibration at the selected resonant frequency and adjust the amplitude of the vibration based on the controls on the generator. Vibration frequencies for ultrasonic systems for lipoplasty range from 22 to 36 kHz. There is no significant difference in the tissue effect across this frequency range; it simply alters the lengths of the resonant pieces by changing the wavelength of the vibration. Because the devices must resonate, the lengths are multiples of 0.5 wavelength. The ultrasonic probe and handpiece vibrate longitudinally at the designed resonant frequency. This means that standing waves are established in the probe and handpiece such that the tip of the probe experiences maximum longitudinal motion, on the order of a

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_41, © Springer-Verlag Berlin Heidelberg 2010

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p­ eak-to-peak displacement of a few thousandths of an inch, barely visible to the naked eye. The amplitude is a function of the vibration frequency and the amplitude setting. It is important to understand that the vibration is not “lateral,” i.e., transverse to the long axis of the probe. When transverse vibration occurs, as it sometimes can with smaller diameter or longer probes, it has a very strong audible “zing.” Such a vibration can easily fracture the ultrasonic probe because the probe was not designed to accommodate bending stresses. It is also important to visualize the standing waves in the probe as opposed to a single back and forth motion of the entire probe. A reciprocating powered cannula device moves the cannula back and forth as a solid unit. Ultrasonic probes vibrate with the standing waves and thus achieve the ability to concentrate energy at the tip of the probe. The peak-topeak vibration amplitudes and probe dimensions for the various first, second, and third generation ultrasonic devices for lipoplasty have been summarized [1]. The available vibration amplitudes for the various devices are actually of little consequence. What matters is the available power at the tip of the device, which does scale with amplitude, but is also a function of frequency. Thus, lower amplitudes and higher frequencies can achieve the same level of power as higher amplitudes and lower frequencies. Electrical power into the generator or amplitude of vibration is a not useful indicator of actual power for effecting tissues. Power deposited in tissues is a function of the generator setting, and also a strong function of the “coupling” between the tip of the probe and the

tissues. A vibrating tip that is pressed strongly into the tissue will couple significantly more energy to the tissue than the same tip that is gently touching the same tissue. Furthermore, the design and shape of the vibrating tip will strongly influence the measure of power that is coupled to the tissue and the point on the tip where the energy will be concentrated. Thus, what is needed is a measure of the maximum acoustic power that could be coupled from a probe with a specific design and a selected amplitude of vibration. This information has been measured and reported [1]. In short, a water bath was used as a repeatable and reliable way to assess the power available from ultrasonic devices. Water is a very effective medium to assess power because it is a consistent and strong coupling agent. The data show that first and second-generation ultrasonic devices, when run in the range of clinically effective amplitudes, deliver between 20 and 30 W of power to the water bath. The third generation devices typically deliver 10–15 watts of power to the water bath; generally 50% of the power of the earlier generation devices. However, the thirdgeneration devices deliver the reduced overall power with much greater efficiency [1]. The measure of the efficiency developed was the energy per unit active volume at the tip, where the active volume of the tip can be determined by measurements of the tip geometry. This measured data showed that the design of the tip greatly influences the efficiency of the coupling. First and ­second-generation devices possess efficiencies in the range of 100–175 mJ/mm3 in the clinically usable amplitude range, whereas the third-generation technology has efficiencies in the range of 175–250 mJ/mm3.

Fig. 41.1  Different lipoplasty probe designs. From the left: second-generation 5 mm hollow, second-generation 5 mm ­golf-tee hollow, third-generation 4.5 mm three ring solid, first-

generation 4 mm solid, third-generation 3.7 mm three-ring solid, third-generation 2.9 mm three-ring solid, and third-generation 2.2 mm two-ring solid

41  Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications

In summary, third generation technology was able to roughly double the efficiency while cutting the power applied in half. There are a variety of probe designs (Fig. 41.1) that can be used to explain this result. The probe on the left is a 5-mm probe with two aspiration holes and a relatively flat front surface. The majority of the frontal surface is active on this probe. Thus, when the probe is pressed strongly into the tissues, there is strong coupling of the ultrasonic energy from the face of the probe. The second probe from the left is a golf-tee design, having a concave surface at the front of the tip. The active area for this probe is inside the concave recess and will not contact the tissue unless the tissue is pulled into the recess with suction or the probe is pressed strongly into a tissue area. Thus, the useful active area for this probe design is actually quite small. The outside ring around the outside diameter of the probe will act as an ultrasonic knife when vibrating, which will be discussed later. The energy density along the outside ring is very high, resulting in the cutting action. The fourth probe from the left is a smooth hemispherical tip. This style is from the firstgeneration UAL technology. This active area for this probe is actually only a small portion in the center of the hemispherical dome. The efficiency of such a design is very low and the energy intensity is very high at the active area. The ringed or grooved probes are from the thirdgeneration technology. The grooves act to increase the active area for each probe and the small flat disc at the center of the hemispherical end increases the useful active area of the tip portion. This probe design has significantly decreased energy density due to the distribution of the total energy delivered by the probe across a much greater area. The efficiency of this style of probe is much greater than first or second-generation designs. The impact of the grooves can be examined and quantified (Fig. 41.2). The efficiency of each probe can be measured by the number of rings on the probe as well as the distribution of the energy around the vibrating tip. The grooves have surfaces that are perpendicular to the vibratory motion. More grooves have more surfaces and hence more coupling. Table 41.1 shows the relative partitioning of the energy for the four probes. Note that as the number of grooves increases, more and more energy, on a percentage basis, is coupled from the sides of the probe tip and less is coupled

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Fig. 41.2  Four identical probes except for the number of rings Table 41.1  Relative partitioning of energy based on the number of rings Probe Front Side (%) Tissue (%) 3.7–0

100

0

Extreme fiber

3.7–1

65

35

Fibrous

3.7–2

55

45

Moderate

3.7–3

42

58

Soft

from the front surface of the tip. Thus, a probe with more grooves will not glide so well in fibrous tissue and is more suited to softer tissues. A probe with fewer grooves will have more energy at the front of the tip and will thus penetrate fibrous tissues better. The extent or reach of the energy from the surface of the probe is a common question and concern. While some energy does radiate away from the tip, such energy is excessively weak and not capable of tissue disruption. The very long wavelength (on the order of 5 cm) means that the energy quickly passes through any tissues and does not concentrate or focus at distal locations. The active energy is associated with the zone very near to the metal vibrating tip. Experiments with tissues, tissue phantoms, fingers, and other media can be used to show that the effective zone around a vibrating tip is limited to approximately 0.5 mm from the surface of the tip. If the tissue is outside of this distance, then generally, it will not be impacted in any way. Therefore, the effective use of an ultrasonically vibrating probe requires that the probe tip be placed in contact with all the targeted tissues. It is not analogous

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to an “air brush” or some other device that has an effect at a distance. Pulsed delivery of energy further reduces the average energy but maintains peak energy densities. This is analogous to the techniques used to calm the thermal delivery in continuous wave lasers. Short bursts of intense (peak) energy achieve the desired effect but limit the overall thermal energy deposition. The duration of the pulse must be short enough and the number of pulses per second must be large enough to achieve the desired effect. Less than about ten pulses per second results in nonsignificant differences relative to continuous wave.

41.3 Tissue Interactions The interaction between the tip of the ultrasonic probe and the tissue is a complex function of three different phenomena and is further strongly influenced by the technique of the surgeon. The three basic tissue interactions are (1) cavitation, (2) thermal, and (3) mechanical. The cavitation theory was the original theory that was advanced for the interaction between the ultrasonic device and the fatty tissue. The theory holds that the ultrasonic energy at the tip of the probe induces an acoustic field that causes gases dissolved in the tissue and fluids to accumulate in bubbles which are then acoustically driven to grow in size until they become unstable at which time they implode. The implosion is a violent process that releases energy in the form of shock waves and heat. The implosion actually releases only a very small amount of energy per bubble because the bubbles are very small. The net energy is the sum of the many bubbles that are being generated by the ultrasonic energy at the tip of the probe. The cavitation bubbles exist as a “beard” around the tip of the ultrasonic probe, seemingly attached to the probe surface and extending no more than a millimeter therefrom. The bubbles exist at profile changes in the tip, not along the smooth surfaces parallel to the axis of vibration. There is significant energy present in these zones of cavitation bubbles; no doubt it is enough to damage or lyse adipose cells. However, the question remains as to whether or not this is the primary interaction with ­tissue. For example, one can examine the interaction between the ultrasonic probe and tissue which is

W. W. Cimino

submerged in degassed water that has a significantly increased cavitation threshold. The tissue can still be easily fragmented/emulsified by the device, even though much of the cavitation has been suppressed. One can also reduce the amplitude of the device until cavitation is either greatly reduced or not present, and then apply the device to submerged tissue. While slower, the fragmentation/emulsification process is still observable. Further still, one can excise a sample of fatty tissue, say from an abdomen, with no infused fluid, and apply the device directly in an open-air environment. The fatty tissue will still dissolve or fragment quickly. Thus, while cavitation may be present, it is not the predominant tissue interaction. A thermal theory has been advanced. This theory holds that ultrasonic energy essentially “melts” the adipose tissue. Certainly, it is possible to generate heat with an ultrasonic probe device. However, this is the opposite of the surgical and treatment objectives. The addition of copious amounts of wetting solution and proper probe motion will ensure that no significant heat is generated. Some small amount of heat will always be generated by a high-frequency vibrating probe. However, the amount and distribution of the thermal energy can be easily controlled and managed such that the fragmentation/emulsification process can occur without untoward thermal effects. The amount of heat generation has been measured and quantified [1]. The mechanical theory holds that when the rapidly moving metal tip of the ultrasonic probe encounters the tissue, it creates high-energy vibration-induced impact and flow conditions that fragment/emulsify the adipose tissue. High and low pressures, rapid acoustic streaming, and impacts with fast-moving metal surfaces, individually and in combination, are enough to fragment/emulsify the tissue [2, 3]. All of the three types of interaction are likely to be present in most situations, to varying degrees. The design of the instrumentation and the technique used by the surgeon will influence how much of each interaction is present. With regard to the design, probes that are run at excessive amplitudes, or which have smooth overall shapes, are inefficient and will result in more thermal energy deposition and less mechanical fragmentation. Probes with flat or concave front surfaces will generate excessive cavitational energy that ultimately converts into thermal energy and also have very high energy densities along these surfaces. Mechanical efficiency is optimized by probe designs

41  Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications

with many surfaces perpendicular to the axis of vibration and the elimination of sharp edges. With regard to the surgical technique, use of sufficient wetting solution and consistent probe movement will eliminate thermal issues. The vibrating tip should not be strongly pressed into any tissue as this removes the protective fluid and strongly couples the ultrasonic energy to the tissue, resulting in a strong thermal energy deposition (end-hit). Large diameter probes should be avoided as they possess excessive vibrational energy and require significant “pushing” to get through the tissue unless the amplitude is turned way up, again resulting in excessive vibrational energy applied to the tissues.

41.4 Results of the Physics and Tissue Interactions This section focuses on results enabled by the use of ultrasonic instrumentation from the perspective of the physics and tissue interactions. Results based on before and after pictures from lipoplasty surgeries are widely available elsewhere. With proper design and surgical technique, the mechanical tissue interaction discussed above can be made to dominate the tissue interactions. The advantage of such a combination is that the ultrasonic energy can be made to be tissue selective. The basis for the tissue selectivity is the “strength” of the various tissues relative to the “strength” of the ultrasonic energy [2, 3]. As the tissue strength increases, the effect of the ultrasonic energy decreases (Fig. 41.3). The ultrasonic energy level can be adjusted so that tissues with

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lower strengths are fragmented/emulsified (fatty tissues), while tissues with higher strengths are relatively undamaged. This is the key to success with ultrasonic instrumentation. Whereas suction-assisted avulsive trauma is not selective (anything pulled into the suction port is torn and removed), properly designed ultrasonic instrumentation can be tissue selective. This phenomenon is the basis for the use of ultrasonic energy in the neurosurgery field where similar type ultrasonic devices are used to fragment and aspirate brain tumor tissue while sparing as much nervous tissue and vascular tissue as possible. In fact, this phenomenon was the genesis of the application of ultrasonic energy to the lipoplasty proce­dure. When done properly, ultrasound-assisted lipoplasty fragments the adipose tissue and creates a soft emulsion (Fig. 41.4). Figure 41.4 shows the soft emulsion in an abdominoplasty sample where an incision has been placed to reveal the emulsified tissues, subsequent to the application of the ultrasonic energy. The collagen structures, vessels, and nervous tissue are spared (Fig. 41.5). Because the emulsified tissue/fluids can be more easily removed with less avulsive trauma than with traditional suction-assisted lipoplasty, more of the tissue matrix can be spared. The body thus experiences less tissue trauma than if the visible tissue matrix was extensively torn, resulting in faster healing, smoother results, and less pain. Further, the reduced tissue matrix trauma results in significantly reduced blood loss as has been shown when comparing the use of ­third-generation technology to suction-assisted lipoplasty in the back [4]. This study found 6–7 times less blood in the ­aspirate for the third-generation technology vs. SAL.

Fat

Increasing fragmentation

Muscle

Collagen Bone

Fig. 41.3  The effect of increasing tissue strength on fragmentation rate

Increasing tissue strength

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W. W. Cimino

a

b Fig. 41.4  Soft emulsified tissue and fluids subsequent to the application of ultrasonic energy

Because the ultrasonic instrumentation is less traumatic to the tissue matrix, it can be used to enhance skin retraction in lipoplasty. Skin retraction is maximized when the superficial fatty layer is “thinned” (to 1 cm below the underside of the dermis) but minimally traumatized, meaning that the connective tissue and vas­ cular structure in this superficial layer remain as undamaged as possible. If this superficial layer is thinned with suction-assisted lipoplasty devices, the result is that the structures in this layer are torn or removed, leaving the skin less attached to the lower layers. The skin therefore does not experience the contractive loading of the connective tissue and tends to settle on the lower layers and scar/heal in place with very little contraction. Alternatively, if the superficial layer can be successfully “defatted” resulting in a volume reduction in the superficial layer but leaving the majority of the tissue matrix intact, then the skin will settle/heal subject to the elastic loading generated during the healing process to eliminate volume. There are two keys to successful defatting of the superficial layer: (1) the technology and technique used must result in minimal trauma to all tissues except the adipose cells; and (2) the technology and technique used must be applied uniformly and evenly in the superficial layer. The objective of proper application of ultrasonic energy to the lipoplasty procedure is to reduce avulsive trauma to the tissue matrix, which thereby promotes smoother results with more skin retraction, faster healing, less bleeding, and less pain. These results can be produced only with proper and appropriate application of ultrasonic energy. Early generation UAL devices had many design characteristics that precluded the

c

Fig. 41.5  Examples of spared collagen structures, vessels, and nerve tissue (a–c)

achievement of these objectives as described above in Basic Physics and below in Complications.

41.5 Complications Complications may be related directly to the design and use of ultrasonic instrumentation for lipoplasty. Complications related to surgical error or judgment for lipoplasty surgery or patient specific situations are not discussed.

41  Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications

Complications can be lumped into two general categories: (1) “pilot error” which are complications due to a surgeon’s lack of knowledge concerning (a) proper use of the ultrasonic instrumentation, (b) tissue effects, (c) surgical endpoints, (d) energy delivery; and (2) ultra­ sonic instrumentation design issues that result in excessive energy delivery or inefficient energy delivery. Pilot error issues can be described as “technique issues” and the design issues can be described as “technology issues.” By far, the largest concern and most frequent complication can be described as “skin burns.” This type of complication is most often a “pilot error,” but can also be related to the design.

41.5.1 Burns at the Incision Site An ultrasonically vibrating probe will create heat through friction when pressed into the skin. The single most important factor is called “coupling.” In short, this refers to how hard the vibrating probe is pressed or torqued into the skin. An incision site acts as a fulcrum point. During suction-assisted lipoplasty the surgeon frequently and commonly torques or lifts the suction cannula about the incision fulcrum, largely without complication, although skin abrasion and stretching will occur. With an ultrasonically vibrating probe, such a technique will result in the immediate heating of the edges of the incision, especially if the incision is too small and the skin is tightly sphinctered around the vibrating probe. Skin ports have been designed to insulate the vibrating probe from the skin incision edges and they do a very good job. However, even skin ports will heat if the vibrating probe is torqued about the incision site and will thus heat the skin edges through the skin port. The proper technique is to avoid torquing and lifting of the vibrating probe about the incision point. Straight radial strokes without torquing eliminate coupling at the incision fulcrum and heating of the skin edges. Common mistakes include lifting the probe to try to reach around a curved body area or pushing the probe to extend the action of the tip beyond the reach of the probe. Additional incisions easily solve these problems. Torquing at the incision is by far the most common mistake of surgeons early in their experience with ultrasonic instrumentation, especially if they are classically trained in suction-assisted lipoplasty.

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41.5.2 External Burns Away from the Incision Site The vibrating probe can be pressed into the unprotected skin away from the incision site and will cause a friction burn. It usually appears as a “line blister” where the probe was momentarily pressed into the skin and most often happens where rounded areas of skin are contacted when the surgeon tries to keep the probe flat and parallel to the skin. The most frequent areas are the “pouch” between the suprapubic area and the umbilicus when the surgeon is working in the epigastrium through the umbilicus and the buttock when working in the banana rolls or medial thighs. This type of skin burn is 100% preventable with proper placement of a protective towel so that when the probe is moved to a position such that it would be in contact with the skin, it is instead pressing on the towel. One layer of towel is usually not sufficient as it will conduct heat rapidly to the skin below. A folded towel with two to three layers provides sufficient protection in almost all instances. The towel may be wet or dry as long as sufficient layers (folds) are used.

41.5.3 End-Hits End-hits are simply pressing (poking) the vibrating tip of the probe into the underside of the dermis. This most often happens when the anatomy curves away from a flatter area and the probe is advanced so that the tip pokes into the skin, resulting in a concentration of energy at the tip of the probe. End-hits will most often leave small points of hyperpigmentation that heal over time. End-hits are 100% avoidable by maintaining a probe orientation as flat as possible with the skin surface and by avoiding the tendency to “reach around a corner.”

41.5.4 Contribution of Excessive Amplitude As the amplitude of vibration in the probe is increased, the potential to generate heat through friction also increases. Amplitude should be set at the minimum value, which allows for graceful gliding motion of the probe without significant “hanging” or “drag.” Directly related to this issue is the proper choice of the probe

396

for the type of tissue. One style of probe is not appropriate for all tissue types. Fibrous tissues require smaller diameter probes and probes with less coupling. Softer tissue allow for larger probe diameters and probes with more coupling. If a larger diameter probe is used in fibrous tissue, excessive vibration amplitude will be required to get the probe to pass through the tissue. This is the source of many of the complications associated with first and second-generation ultrasonic instrumentation.

41.5.5 Complications Associated with Volume of Wetting Solution Ultrasonic instrumentation requires more wetting solution than suction-assisted lipoplasty. The wetting solution provides thermal protection to the tissues, aids in forming a soft emulsion for removal with aspiration cannulas, and ensures wide and uniform distribution of epinephrine for vasoconstriction. Two of these three benefits are not required for suctionassisted lipoplasty. When insufficient wetting solution is used, patients may experience prolonged edema, induration, a tingling/burning sensation, or increased pain. Use of sufficient wetting solution will largely, if not completely, eliminate these problems. Suctionassisted lipoplasty generally and widely uses a 1:1 ratio for wetting fluid infused to estimated aspirate out, most commonly referred to as the “superwet technique.” Other techniques use more wetting solution, with upper ranges as high as 2:1 or 3:1. Ultrasoundassisted lipoplasty requires a range of 1.5:1–2:1. This amount of fluid generally eliminates the potential complications discussed above and is widely and successfully used in ultrasound-assisted lipoplasty surgery. Other than skin burns, the most frequent complaint related to the use of ultrasound-assisted lipoplasty devices is prolonged healing or edema, or pain. This result can almost always be directly correlated with the use of insufficient fluid. Suction-assisted lipoplasty surgeons are often slow to adopt the increased requirements for wetting solution in ultrasoundassisted lipoplasty, believing that the familiar 1:1 should be sufficient. It is important to the final result and to the comfort of the patient postoperatively that sufficient wetting solution be used.

W. W. Cimino

41.5.6 Complications Associated with Aggressive Aspiration Once the adipose tissue has been emulsified, it does not require aggressive avulsive aspiration. Special cannulas have been designed to rapidly remove the emulsified tissues and fluids with minimal avulsive trauma. When the emulsified tissues and fluids have been removed, an amount of traditional suctionassisted lipoplasty with its attendant avulsive trauma may be required to achieve the final contour. If the avulsive suction phase is pursued aggressively, it will destroy the benefit and gains of the ultrasonic phase, namely the emulsification of the adipose tissue with no avulsive trauma. Thus, it is important not to use overly aggressive aspiration subsequent to the ultrasonic emulsification phase.

41.5.7 Complications Associated with Over Application of Ultrasonic Energy Any energy source can be overused or overapplied, and the same holds true for ultrasonic energy. Safe and effective guidelines for ultrasonic energy amplitude and duration have been developed and are supplied as general guidelines with the instrumentation. Generally speaking, 1 min of ultrasonic time per each 100 mL infused into an area results in good emulsification and no postoperative problems. With experience and sufficient wetting solution, 1 min and 30 s of ultrasonic time per 100 mL of infused wetting solution is commonly used. As ultrasonic time approaches 2 min/100 mL of infused wetting solution, the complications described above related to the volume of wetting solution begin to become more pronounced. Fortunately, almost all of the targeted adipose tissue can usually be addressed before the 1 min 30 s/100 mL infused limit is reached. It is important to note that not all ultrasonic instrumentation can be treated similarly in this regard. First and second-generation UAL devices are generally too much powerful to be used with these time/ amplitude guidelines and should be adjusted accordingly.

41  Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications

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41.5.8 Complications Associated with Instrumentation Design The original ultrasonic instrumentation for lipoplasty was the SMEI Sculpture system. This system had large diameter probes with blunt smooth ends. Such a design has no area of ultrasonic activity except the central portion of the hemispherical tip, a very small area. This design was so inefficient that extended application was required to produce emulsification. This design thus resulted in unnecessarily extended application times. Second generation devices added a central lumen to the vibrating probes for aspiration. The central lumen was approximately 2 mm in diameter on a 5-mm probe. Usually a 1.8–2.0-mm aspiration cannula is much shorter than the 27–32 cm lengths of these ultrasonic probes, specifically because aspiration with such a small diameter lumen is extremely slow and applicable to only small volumes. Thus, a very slow aspiration system was combined with a large and powerful 5 mm ultrasonic probe. Surgeons had the mistaken concept that the aspiration that they were seeing was related to the effect of the ultrasound in the tissue as they were visualizing the aspirant. This is not correct. The transit time for the aspirant up the 2 mm lumen was on the order of 2–5 s, while the tip was vibrating at 22,000– 27,000 times/s. Only a single to a few hits of the vibrating probe are required to fragment the adipose tissue in a particular area, requiring only thousandths of a second. Thus, surgeons tended to continue applying excessive ultrasonic energy because they were working with a time constant of 2–5 s or more (visual) and the ultrasound was effective with a time constant of a few thousandths of a second. Further, adipose tissue and saline were essentially “frothed” in the vibrating aspiration channel, changing the color and texture of the aspirant relative to the actual emulsified tissue/fluids in the body, further distorting the perception of the surgeon. Further still, the vacuum at the tip of the vibrating probe pulled the tissue up against the vibrating probe tip and strongly increased coupling, unnecessarily damaging the tissue. Ultrasonically, vibrating probes generate an acoustic pressure that pushes the tissue away from the probe, thus minimizing the excessive application of energy unless the probe is pressed strongly into the tissue. All third-generation ultrasound technology for lipoplasty is solid probe technology for these reasons and the complications associated with a central lumen for aspiration have been eliminated.

Fig. 41.6  A 5-mm hollow golf-tee ultrasonic probe

A golf-tee type tip design was introduced with the second-generation Lysonix 2000 system (Fig. 41.6). This design had a concave tip with a central lumen and a reasonably sharp edge around the edge of the tip. When vibrated at ultrasonic frequencies, the sharp edge becomes very sharp, in fact making this probe design a “powered curette.” This design is thus responsible for many of the reported complications with early generation UAL systems. For the past decade, there has been wide circulation of certain photos showing large areas of necrosed skin related to the use of ultrasonic instrumentation for lipoplasty. While such a result could be produced through improper and excessive use of ultrasonic instrumentation, the same result could be produced through improper and excessive use of suction-assisted lipoplasty. These are pictures of “bad surgery”; not pictures of “results of ultrasonic instrumentation for lipoplasty.” If indeed these pictures are the result of a surgery where ultrasonic instrumentation was used, the disastrous results could have been easily avoided with (1) sufficient use of wetting solutions, (2) appropriate

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application of ultrasonic energy addressing both the duration of application and the amplitude of vibration, and (3) proper and reasonable aspiration of the emulsified tissues, thus limiting the avulsive trauma of the suction cannula.

41.6 Conclusions Ultrasound-assisted lipoplasty is now a stable and growing method of lipoplasty. Applications have been expanded from basic body contouring to the contouring of the face and neck, breast, and other delicate areas such as the knees and ankles. New applications and treatments are under investigation for the permanent treatment of axillary hyperhidrosis. Complications resulting from first to second-generation ultrasonic technology/devices have been largely eliminated; firstly by significantly improved third generation instrumentation design, and secondly, by significantly improved information and understanding of proper techniques and surgical endpoints when using ultrasonic instrumentation for lipoplasty. Published

W. W. Cimino

studies now show the substantial decrease in blood loss when using third-generation UAL technology compared to SAL. Ultra­sonic technology for lipoplasty has progressed from initial high excitement with rudimentary first-generation technology to waning excitement with second-generation technology to stable and growing acceptance and utilization with third-­generation technology.

References   1. Cimino WW. Ultrasonic surgery: power quantification and efficiency optimization. Aesthetic Surg J. 2001;21(3):233–40.   2. Cimino WW, Bond LJ. Physics of ultrasonic surgery using tissue fragmentation: part I. Ultrasound Med Biol. 1996; 22(1):89–100.   3. Bond LJ, Cimino WW. Physics of ultrasonic surgery using tissue fragmentation: part II. Ultrasound Med Biol. 1996; 22(1):101–12.   4. Garcia O, Nathan M. Comparative analysis of blood loss in suction-assisted lipoplasty and 3rd-generationinternal ultrasound-assisted lipoplasty. Aesthetic Surg J. 2008; 28:430–5.

History of Ultrasound-Assisted Lipoplasty

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William W. Cimino

42.1 Introduction The use of high-frequency vibrations in surgical instru­ ments, commonly referred to as ultrasonic surgical instrumentation, typically involves a frequency of vibration in the range from 20,000 cycles per second (20 kHz) to 60,000 cycles per second (60 kHz). The metal probe or tip of the surgical instrument moves forward and backward at the aforementioned frequencies to create a desired surgical effect. The choice of frequency and the design of the tip of the metal probe determine the application of the instrument and how the device interacts with the targeted tissue.

42.2 History Ultrasonic instrumentation for surgical application was first introduced for the dental descaling of plaque in the late 1950s and early 1960s [1]. This technique and technology for dental scaling are still widely used today. In 1969, Kelman [2, 3] adapted the vibrating metal probe to the phacoemulsifcation procedure. Aspiration and irrigation capability were added to the basic vibrating device to facilitate the safe and effective removal of the cataract. Today, over two million cataracts each year are removed in the U.S. using this technology and associated technique [4]. The clinical effect of the phacoemulsification device on the cataract has been attributed to a micro-chopping effect [5].

W. W. Cimino  578 W. Sagebrush Ct., Louisville, CO 80027, USA e-mail: [email protected]

Safe and effective techniques and technology for this ultrasonic instrumentation have evolved to the degree that the cataract removal portion of the phacoemulsification procedure is often finished in less than 5  min per eye and over 98% of all cataract removals in the U.S. are now done using the phacoemulsification technique. In 1974, the phacoemulsification device was further modified and applied to neurosurgery for tumor re­moval. The objective of the device was to selectively remove pathologic brain and spine tissues with minimal residual trauma to remaining tissues. The CUSA (cavitron ultrasonic surgical aspirator) device, the first such instrument, is still in wide use today. Several companies produce ultrasonic aspirators for neurosurgery and are used in over 200,000 procedures per year worldwide. The tissue selective nature of the devices, i.e., the ability to spare nerves and vessels, has been attributed to the device’s ability to differentiate between tissues with different water contents and to a process called cavitation. The cavitation theory has never been proven and alternative theories have been presented that base the selective tissue effect on an interaction between the strength of the tissue and a mechanical action of the device [6–8] and view the cavitation process as an unavoidable consequence, but not the primary mechanism of tissue interaction. In the late 1980s and early 1990s, the concept of an ultrasonic instrument was adapted to a cutting and coagulating device with application to laparoscopic surgery in the abdomen. Techniques and technology were developed and are used today for laparoscopic cholesystectomies, laparoscopic appendectomies, laparoscopic Nissen fundoplications, and other laparoscopic procedures. It is estimated that between 400,000 and 600,000 procedures per year are done using this technology (worldwide).

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The application of ultrasonic instrumentation to body contouring surgery began in the late 1980s and early 1990s. Scuderi [9] and Zocchi [10–14] pioneered the application of ultrasonic vibration to fat emulsification and removal. The hope and objective of this effort was to create both technology and associated techniques that consistently produced a safer and more effective means of aesthetic body contouring when compared to known methods of the time, namely suction-assisted lipoplasty (SAL). The benefits of tissue selectivity demonstrated and utilized in the previously mentioned surgical applications, especially neuro­ surgery, were expected to produce a method of lipoplasty that was more “fat specific” than the existing and well-known suction cannula. This technology (and technique) was named ultrasound-assisted lipoplasty (UAL). The first-generation UAL device was produced by the SMEI Company of Italy and utilized smooth, solid probes at a frequency of 20 kHz. The solid probes had a stepped design with diameters at the tip as small as 3.0  mm (small probe) and diameters at the base as large as 6.0  mm (large probe). The basic technique involved good surgical practice and two fundamental rules: (1) the essential use of a wet environment produced by infiltration of sufficient wetting solution, and (2) constantly moving the probe to prevent thermal injury [13]. Initial surgical times were in the range from 10 to 12 min for a 250–300 ml removal or approximately 4 min of ultrasound time per 100 ml of aspirate [13]. Around 1995, a growing interest in UAL in the United States prompted the plastic surgery community leadership to create a UAL Task Force that included representation from the American Society for Aesthetic Plastic Surgery, Aesthetic Society Education Research Foundation, American Society of Plastic Surgery, Lipoplasty Society of North America, and Plastic Surgery Education Foundation. The mission of the Task Force was to evaluate the new ultrasonic instrumentation for lipoplasty and to assist in its teaching and introduction in the United States. Teaching courses were offered under the oversight of the Task Force with didactic and hands-on training. Subsequent to his Task Force efforts, Fodor [15] published his experience on 100 patients using a contralateral study model. His conclusions comparing SAL to UAL found no significant differences between SAL and UAL and failed to prove the claimed benefits attributed to UAL.

W. W. Cimino

During the UAL Task Force period, second-generation UAL devices became available. These devices included the Lysonix 2000 (Lysonix Inc., Carpinteria, CA) and the Mentor Contour Genesis (Mentor Corporation, Santa Barbara, CA). The Lysonix system operated at a frequency of 22,500 Hz (22.5 kHz) and utilized hollow ultrasonic cannulae that aspirated emulsified fat simultaneously with the emulsion process. Cannula offerings were “golf-tee” and “bullet” designs with diameters of 4.0 and 5.1 mm. The “golf-tee” tip design with a 5.1 mm diameter was, in theory, the most commonly used design because of its “higher” efficiency. The Mentor Contour Genesis was an integrated system with suction, infusion, and an ultrasonic generator all packaged in one moveable system. The ultrasonic frequency was 27,000 Hz (27.0 kHz) and also utilized hollow ultrasonic cannula, with diameters offered from 3.0 to 5.1 mm. The shape of the tip of the Mentor cannulae was flat with side ports for aspiration for all tip diameters. The UAL technique continued to evolve with both the Lysonix and Mentor devices. Originally, application times were long, and significant complications were reported, and safety was questioned [16–21]. As application times were reduced, the complication rate declined. Application times were reduced to 1 min of ultrasound per 100 ml of aspirate [22, 23]. The concept of “loss of resistance” became widely known as a realistic surgical endpoint. Rapid probe move­ment [23] was introduced as another means to safely con­trol the energy presented by the second-generation machines. Overall, results ranged on one end from safe and ­effective use of UAL to high complication rates and questionable safety on the other end. In 1998, Topaz [24] published an article concerned with the long-term impact of UAL due to hypothesized sonoluminescence, sonochemistry, and free-radical generation. To study the safety issues raised by this publication, ASERF organized a Safety Panel Meeting, held in St. Louis in November 1998, which included experts in biochemistry, ultrasonic surgery, cavitation physics, and experienced UAL users. A number of research efforts and studies were launched and completed to address issues identified at the meeting, and a summary report was produced by the Safety Panel coordinator [25]. Conclusions reached by the panel of experts record that (1) more needs to be known about the tissue interaction process, (2) hydrogen peroxide is the only reactive oxygen species potentially produced

42  History of Ultrasound-Assisted Lipoplasty

by UAL that is capable of inducing DNA damage, (3) that hydrogen peroxide was not detectable following direct sonication of wetting solution with a UAL machine (100 nmol resolution), and (4) that the authors must conclude that there is no significant risk of malignant transformation from H2O2 (or any other ROM) produced during UAL [25]. In the late 1990s, the Lysonix Company and the Mentor Corporation, the 2nd generation device manufacturers and distributors, became involved in litigation concerning patent infringement. The lawsuit lasted until late 2001 when the Mentor Corporation prevailed and received a judgment against Lysonix. As a direct consequence, the Lysonix Company was subsequently absorbed by the Mentor Corporation. During this litigation period, technologic advancement and continued development of the equipment and accessories were literally frozen, resulting in a complete lack of response to clinical and market needs. As a consequence of the Topaz article, the Lysonix/ Mentor litigation, the generally less-than successful clinical success, and clearly visible feuding between the European progenitors of the UAL technique and the plastic surgery leadership in the United States, ultrasonic instrumentation for body contouring surgery began to fall into disfavor as a technique of choice for body contouring surgery. Analysis of this process showed that cost of the equipment, a long learning curve, manufacturer marketing without sufficient clinical and fundamental science, improper application techniques, larger incisions, longer surgical times, and conflicting results presented at major plastic surgery meetings resulted in confusion and disappointment in the surgical community worldwide. A number of surgeons continued to use the ultrasonic instrumentation safely and effectively [42–45]. Their evolving technique allowed them to get effective results without the complications noted at the introduction of the technology. Further, use of the ultrasonic devices was safely expanded to the face and breast [26, 27]. In early 2001, a third-generation of ultrasonic instrumentation for body contouring surgery became available. This technology was named VASER, for Vibration Amplification of Sound Energy at Resonance. The VASER technology and associated technique (Sound Surgical Technologies, Louisville, CO), referred to as VAL for VASER-Assisted Lipoplasty, was designed to minimize or eliminate known complications from earlier generations of UAL technology

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and to simultaneously realize the benefits of ultrasonic instrumentation as established in other surgical arenas. The guiding concept was to develop instrumentation that would emulsify fatty tissue quickly and safely with the absolute minimum amount of energy, thereby achieving the desired result with little or no residual trauma to the remaining tissues. VASER instru­ mentation introduced the concepts of pulsed delivery of ultrasonic energy, small-diameter solid probes (2.2–3.7 mm), and grooved probe designs to increase efficiency. Gentle emulsion cannulae for the aspiration phase were introduced to preserve the delicate structure of the tissue matrix after the emulsion process was completed. In 1999 and 2001, Cimino [8, 28] published the first scientific studies that defined the amount of power delivered to the tissues by various ultrasonic surgical devices and clearly defined the variables under the control of the surgeon that determine safety and outcomes. This basic scientific information led to clearly understood relationships between “causes” and “effects” when using ultrasonic surgical instrumentation for body sculpting surgery. As a direct consequence, the suction aspect of the ultrasonic instrumentation was eliminated (hollow ultrasonic cannulae) and replaced by solid probe designs, probe diameters were significantly reduced, efficiency was improved using the grooved probe designs, and pulsed energy delivery was introduced, all of which significantly reduced the energy delivered to the patient. A pilot clinical study on 77 patients completed by Jewell et al. [29] using the VASER and the VAL technique (multicenter) showed zero complications and effective results.

42.3 Conclusions At present, the first-generation SMEI technology (Sculpture) and the second-generation Mentor technology (Contour Genesis) have been removed from the market. The second-generation Lysonix tech­­nology remains in the market, largely unchanged, and with declining overall presence. The third-generation VASER technology is stable and growing, and has become the dominant internal UAL instrumentation in the market. The precise energy control and refined instrumentation provided by the VASER system have expanded

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utility, principally due to safe and effective application in the superficial layers. The VASER is currently being used to contour the face and neck [30, 31], for breast contouring and reduction [32–34], and for an ad­vanced “high-definition” contouring procedure [35]. New VASER applications are being developed such as a treatment for permanent elimination of axillary hyperhidrosis [36]. Published scientific studies have shown reduced blood loss when using VASER compared to SAL [37] and the viability of VASER aspirate for autologous fat transfer [38]. VASER has been successfully and safely combined with excisional surgery and is a key component of new methods of lipoabdominoplasty [39–41].

References   1. Forrest JO. Ultrasonic scaling. A five-year assessment. Br Dent J. 1967;122(1):9–14.   2. Kelman C. Phacoemulsification and aspiration. A new technique of cataract removal. A preliminary report. Am J Ophthalmol. 1967;64(1):23–5.   3. Kelman C. Phacoemulsification and aspiration: a report of 500 consecutive cases. Am J Ophthalmol. 1973;75(5): ­764–8.   4. http://www.alconlabs.com   5. Seibel BS. Phacodynamics. Thorofare, NJ: Slack; 1993.   6. Cimino WW, Bond LJ. Physics of ultrasonic surgery using tissue fragmentation: Part I. Ultrasound Med Biol. 1996;22(1): ­89–100.   7. Bond LJ, Cimino WW. Physics of ultrasonic surgery using tissue fragmentation: Part II. Ultrasound Med Biol. 1996;22(1):101–12.   8. Cimino WW. The physics of soft tissue fragmentation using ultrasonic frequency vibration of metal probes. Clin Plast Surg. 1999;26(3):447–61.   9. Scuderi N, Devita R, D’Andrea F, Vonella M. Nuove prospettive nella liposuzione la lipoemulsificazone. Giorn Chir Plast Ricostr ed Estetica. 1987;2(1):33–9. 10. Zocchi ML. Metodo di trattamento del tessuto adiposo con energia ultrasonica. Congresso dell Societa Italiana di Medicina Estetica. Roma, Italy: Apr 1988. 11. Zocchi ML. New prospectives in liposcultpuring: the ultrasonic energy. 10th ISAPS Congress. Zurich, Switzerland; 1989. 12. Zocchi ML. Clinical aspects of ultrasonic liposculpture. Perspect Plast Surg. 1993;7:153–74. 13. Zocchi ML. Ultrasonic assisted lipoplasty. Clin Plast Surg. 1996;23(4):575–98. 14. Zocchi ML. Basic physics for ultrasound-assisted lipoplasty. Clin Plast Surg. 1999;26(2):209–20. 15. Fodor PB, Watson J. Personal experience with ultrasoundassisted lipoplasty: a pilot study comparing ultrasoundassisted lipoplasty with traditional lipoplasty. Plast Reconstr Surg. 1998;101(4):1103–16.

W. W. Cimino 16. Troilius C. Ultrasound-assisted lipoplasty: is it really safe? Aesthetic Plast Surg. 1999;23(5):307–11. 17. Lack EB. Safety of ultrasonic-assisted liposuction (UAL) using a non-water-cooled ultrasonic cannula. A report of six cases of disproportionate fat deposits treated with UAL. Dermatol Surg. 1998;24(8):871–4. 18. Baxter RA. Histologic effects of ultrasound-assisted lipoplasty. Aesthetic Surg J. 1999;19:109–14. 19. Perez JA. Treatment of dysesthesias secondary to ultrasonic lipoplasty. Plast Reconstr Surg. 1999;103(5):1534. 20. Gerson RM. Avoiding end hits in ultrasound-assisted lipoplasty. Aesthetic Surg J. 1997;17:331–2. 21. Grolleau JL, Rouge D Chavoin JP, Costagliola M. Severe cutaneous necrosis after ultrasound lipolysis. Medicolegal aspects and review. Ann Chir Plast Esthet. 1997;42(1): 31–6. 22. Tebbetts JB. Minimizing complications of ultrasoundassisted lipoplasty: an initial experience with no related complications. Plast Reconstr Surg. 1998;102(5): 1690–7. 23. Tebbetts JB. Rapid probe movement ultrasound-assisted lipoplasty. Aesthetic Surg J. 1999;19(1):17–23. 24. Topaz M. Long-term possible hazardous effect of ultrasonically assisted lipoplasty. Plastic Reconstr Surg. 1998;102(1):280; author reply 280–1. 25. Young VL, Schorr MW. Report from the conference on ultrasound-assisted liposuction safety and effects. Clin Plast Surg. 1999:26(3):481–524. 26. DiGiuseppe A. The harmonic lift: ultrasonically assisted skin remodeling. Int J Cosmet Surg. 2000;2(2):125–31. 27. DiGiuseppe A, Santoli M. Ultrasound assisted breast reduction and mastopexy. Aesthetic Surg J. 2001;21:493–506. 28. Cimino WW. Ultrasonic surgery: power quantification and efficiency optimization. Aesthetic Surg J. 2001;21(3): 233–40. 29. Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari MA. Clinical application of VASER-assisted lipoplasty: a pilot clinical study. Aesthetic Surg J. 2002;22(2):131–46. 30. Di Giuseppe A. Ultrasound-assisted lipoplasty for face contouring with VASER. In: Shiffman MA, Di Giuseppe A, editors. Liposuction: principles and practice. Berlin: Springer; 2006. p. 245–53. 31. Di Giuseppe A., Commons G. Face and neck remodeling with ultrasound assisted (VASER) lipoplasty. In: Shiffman MA, Mirrafati SJ, Lam SM, editors. Simplified facial rejuvenation. Berlin: Springer; 2008. p. 137–48. 32. Di Giuseppe A. Breast reduction with ultrasound-assisted lipoplasty. Plast Reconstr Surg. 2003;112(1):71–82. 33. Di Giuseppe A. Mastopexy (breast lift) with ultrasoundassisted lipoplasty. In: Shiffman MA, Di Giuseppe A, editors. Liposuction: principles and practice. Berlin: Springer; 2006. p. 254–7. 34. Di Giuseppe A. Ultrasound-assisted lipoplasty for breast reduction. In: Shiffman MA, Di Giuseppe A, editors. Liposuction: principles and practice. Berlin: Springer; 2006. p. 415–24. 35. Hoyos AE, Millard JA. VASER-assisted high-definition liposculpture. Aesthetic Surg J. 2007;27:594–604. 36. Commons GW, Lim AF. Treatment of axillary hyperhidrosis/bromodrosis using VASER ultrasound. Aesthetic Plast Surg. 2009;33(3):312–23.

42  History of Ultrasound-Assisted Lipoplasty 37. Garcia O, Nathan M. Comparative analysis of blood loss in suction-assisted lipoplasty and 3rd-generation internal ultrasound-assisted lipoplasty. Aesthetic Surg J. 2008;28:430–5. 38. Panetta NJ, Gupta DM, Kwan MD, Wan DC, Commons GW, Longaker MT. Tissue harvest by means of suction assisted or 3rd-generation ultrasound assisted lipoaspiration has no effect on osteogenic potential of human adipose-derived stromal cells”. Plast Reconstr Surg. 2009;124(1):65–73. 39. De Souza Pinto EB, Federico R, De Melo SP, Contin L, De Souza RPM. Lipomioplasty with VASER: a new approach to body contouring. In: Eisenmann-Klein M, NeuhannLorenz C, editors. Innovations in plastic and aesthetic surgery. Berlin: Springer; 2008. p. 433–42. 40. Jewell ML. Innovation in plastic and aesthetic surgery. In: Eisenmann-Klein M, Neuhann-Lorenz C, editors. Lipoplasty

403 innovations in plastic and aesthetic surgery. Berlin: Springer; 2008. p. 443–53. 41. Senyuva C. VASER lipoabdominoplasty, Turkey: Elit Ofset; 2007. 42. Maxwell GP. Use of hollow cannula technology in ultrasoundassisted lipoplasty. Clin Plast Surg. 1999;26(2):255–60. 43. Kloehn RA. Liposuction with “sonic sculpture”: six years’ experience with more than 600 patients. Aesthetic Surg J. 1996;16(2):123–8. 44. Rohrich RJ, Beran SJ, Kenkel JM, Adams WP Jr, DiSpaltro F. Extending the role of liposuction in body contouring with ultrasound-assisted liposuction. Plast Reconstr Surg. 1998; ­101(4):1090–102; discussion 1117–9. 45. Gilliand MD, Commons GW, Halperin B. Safety issues in ultrasound-assisted large volume lipoplasty. Clin Plast Surg. 1999;26(2):317–35.

Face and Neck Remodelling with Ultrasound-Assisted Lipoplasty (Vaser)

43

Alberto Di Giuseppe

43.1 Introduction The author started to apply an internal ultrasound solid probe to face and neck in 1996 to defat the heavy face or to undermine lax skin of the neck to possibly achieve skin retraction, utilizing the sculpture ultrasound device (SMEI, Italy) with a solid probe 2.5 mm in diameter and 17 cm long [1]. While utilizing the solid probe in the face, the power administered was 30% of the total potential of the ultrasound tool to reduce the undesirable side effects of ultrasound energy (essentially heat). The aim of the technique was: 1. To reduce the number and extension of scars of the face for remodeling procedures of face and neck. 2. To perform essentially the majority of facial contouring surgery under local tumescent anesthesia. 3. To induce skin retraction in face and neck even with lax skin, avoiding major open surgery operation such as the standard face-lift. 4. To undermine and induce skin retraction with minimal trauma by utilizing a solid probe and ultrasound energy, instead of an open approach and a scalpel. 5. To debulk the heavy face, neck, and jowls with a smooth device able to emulsify fat in specific target with a minimal trauma, low energy, and safe surgical planes. 6. To contour difficult areas such as the mandibular border, neck line, and chin.

A. Di Giuseppe Department of Plastic and Reconstructive Surgery, School of Medicine, University of Ancona, 1, Piazza Cappelli, 60121 Ancona, Italy e-mail: [email protected] e-mail: [email protected]

7. To make facial surgery accessible even for patients who refuse major open surgical operations that normally lead to a longer recovery time. Under those circumstances, what the author called at that time “The harmonic lift” was not used as a substitute for standard rhytidectomy, but to offer an alternative technique in facial contouring surgery.

43.2 Patient Selection The “harmonic lift” can be used in young patients with fatty necks and cheeks, as well as in older patients with loose skin and wrinkles. Each patient is evaluated as to the aims of surgery such as treatment of crow’s feet, nasolabial and commissural folds, jowls, and waddle neck. The procedure is appropriate in the following type patients: 1. Face and neck lift in Fitzpatrick type 4–6, thereby avoiding keloid formation and postinflammatory hyperpigmentation that may occur with skin rejuvenation using laser or peel. 2. Young patients who require only treatment of chubby cheeks and double chin. 3. To enhance neck definition with chin augmentation. 4. To substitute for endoscopic forehead lift in balding scalps. 5. To achieve dermal stimulation and retraction in the neck beyond areas amenable to laser resurfacing. 6. To release acne scarring of the cheeks. 7. In secondary and tertiary face-lifts when partial removal of the skin is a questionable procedure, but the central face needs further tightening.

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Other indications include rhytids in the malar area, crow’s feet, frontal, nasolabial, glabella (horizontal and vertical), and neck as well as descent of the cheek fat, ptosis of the lateral eye-brows, laxity of the upper lids, jowls, and diffuse acne scarring of the cheeks and neck.

43.3 Technique Lines are drawn on the face to show the full area of undermining, the vectors of muscle tension, relaxation creases and folds, and crisscrossing lines of tunneling and dermal stimulation. Incisions are placed at different sites to allow ease of access depending on the target areas (Fig. 43.1). In the forehead, incisions are vertical to avoid nerve damage and are at the hairline, midline, or frontal recess. Temporal incisions are parallel to the hairline while submental incisions are at the submental crease. Preauricolar incisions are made at the earlobe and upper and lower eyelid incisions are at blepharoplasty sites.

Fig. 43.1  Incision lines: frontal, temporal, retroauricular, submental, laterocervical, and eyelid

A. Di Giuseppe

The use of the tumescent technique reduces ­bleeding and bruising and decreases surgical time. Klein’s solution [2] used contains 1,000 mL of normal saline with 1.5 mL epinephrine (15 mg), 1,500 lidocaine, and 12.5 mEq sodium bicarbonate. Intravenous sedation is generally utilized but when general anesthesia is used and lidocaine is reduced to 200 mg with elimination of sodium bicarbonate. Between 75 and 1,510 mL of solution is utilized on each side. Total infiltration never exceeds 450 mL in the heavy face plus neck. A blunt-tipped, 14 gauge cannula is used to infiltrate the subcutaneous tissues of the neck, jowls, cheeks, temple, and brow. Digital pressure aids in directing and expanding the fluid evenly.

43.4 Ultrasonic-Assisted Dissection Ultrasonic dissection is performed with a titanium solid probe 2.2 mm diameter, which is the thinnest armamentarium produced by S.S.T. (Sound Surgical Technologies, Denver, Co, USA) Vaser ultrasonic device. The power setting is lowered to 30% of total power [3, 4]. The areas include frontal from the hairline to the brow, glabella, dorsum of the nose, temple, lateral canthal region (crow’s feet), cheeks to nasolabial grooves, chin, jowls, and anterior neck from chin to sternal notch (anterior triangles). The probe is advanced subdermally and the tip of the probe tents the skin while it is withdrawn. Blanching of the skin occurs with treatment and is more noticeable in the patient with ruddy complexion. The skin softens and smoothes following use of the probe. The sequence of dissection starts with the submental area and neck from the submental and earlobe incisions. The probe is then used over the mandible, cheek, and temple reaching the nasolabial fold, side of the nose, and the crow’s feet in a radiating fashion through the earlobe incision. An upper eyelid incision allows access to the glabella and central portion of the forehead releasing the cutaneous insertion of the corrugator and procerus muscles without altering skin sensation. The rest of the forehead is dissected through a separate hairline incision (Fig. 43.2). The fat emulsion and tumescent fluid is evacuated by gentle massage of the areas. When the harmonic face-lift (ultrasonic skin rejuvenation) is used alone, the skin incisions are closed with skin sutures and

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Epifoam is applied to the skin and a chin strap applied. Ice packs are used on the face and orbital regions not covered by the foam. A supporting garment is applied for 1 week, and then for 2 weeks more, at night time (Fig. 43.3).

43.5 Concomitant Procedures The superficial musculoaponeurotic system (SMAS) can be tightened by dissection and resection or imbrication for face- and neck lift. Skin excision is usually minimal, if required at all (Fig. 43.4) [5]. Any other cosmetic procedure can be performed at the same time including upper and lower blepharoplasty, platysmaplasty, face-lift, neck lift, chin or cheek implants, temporal lift, forehead lift, and skin rejuvenation with laser or chemical peel. Vaser can be used for face remodeling with autologous fat transfer. Fig. 43.2  Tension lines of action with Vaser UAL solid probe: 50% of total power, 5–12 min for full face undermining

43.6 Complications Two patients developed postoperative hematoma that required aspiration; however, both were hypertensive and noncompliant with their medications. Contour deformities of the neck were noted in three patients with two of them improving over 2 months. One patient required surgical release of the subdermal scar and asked for a more extensive surgery, a standard open face-lift with SMAS (Fig. 43.5) [6, 7]. There were no instances of nerve injury, alopecia, or a vascular necrosis. The ultrasonic assisted facial rejuvenation was safe, effective, and reproducible. The results were comparable to more extensive, difficult surgeries with higher morbidity, risks, and costs.

43.7 Discussion

Fig. 43.3  Face supporting garment

There has been a lot of interest in the use of ultrasonic liposuction for body contouring. Skin ­retraction has been reported as a result of the concomitant use of internal ultrasound from the large amount of fat removed, removal of subdermal fat, skeletonization

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a

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b

c d

Fig. 43.4  (a) Flap harvesting. (b) Vaser undermining. (c) Emulsion cleaning. (d) Verifying tunnels made by probe. Note untouched supporting structures of the skin

of the superficial fascial system, and thermal effects on the subdermal surface and ­collagenous structures of the superficial facial system (Fig. 43.6) [8–11]. Facial aging is due to fat and skin ptosis and not muscle or facial ptosis. Therefore, the supra-SMAS plane is ideal for the harmonic lift with ultrasonic rejuvenation of the face. The osteofacial dermal ligaments can be released or attenuated in this plane allowing direct contouring of the malar, nasolabial, jowl, and submental fat collections. Fat removed close to the under surface of intact skin results in skin retraction with permanent contour changes. Postoperative care requires careful nursing assistance, punctilious wound protection, and prolonged seclusion of elaborate makeup. Recovery time varies from 4 to 14 days. The postoperative care is limited to the use of Reston foam and elastic compression bandages that are changed by the

patient. Although there are no histological ­examinations in this study, there have been previous reports on the results of sub­dermal ultrasound and liposuction [12, 13]. The long-term results have not been evaluated and are probably related to the type of skin, patient age and sex, and the long-term effect of ultrasound energy. Disadvantages are the cost of ultrasonic machine, increased hassle factor in the operating room, and machine dependency, but after achieving proficiency in using the machine, there is no turning back because it is addicting. The conclusion, at that time, was that the harmonic lift is a safe, effective, and reproducible form of skin remodeling. It can be ­performed under local, regional, or general ­anesthesia, and can be repeated with no increase in surgical ­difficulty or cumulative effect. Advantages include negligible blood loss and pain, short and

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a1

a2

a3

b1

b2

b3

Fig. 43.5  Vaser UAL with poor result, face-lift with SMAS flap: (a) Preoperative. (b) Postoperative

Skin Contraction: 3 Theories Collagen contraction due to injury (thermal?, original proposition) Defatting the superficial layer-retained structures minus fat allow skin to contract Gentle stimulation to cause contraction through controlled damage

Fig. 43.6  Skin contraction theories

uncomplicated recovery, and simple postoperative care. The results are comparable to those obtained with more extensive surgery that frequently involves overnight stay, higher risks, increased morbidity, and higher costs. In United States, from 1995 to 2000, a series of articles published in the medical literature pointed out the increasing number of complications related to body contouring procedures when ultrasound energy was involved [14]. Analysis of all these complications,

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though there is difficulty assembling all clinical data, brought the following results: • • • • • • • •

Seroma (30% of body contouring cases) Delayed wound healing (18% of clinical cases) Prolonged edema (15% of clinical cases) Dysesthesia (12% of clinical cases) Fibrosis (8% of clinical cases) Asymmetries (4% of clinical cases) Skin necrosis (0.3% of clinical cases) Burn (0.2% of clinical cases)

Despite that burn and skin necrosis were largely the less common related complications and represented really a rare issue, the potential risk of these two complications was overemphasized. A major issue was introduced by many authors in the literature, probably because these two related to procedure complications were not seen with the other technique of liposuction (superficial, traditional, power assisted). The task force established by the American Society of Aesthetic Plastic Surgery (ASAPS), by the American Society of Plastic and Reconstructive Surgery (ASPRS), and the Educational Foundation met many times in order to establish safety criteria of utilization of ultrasound energy in body contouring surgery. The first safety indication, to prevent complications such as burn and skin necrosis, was to avoid the utilization of the ultrasound probe close to the underlying skin-dermis, which was really, on the contrary, the most important step of once so called “Harmonic-lift.” However, only working “superficially” with a solid ultrasound probe, the surgeon can undermine the cutaneous and subcutaneous layers, assembling a thin but vascularized flap more prone to retract and adapt to a reduced body volume. The great misunderstanding in those years, which led to and created confusion and mixing of clinical data, was due to the fact that all the complications-related data came through the utilization of the two most diffused ultrasound tools in the U.S. market: The Contour Genesis (Mentor, Santa Barbara, California), and the Lysonics (Inamed Corporation). These two ultrasound tools have similar technical characteristics: • High energy. • Hollow probes with simultaneous ultrasound energy administration, thus emulsification and simultaneous subsequent aspiration. • 5.0 mm large probe. The SMEI sculpture tool is a less powerful tool with solid titanium probes and without aspiration at the time of emulsification (which are two different clinical

Fig. 43.7  Sculpture by SMEI (low) and infiltration peristaltic pump. Not in production since 2001

phases). Adopting a finer probe for the face and neck, the author never had such kind of complications as related in American Literature in those years. However, the number of ultrasound tools sold by SMEI (Fig. 43.7) in the world (probably 700) was far less than those sold by Mentor and Lysonics (probably more than 2,500 units). The American market was far superior to all the remaining worldwide market, thus the published literature included only the experience (and complications) of the American technology in internal ultrasound energy. In 2001, Cimino, a physician who had great experience in ultrasound energy and had been previously involved with the task force on ultrasound energy, published an article on power quantification and efficiency of ultrasound energy [15]. This article was of capital importance to understand all the mistakes made by the two main American manufacturers in assembling the two most common ultrasound tools. • Too much energy that produced unnecessary overheating, which increased the side effects of ultrasound (seroma, mainly) without enhancing the results and the clinical outcomes. • Too large probes with low efficacy in transmitting energy to the tip, and thus, reducing the emulsification rate. • Poor design of the tip of the probe due to lack of technological research, with a reduced efficacy of the system in order to raise the rate of ­emulsification, the manufacturer increased the power of the tools.

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Fig. 43.9  Different probes: 1, 2, and 3 rings at the top of the shaft

Fig. 43.8  Vaser System Ultrasound with aspiration-ventex and infiltration

The two main ultrasound devices were far from a good technical standard, technologically was low in the development of the machines, and the majority of complications came from these limits. Fortunately, in 2001, a new ultrasound device, called Vaser, (by SST-Denver, Colorado, USA), was introduced in the US market (Fig. 43.8). This new tool has new features such as: • New designed probes of different caliber and shape. • The tip is designed (with one, two, and three rings) to increase the efficiency of the emulsification, which now affects not only the tip, but also the sites of the last part of the shaft (Fig. 43.9).

• The number of rings are related to the efficacy of the emulsion depending on the type of tissue encountered (more or less fibrotic, type of fat, more or less dense). • New generator of ultrasound energy with less power, but optimization of the distribution of energy at the different frequencies and wave length. High efficiency with less energy, which means less related complications due to overheat of the system. So far, in the last 5 years of the “Vaser Ultrasound Generation,” no report of burn or skin necrosis has been published. An insignificant percentage of seroma was reported. • New aspiration system, the so called VENTEX, with a new pathway expressively designed for increasing the rate of aspiration, without damaging the tissue, thereby aspirating “noble” structures such as vessels nerves and elastic tissue and impossible to be blocked by undue aspiration of wrong tissue. • Skin protector, expressly designed to prevent tissue damage from friction injuries related to the consecutive passages of the probe from the same entrance point (Fig. 43.10). • Reduced extension entrance scar of skin to allow introduction of the solid titanium probes, which are smaller in diameter (standard probe varies from 2.2 to 3.7 mm). Facial probe is 2.2 mm in width. • Tissue trauma is minimal, edema is largely reduced, bleeding is virtually absent, and the recovery of tissue is consistently reduced. Even the sites of entrance are now compatible with the typical diameter of the standard liposuction cannulas (between 2 and 4 mm of diameter). The author has started utilizing the Vaser system for body contouring surgery, breast reduction, facial contouring, reduction of breast tissue in male and female, treatment of Buffalo hump lipodystrophies, face and neck ­contouring, and axillary hyperhidrosis treatment.

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Fig. 43.10  Skin ports

This method is not a substitute of the standard facelift technique, but may shorten and make easier many procedures of facial contouring, with minimal trauma and virtually no complications, if performed by a surgeon trained with Vaser. The role of the dermis in the subcutaneous anatomical structure has been undervaluated in the past. Rudolph (1977) [16] first described the importance of dermis layer for skin retraction. In plastic surgery, it is commonly known that a split skin graft (no dermis left, in this case) is not really indicated to cover joint-areas (as elbow) for the possibility of leading to skin retraction, thus functional problems to the area. If a full thickness graft is utilized (with a layer of dermis but no fat), the same area is less prone to contraction, and to functional problems (Fig. 43.11). This is connected with the role of the dermis [16]. This aspect has never been considered in skin contraction after ultrasoundassisted body contouring [17, 18]. Emulsifying the body fat and thus conserving the connective tissues and supporting structures of the subcutaneous tissue (Fig. 43.12), the skin retracts much more than in standard condition. If the surgeon can harvest a skin dermal flap

Fig. 43.11  The thinner the subcutaneous fat, the greater the retraction achieved. UAL solid titanium probe works close to the dermis to thin the subcutaneous fat and achieves retraction

Fig. 43.12  Layers of emulsification with Vaser UAL: S superficial; I intermediate; P deep

43  Face and Neck Remodelling with Ultrasound-Assisted Lipoplasty (Vaser)

that is well vascularized and with the addition of an instrument that helps preparing such a surgical plane, the potential of skin retraction is minimized and it results in a safe procedure (Fig. 43.13). In this Vaser technique for face and neck contouring, the surgeon can emulsify fat areas (chin, jowls) or just extensively undermine the interested areas, counting on a deep, severe, intense skin retraction and simulating the effect of a subcutaneous rhyti­ dectomy, but without cutaneous scars (Figs. 43.14–43.18).

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Fig. 43.13  Fat thickness varies in different body areas. Thigh and abdomen are the thickest. Back and face are the thinnest

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Fig. 43.14  (a1, 2) Preoperative 38-year-old patient. (b1, 2) Postoperative after jowl, chin, and neck contouring with Vaser UAL

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Fig. 43.15  (a) Preoperative 37-year-old female. (b) Postoperative following neck–chin–jowl contouring

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Fig. 43.16  (a1, 2) Preoperative 28-year-old male with heavy cheeks and chin retrusion. (b1, 2) Postoperative after neck contouring and intra oral chin implant

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Fig. 43.17  (a1, 2) Preoperative 42-year-old female. (b1, 2) Postoperative following endo brow lift and Vaser to cheek and neck. (c1, 2) One year postoperative

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Fig. 43.18  (a1-3) Preoperative 45-year-old female. (b1-3) Postoperative after Vaser of neck, chin contouring, and fat transfer. ­(c1-3) One year postoperative

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References   1. Di Giuseppe A. The harmonic lift: ultrasonic assisted skin remodelling. Int J Cosm Surg Aesthet Dermatol. 2000;2(2): 125–31.   2. Klein J. Tumescent technique: tumescent anesthesia & microcannular liposuction. St. Louis: Mosby; 2000.   3. Rohrich RJ, Beran SJ, Kenkel JM. Ultrasound assisted liposuction. St. Louis: Quality Medical Publishing; 1998.   4. Grotting JC, Beckenstein MS. The solid probe technique in ultrasound-assisted lipoplasty. Clin Plast Surg. 1999;26(2): 245–54.   5. Toledo LS. Facial rejuvenation: the role of the skin retraction. In: Annals of the International Symposium: Recent Advances in Plastic Surgery. Brazil: Sao Paulo; March 1992.   6. Gingrass MK. Lipoplasty complications and their prevention. Clin Plast Surg. 1999; 26(3):341–54.   7. Tebbetts JB. Minimizing complications of ultrasoundassisted lipoplasty: an initial experience with no related complications. Plast Reconstr Surg. 1998;102(5):1690–7.   8. Illouz YG. Study of subcutaneous fat. Aesthetic Plast Surg. 1990;14(3):165–77.   9. Gibson T. Physical properties of skin. In: McCarthy JG, May JW, Littler JW, editors. Plastic surgery. Philadelphia: WB Saunders; 1990.

A. Di Giuseppe 10. Gibson T, Kenedi RM. The structural components of the dermis. In: Montagna W, Bentley JP, Dobson L, editors. The dermis. New York: Appleton-Century Crofts; 1970. 11. Southwood WF. The thickness of the skin. Plast Reconstr Surg. 1955;15(5):423–9. 12. Pitman GH. Liposuction and aesthetic surgery. St. Louis: Quality Medical Publishing; 1993. 13. Fodor PB, Watson J. Personal experience with ultrasound assisted lipoplasty: a pilot study comparing ultrasound assisted lipoplasty with traditional lipoplasty. Plast Reconstr Surg. 1998;101(4):1103–16. 14. Scheflan M, Tazi H. Ultrasonically assisted body contouring. Aesthetic Surg J. 1996;16:117–22. 15. Cimino WW. Ultrasonic surgery: power quantification and efficiency optimization. Aesthetic Plast Surg J. 2001;21(3): 233–41. 16. Rudolph R, Guber S, Suzuki M, Woodward M. The life cycle of the myofibroblast. Surg Gynecol Obstet. 1977; 145(3):389–94. 17. Becker H. Subdermal liposuction to enhance skin contraction: a preliminary report. Ann Plast Surg. 1992; 28(5):479–84. 18. Gasparotti M. Superficial liposuction: a new application of the technique for aged and flaccid skin. Aesthetic Plast Surg. 1992;16(2):141–53.

High Definition Liposculpting

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Alfredo Hoyos

44.1 Introduction Beauty, or the lack of it, plays a crucial role in virtually every human function and endeavor. It determines our popularity, our perception of ourselves, and often our success in business and career. Darwin postulated that beauty, in certain animals and human beings, also plays an important role in sexual selection and reproduction. While noone questions the importance of the role of beauty, the concept of what is beautiful has changed dramatically over the years. From the traditional GrecoRoman beauty standard, changes are seen according to factors as economics and fashion, sometimes in complete opposition to the previous one. For instance, in the eighteenth century, the full-figured, buxom women were considered to be the epitome of beauty; this Ruebenesque notion of beauty lauded the round shaped body as it was considered a sign of wealth and, ironically, good health, just the opposite as today’s mindset. In more recent times, there has been a continuous shift in the concept of beauty. Starting in the 1970s, the concept of beauty moved from the large and round to the slender and angular. In the recent decade, as we see more and more obesity in the general population, the trend has moved even more toward to a fit, athletic body. The muscular, athletic body shape has become the gold standard for the new millennium. Typically, one strives to achieve this athletic look through the efforts of rigorous diet and exercise. Aerobic and weight bearing exercises can all lead to a well-­developed muscular appearance. However, diet

A. Hoyos Evolution Medical Center Calle 119, 11D-30 (Nueva), Bogota, Colombia e-mail: [email protected]

and exercise do not always provide the desired results. Many individuals have stubborn areas of fat that block their goals despite strenuous exercise and diet. This may drive many to resort to the use of questionable drugs such as steroids.

44.2 History Over the years a number of surgical techniques have been developed to assist patients in reaching their goals. Gastric bypass surgery has helped patients where diet has failed. Liposuction, first described by Fischer [1] in 1975, has addressed the issue of stubborn areas of fat. In groundbreaking work, Illouz and de Villers [2] described the use of liposuction to sculpture the female body. Recently, new and innovative surgical techniques have been developed which present these patients with the opportunity to reach their goal. The tumescent technique, the super-wet technique, and ultrasound-assisted lipoplasty (UAL) have all proved to help plastic surgeons in their mission to provide patients with more precise results and quicker recovery time. VASER (Vibration Amplification of Sound Energy at Resonance) assisted lipoplasty, the most recent addition to the UAL, provides a significantly improved ability to contour fat [3]. Not only is it selective in what is resected, but also in what it leaves behind. Much of the connective tissue, nerve and vascular tissue, that are important in the patients’ healing process are left untouched. Mentz et  al. [4] point out that traditional liposuction techniques often fail to achieve the “washboard” aesthetic goal because “subdermal fat obscures the muscular detail.” Their response to this challenge is a technique used in male contouring called abdominal etching, which refers to differential liposuction hat

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details abdominal musculature, specifically to the rectus abdominis muscle. The anatomical appearance of this muscle is enhanced with localized superficial liposuction to deepen the natural grooves or furrows. While this technique offered options in body sculpting in males, it still results in a common problem where the muscles may appear unnatural. As a result, it is limited in that it focuses on only one muscle group, while not addressing many other muscles that contributed to that area of the anatomy. The term “liposculpture” first appeared in 1991 and was described as a technique that “shapes the body by removing fat cells in areas where there is excess fat and/or by adding fat cells to areas where additional padding is desired” [5]. It is a highly surgeon-dependent procedure in that the results depend entirely on the skill and the aesthetic “eye” of the surgeon. The next big contribution to the area of body contouring was superficial liposuction. De Souza Pinto developed this approach of addressing the superficial layer by removing and relocating fat using small caliber cannula. This technique achieved skin retraction along with resection of fatty excess, but often resulted in contour irregularities and asymmetry. Addressing superficial liposuction with VASER also became much more efficient, consistent, and rapid technique. The traditional goal of the liposuction techniques is to achieve flat surfaces. In opposition to the previous goals, the author has taken the liposculpture technique to the next level by refining it even further into what is referred to as High Definition Liposculpture. The idea is to create the natural muscular anatomy and enhance it. By using deep, superficial, or transitioning techniques over the rectus abdominus, serratus magnus, external obliques, pectoralis major, inguinal ligaments, and in the sacral area, the author has been able to create a more natural muscular appearance [6]. Through the appropriate use of contouring by liposuction, a new alternative is now available for the treatment and improvement of the gluteal, pectoralis, and other regions.

44.3 Anatomy The surface anatomy is an accurate reflection of the disposition and development of the abdominal wall muscles, specifically the rectus abdominis and obliquus abdominis muscles. They act as the blueprint for High Definition Liposculpture.

A. Hoyos

The rectus abdominis are strong, paired, longitudinal muscles that extend from the xyphoid process of the sternum and the 5th, 6th, and 7th costal cartilages to the pubis symphysis and the pubic crest. These two muscles are attached to each other in the middle by connective tissue forming the linea alba. The muscle is enclosed within the rectus sheath formed by the aponeuroses of the lateral abdominal muscles. Along the length of this strap muscle, there are three fibrous intersections separating the muscle into four segments. When the space between these muscles deepens, it results in a depression in the wall above the umbilicus. These are the muscles patients relish and refer to as “six-packs” or “washboards.” The transition between the lateral border of the rectus muscle and the oblique creates a well-defined depression and extends to the waist. This transition in the lateral view is the “double S.” This is the pillar of the natural muscular appearance that patients desire. In the lower portion of the back, the sacrum surface anatomy is focused on. Athletic individuals have minimal adipose tissue in this region. The result is the formation of a triangular-shaped depression covering the sacrum and terminating in the intergluteal crease. Examining the surface reveals two depressions located where the sacrum junction is closest to the skin. These depressions also tend to accentuate the gluteal region. There are substantial differences in the surface anatomy of men and women. In men, there is a more clear visualization of the six-pack, while in women it is generally not as desirable to see the musculature as well defined because they may give a more masculine appearance. In women, the waist, lateral to the limit of the rectus abdominis, is a key point of feminine definition, as is the waist contour above the gluteal region. The obliquus muscles form two lateral prominences in their junction with the inguinal ligament due to high muscular development. While this is desirable muscle pattern in men, a mild depression in this region is more desirable in women. In the dorsal view, the sacral region should be well defined in women due to the more accentuated lordosis and less fat present in that region. The increased muscular enhancement of the latissimus dorsi of the male results in an inverted triangular shape in the back area, which can be useful in liposculpture because some fat can be left there. In females, because of the lack of this defined muscular development, this shape is rectangular. As a result, with females, there is less aesthetic tolerance to remaining fat deposits in this area.

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44.4 Surgical Technique

44.4.3 Superficial Liposculpture

High Definition Liposculpture technique follows four general steps as follows:

Starting in the prone position, most cases had only liposuction to the superficial layer. When starting, the VASER is used at 80% power in the pulse mode, initiating the VASER and liposuction on the superficial layer and then advancing to the deep layer. This makes the work on the superficial layer less challenging by providing a stable deep layer. Later, aspiration sculpting is performed on the sacral triangle, the lateral portion of the waist, the midline, and the sacral depressions, as well as the back rolls that are going to be detached from the profound layer. The waist is then worked on in the midline above the umbilicus, the lateral lines of the rectus abdominis muscle, and portions of the rib cage. Special attention was given on the lateral border of the rectus beneath the ribs, where we do more superficial work to define the rectus abdominis. When working on the abdominal area, special attention must be given to the preoperative interview to accurately gauge the expectations of the patient. In patients who want a more muscular shape and desire a more athletic look, the author highlights the lateral border of the rectus abdominis, the depression beneath the ribs, and indicates mild depressions on the serratus area and above the inguinal ligament lateral to the rectus abdominus muscle. The transition areas lateral to the rectus and above the umbilicus are treated very aggressively. In female patients who fear having a “masculine look” or those who have mild-to-moderate obesity, the lateral lines of the rectus abdominis and the transition areas of this zone are only treated. This leaves a very natural look, particularly in obese patients where a very highly defined abdomen would look unnatural. The transition zones or union areas of the superficial and deep layer liposculpture area require special attention. These areas in the female body are defined as the union of the lateral rectus abdominis muscle, the supra and infragluteal areas, and the union of the sacral triangle and the lower back. If these areas are not treated properly or if the patient gains weight, there will be localized accumulation of fat resulting in an out-ofproportion appearance. The treatment of the transition zones must be a melding of deep and superficial liposculpture for it to look very smooth and natural.

44.4.1 Marking With the female patient in a standing position, the fat deposits to be removed to improve the body contour are marked. These deposits will be removed with deep liposculpture. The areas of depression that will need more projection such as the gluteal region, particularly if there is lateral depression in that area, are marked. Those areas will be treated with fat transplant. After the conventional marking, the surface anatomy that is going to be reproduced by superficial liposculpture is traced: in the dorsal view, the sacral triangle, the sacral depressions, the desired position of the infragluteal crease, and the areas of fat deposits in the back, specifically the fat rolls and creases. In the ventral view, the lateral borders of the rectus abdominis muscle, the obliquus muscle, the rib cage, and the alba line above the umbilicus. The author strives to produce a mild supraumbilical depression as it tends to give a more natural look.

44.4.2 Deep Layer Liposculpture With the patient under general or epidural anesthesia and in the prone position, tumescent solution is infiltrated consisting of 1,000 mL of normal saline and two ampules of epinephrine 1:1,000. In the current study, only suction-assisted liposculpture was done in 638 patients, and in 264 patients, VASER and liposuction were used. The VASER was used in the deep layer at 80% of power in continuous mode, approximately 1 min per each 100 mL of infiltration. On the lateral and medial thighs or legs, 50% power at pulsed mode was used. Later, aspiration at low power suction was performed. The ratio of infiltration to volume of fat removed was approximately 1:1. The aspiration of fat was performed on the medial and lateral thighs, the back, the waist, and sometimes on the arms and legs. In the supine position, liposuction was performed on the medial and lateral thighs, the flanks, and abdomen, and was limited to the deep layer.

44.4.4 Fat Grafting With the patient in the prone position, fat is harvested with a 5-mm blunt cannula into a sterile bottle trap

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containing 1 g of cefazoline. Decantation is the only process used to separate the fat cells from the saline and serosanguinous components. In the gluteal area, the volume of the fat injection ranges from 400 to 1,000 mL, with a mean of 472 mL/patient. This “fat reorientation” is done through injection using a 3-mm blunt cannula in the intramuscular plane, and a 2-mm blunt cannula in the subdermal plane.

44.5 Discussion The High Definition Liposculpture technique was developed to address the large demand for a procedure that

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can naturally reproduce an athletic female body shape. This exacting technique, combining superficial and deep liposculpture to reproduce the superficial anatomy, was developed over 3 years. The process of producing a natural athletic appearance required a steep learning curve. This was especially true in women where the anatomy is somewhat well defined but, at the same time, smooth. A three-dimensional contouring of the female body has been achieved. (Fig. 44.1) The author chose not to address just the rectus abdominis, but the entire torso and, in doing so, achieved a healthy natural result with a combination of superficial and deep layer fat extraction and reassignment. The adequate melding of these transitional areas insured a natural and long-lasting

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Fig. 44.1  Three-dimensional contouring of the female and male torso. (a1–5) Preoperative. (b1–5) Postoperative

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Fig. 44.1  (continued)

result. The overall volume extracted by this technique was less than that in the more traditional techniques. The use of autologous fat to augment the gluteal area, used as part of the procedure, enhanced the final results. The patients not only experienced a change in their body fat distribution, but also in their fat deposit zones. As a result, if the patients gain weight, they maintain the improvement in their appearance even though they are overweight. Less than satisfactory results were directly attributable to the following: • Inadequate presurgical marking, • Insufficient fat extraction from the superficial layer of the lateral abdomen or from the deep layer of the central abdomen,

• The asymmetrical union of the lower back and the waist. The use of the VASER has proved to be a powerful tool to facilitate fat extraction while increasing the volume of aspirated fat permitted per patient. It also ensured excellent results in the superficial layer liposculpture, and keeps to a minimum postoperative pain and bruising. The VASER patients experience a faster decrease in swell­ing and minimal contour irregularities, postoperatively. Results appeared more quickly and were longer lasting. If the High Definition Liposculpture patient should gain weight over time or experience a change in the body fat pattern of the back, arms, lower limbs, and/or the gluteal region, a second procedure can correct the situation.

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In women, addressing the vertical component of the rectus abdominis muscle was usually enough to provide an athletic look. Working with the entire torso, sculpting the waist, the perigluteal area, and the buttocks provides a very impressive change resulting in a more feminine look. High Definition Liposculpture is a refinement that efficiently reproduces all the anatomical landmarks of an athletic body. It was developed in a systematic way to ensure an adequate technique and to obtain natural, long-lasting results.

References   1. Fischer G. Surgical treatment of cellulitis. IIIrd Congress International Acad Cosm Surg. Rome: 31 May, 1975.

A. Hoyos   2. Illouz, YG, de Villers Y. Body sculpturing by lipoplasty. Edinburgh: Churchill Livingstone; 1989.   3. Jewell ML, Fodor PB, Souza Pinto EB, Al Shammari MA. Clinical application of Vaser assisted lipoplasty: a pilot clinical study. Aesthetic Surg J. 2002;22(2):131–46.   4. Mentz HA III, Gilliland MD, Petronella CK. Abdominal etching: differential liposuction to detail abdominal musculature. Aesthetic Plast Surg. 1993;17(4):287–90.   5. Toledo LS. Syringe liposculpture: a two-year experience. Aesthetic Plast Surg. 1991;15(4):321–6.   6. Hoyos AE. VASER-assisted high-definition liposculpture. Aesthetic Surg J. 2007;27(6):594–604.

Vaser-Assisted Liposculpture for Body Contouring

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Alberto Di Giuseppe

45.1 History Body contouring is an expression of the surgical capability of the plastic surgeon to modify lines and volumes of the body in all its parts. The artistry of the surgeon consists in his tridimensional vision of the body and in the full understanding of a surgical project of recreating pleasant lines and new proportions among all the body parts. To fulfill this target, the surgeon should utilize the best device and techniques in the market. Since 1992, the author has been using ultrasound-assisted lipoplasty (UAL) with the solid probe of the SMEI Sculpture that was later called first generation ultrasound (US). This device was developed in Italy after the initial study of Scuderi et  al. (1987) [1], who applied US energy to emulsify fat instead of mechanically destroying it as in Suction-assisted lipoplasty (SAL). The second generation US was represented by Lysonics and Mentor devices. They had 5 mm cannulas, bullet tip design, 2 mm internal lumen for simultaneous aspiration, golf tee or bullet design, and sheath style cannulas with infuse wetting solutions (Mentor). US energy was administrated only in a continuous fashion. Sound Surgical Vaser represents the third generation of UAL devices, with smaller probes (Fig. 45.1) that are 2.2, 2.9, 3.7, and 4.5 mm, all side grooved, solid probes for tissue fragmentation, pulsed US or continuous, 4 mm access incisions, and upgrade pathway.

A. Di Giuseppe Department of Plastic and Reconstructive Surgery, School of Medicine, University of Ancona, 1, Piazza Cappelli, 60121 Ancona, Italy e-mail: [email protected] e-mail: [email protected]

Fig. 45.1  Probe vs. cannula design. Left: Lysonic 5.1 gauge cannula. Middle: 3.7 mm three grooved Vaser probe. Right: 2.9 mm two grooved Vaser probe

The technical advancements of Vaser in comparison with the previous technologies are as follows: 1. Power of the device that is nearly half of the previous devices. This reduced consistently the rate of complication connected with an excess of unnecessary energy utilized in the past. 2. Efficiency of the device, connected with the new solid probes that are all grooved. One, two, and three grooves are located at the tip of the shaft increasing the surface of emission of the US energy, which means more fat emulsification in unit of time. 3. Optimization of power to prevent excess US. 4. Role of pulsed delivery of US energy that cuts by 50% the energy delivered in the unit of time, thereby decreasing unnecessary power, which rather becomes heat. Vaser shows that it is possible to minimize US energy and achieve emulsification. High power with low

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efficiency becomes heat, high efficiency with low power means emulsification. Technically, grooves significantly increase efficiency, and with high efficiency, small diameter probes can be used, allowing smaller access incisions and minimizing scars. The Vaser system consists of the US device, the aspiration system, and the infiltration system. All together it is assembled in a built-in unit. Vaser means vibration amplification of sound energy at resonance. The system has different alarms for preventing technical problems. It stops the device in case of bad connection, broken handpiece, torquing and levering a probe, or finally using high efficiency probe in fibrous tissue, which leads to change and use of the correct probe. Probe size should be utilized following the tissue encountered. For more fibrotic tissue, the surgeon should prefer a one ring probe, as for standard fat, the two or three rings probe is indicated. The aspiration system is very efficient, with new types of eight holes cannula, Mercedes type. The aspiration of the Ventx cannula is highly efficient and makes the removal of emulsification fat really fast.

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were done and where a good maneuver was achieved. The surgeon must keep in his hands and brain the feeling and the sensation he had in molding a buttock or a trochanter, how to direct his cannula and probe, how to stay superficial with the level of undermining, where there is a need to increase fat removal to shape a flank, where and how to remove fat to thin a gluteus in order to lift it up, and how to treat superficial cellulite or peau d’orange appearance to improve skin tone and look. All plastic surgeons know that talent is a peculiar aspect of their work and that it is a sense of proportion, aesthetic, and taste, and is not on sale. Technique can be learnt with time and constant application, whereas talent is unique and normally shows only in a later stage of our professional life and helps establish if you really are a great artistic surgeon or just a simple handyman. Results have to be repeatable in order to show the ability of the surgeon and correct understanding of the maneuver act to obtain a certain result.

45.2.1 Planning and Marking 45.2 Technique Planning is essential in all aspects of life and work and in aesthetic plastic surgery more than ever. Body is tridimensional, so the approach to the vision of the image has to be full as the understanding of the beauty appearance and the harmony which should be created or restored ideally. These concepts will groove with experience as in all kinds of aesthetic surgeries. The ability to fully restore a low gluteal fold, to correct the wrong line of a trochanter, to lift a flank, or to give lines to thorax and spine lines is part of the talent of the surgeon. Body contouring is not mere reduction of volume, but a sense of proportions and the vision of the body in its full displacement. The surgery restores body lines and shape and gives a natural and nice appearance to the areas being treated. This approach became systematic to the author and gave constant good results. Feeling the tissue is another aspect that is difficult to explain. Only plastic surgeons, aestheticians, and body massage therapists develop a sense of interaction with their hands and the mass of the body they are treating. Constant vision of the body shape and how changes, as a consequence of a surgical procedure, are essential to evaluate the result of the action. Preoperative and postoperative photographs help to visualize good and bad results in order to analyze honestly where mistakes

With the patient standing nude, front, back, lateral, oblique, left, and right photos are taken with a digital camera with the same distance and zoom. It is essential to remove all elastic which can change also minimally the lines at the trochanter and flanks. The need for the lateral view and the oblique view will be clear when examining the tridimensional thigh. In a standard case of body contouring, the author prints a picture where areas are marked for volume reduction, areas to be conserved, areas of undermining that require redraping and contraction, and areas to be left untouched (Fig. 45.2) Correction and planning are marked in all the photos in order to have a systematic view of the body balance and the requirements of shaping. Single areas need a special approach to understand how to address surgical maneuvers. Correction of trochanter deformity, which is the result of the presence of a zone of adherence as a gluteal depression over the great trochanter, requires to draw a line of the new shaped gluteal and trochanter definition by placing a fully extended hand in order to press the tissue excess and define the area to thin and the lines to obtain and shape (Fig. 45.3). Flank deformity is similar in men and women. A new line is obtained by gently pressing over the excess of tissue in order to draw the line according to the proportions of the body (Fig. 45.4). When planning a full remodeling of flanks, abdomen, gluteus, trochanter, and thighs

45  Vaser-Assisted Liposculpture for Body Contouring Fig. 45.2  (a) Marking. (b1-3) Left: Preoperative. Middle: Plan markings. Right: Postoperative

a Green: area to be conserved

Red: untouched areas

Yellow: fat contouring

b1

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A. Di Giuseppe

b3

(internal, external, and anterolateral), the author takes photographs in all these projections (Fig. 45.5). A Pentel pen of a fine marker may be used to shape or draw new lines of contouring to show to the patient and to keep in the record, but mostly to remind the surgeon of the plan in the operating room. All the photos are kept on a printed paper sheet and are shown in the diafanoscope during the surgical procedure in order to check the behavior of tissue during shaping. Some cases may show significant asymmetries with uneven side, volume asymmetry, and different lines of contouring that are rather difficult to correct (Fig. 45.6). Despite being more difficult and challenging, the final result is nice a result of multiple maneuvers for a new and more symmetrical shaped (Fig. 45.7). In abdomen and flank contouring, a concave line needs to be recreated from thorax to iliac crest (Fig. 45.8). Clear defatting of this area is essential to give a natural shape and contour mainly to the female body. With aging, the flank areas tend to enlarge, due also to hormonal changes that deeply influence body appearance. In males this phenomenon is less pronounced (Fig. 45.9). Vaser superficial undermining and sculpturing is mandatory in older skin and in lax skin type, which is rather frequent in most of the author’s patients demanding abdomen molding (Fig. 45.10). The real ability is to thin carefully all the areas, respecting the anatomy of the body, leaving fat in the umbilical area, and vertically defining the external part of the rectus abdominis (Fig. 45.11). The epigastric fat is typically fibrous in older patients, impossible to be eliminated with ­gymnastics, exercise, or diet. Only superficial and deep Vaser is able to correctly thin the area, leaving no dead  space, no depression, no bulges, and no skin irregularities. Correct wide undermining is essential as

careful control of skin adhesion to the deeper planes. This is accomplished with elastic postoperative compression with a garment for nearly 2 months or as much as required and with a cycle of lymphatic drainage, with Endermologie LPG. It is much easier to deal with healthy young skin that is suitable to an excellent skin retraction despite the technique utilized (Fig. 45.12). The real challenge is to nicely shape the body, giving particular emphasis to the shape of the dorsum and flank areas. The final shape should harmonize with the new concavity that should enhance the natural appearance (Fig. 45.13). In older women, this radical approach allows to redefine the full shape of the anatomy despite aging, skin quality, and laxity (Figs. 45.14 and 45.15). Other patients feature the gynoid type of fat with a sort of double plies and double rolls over the abdomen. This type of case requires extensive superficial work and deep volume reduction as well, but the final result gives reason to the use of good technique. In major cases, utilizing the 4.5 mm probe is faster in emulsifying the deeper layers. For postoperative elastic compression, silicone baked foam such as Epifoam is recommended (Fig. 45.16) and is excellent for helping skin adhesion and preventing skin irregularities. When approaching thigh and buttock contouring, first choose the patient position in the operating table because: 1. It is impossible to simulate real gravity affecting the tissue if the patient lies flat in the table. 2. The orthostatic bed invented by Fisher is a great idea, but allows surgery only under local anesthesia and not entire body contouring in one session. 3. The idea in positioning is simple and easily applied in most operating rooms.

45  Vaser-Assisted Liposculpture for Body Contouring

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a2

a1

Zone of adherence (woman)

Gluteal depression over great trocanter

b

Fig. 45.3  (a1, 2) Zone of adherence in the female with glutel depression over the greater trochanter. (b) Correction of trochanteric deformity

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a

b1 Zone of adherence (man)

Iliac crest inferior flank margin

b2

Fig. 45.4  (a) Zone of adherence in the male causing flank deformity. (b1, 2) Correction of the flank deformity

45  Vaser-Assisted Liposculpture for Body Contouring

a

MARKINGS

Fig. 45.5  (a) Markings and photos in all projections. (b1, 2) Left: preoperative. Middle: plan markings. Right: postoperative

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Fig. 45.5  (continued)

A. Di Giuseppe

45  Vaser-Assisted Liposculpture for Body Contouring

Fig. 45.5  (continued)

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434 Fig. 45.6  (a) Left: preoperative. Right: planning. (b) Left: Postoperative 5 weeks. Right: Postoperative

A. Di Giuseppe

a

b

45  Vaser-Assisted Liposculpture for Body Contouring

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Fig. 45.7  Left: preoperative. Right: postoperative

An operating bed is used that can be partially flexed. The hip area is suspended with a rigid silastic pillow to elevate the hips and the bed flexed 30° (Fig. 45.17). All surgery is performed under these conditions, having recreated the natural position of the gluteal and legs with no interference of the gravity forces. Finally, the operating table is flexed to 90° allowing full assessment of how tissue has changed after completing sculpturing (Fig. 45.18). Eliminating the gravity forces is essential for a correct analysis of the new body shape. There is no other method of performing surgery in this area that allows direct control of the tissue and body shape. In the young patient with good skin tone, it is easy to obtain these fine harmonizing results (Fig. 45.19). With really lax skin, in secondary surgery or in legs elephantiasis, the technique is important. Vaser is probably the only technique suitable in these cases where circumferential remodeling is performed to reduce volume and help skin redraping all over the area (Fig. 45.20). Even postbariatric cases are really challenging and difficult to perform with standard SAL. With Vaser, on the contrary, you can operate on these cases with a reasonable amount of quality of the result (Fig. 45.21). Many of the patients who have had abdominoplasty may be suitable for Vaser liposculpture, sparing long

scars, a long postoperative recovery period, and sensory frequent loss in the hypogastric skin. The key is to fully undermine superficially at the subdermal layer together with a deep plane defatting (Fig. 45.22). Even the large abdomen is suitable for good early results and rapid skin tightening when 6,000 mL of solution is removed in one stage (Fig. 45.23). In patients with extremely lax skin and poor abdominal tone, the potential for skin retraction is still great even in a case probably indicated for an abdominoplasty elsewhere. To allow this kind of dramatic improvement, the surgeon must thin and undermine the full area to obtain a thin, viable flap, with minimal dermal thickness (Fig. 45.24). The thinner the subcutaneous fat, the greater the skin retraction that is achieved. The dermis plays the most important role in skin contraction, as is clear in plastic reconstructive surgery when flaps are preferred to skin graft to prevent retraction, or full thickness grafts are preferred to skin graft for the same indication and reason. Vaser works in superficial layer initially, and once undermining is completed, can go deep to the real fat deposit (Fig. 45.25). Fat thickness varies in different body areas, with thigh being the thickest and back and face the thinnest (Fig. 45.26).

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Markings pre operative planning

Concave line from thorax to flanks Fig. 45.8  Markings for preoperative planning and concave line from thorax to flank

45  Vaser-Assisted Liposculpture for Body Contouring Fig. 45.9  (a) Left: pre­operative. Right: post­operative. (b) Left: preoperative. Right: postoperative. (c) Left: preoperative. Right: postoperative

a

b

437

438 Fig. 45.9  (continued)

A. Di Giuseppe

c

Fig. 45.10  Left: preoperative. Middle: planning. Right: postoperative

45  Vaser-Assisted Liposculpture for Body Contouring Fig. 45.11  (a) Left: pre­operative. Right: post­operative. (b) Left: preoperative. Right: postoperative

a

b

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Fig. 45.12  Left: preoperative. Middle: planning. Right: postoperative

a1

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a3

b

Fig. 45.13  (a) 1 Preoperative. 2 Plan with marking. 3 Postoperative. (b) Left: preoperative. Right: postoperative

45  Vaser-Assisted Liposculpture for Body Contouring Fig. 45.14  Left: ­preoperative. Right: postoperative

Fig. 45.15  Left: preoperative. Right: postoperative

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Fig. 45.16  Compressive garment and foam

Fig. 45.17  Positioning

Fig. 45.18  Positioning at the end of surgery

A. Di Giuseppe

45  Vaser-Assisted Liposculpture for Body Contouring Fig. 45.19  (a) Left: preoperative. Right: planning. (b1-3) Left: preoperative. Right: postoperative

a

b1

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444 Fig. 45.19  (continued)

A. Di Giuseppe

b2

b3

45  Vaser-Assisted Liposculpture for Body Contouring Fig. 45.20  (a) Left: pre­operative. Right: 3 months post­operative. (b) Left: preoperative. Right: 3 months postoperative (c) Left: pre­operative. Right: 3 months post­operative. (d) Left: preoperative. Right: 3 months postoperative

a

b

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446 Fig. 45.20  (continued)

A. Di Giuseppe

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d

45  Vaser-Assisted Liposculpture for Body Contouring Fig. 45.21  (a) Left: pre­operative. Right: 3 months post­operative. (b) Left: pre­operative. Right: 3 months postoperative (c) Left: pre­operative. Right: 3 months post­operative

a

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447

448 Fig. 45.21  (continued)

A. Di Giuseppe

c

a

Fig. 45.22  (a) Left: pre­operative. Right: 3 months post­operative. (b) Left: preoperative. Right: 3 months postoperative (c) Left: pre­operative. Right: 3 months post­operative

45  Vaser-Assisted Liposculpture for Body Contouring Fig. 45.22  (continued)

b

c

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450 Fig. 45.23  (a) Left: preoperative. Right: postoperative. (b) Left: preoperative. Right: post­operative. (c) Left: preoperative. Right: postoperative

A. Di Giuseppe

a

b

45  Vaser-Assisted Liposculpture for Body Contouring Fig. 45.23  (continued)

c

Fig. 45.24  Thinning the skin flap with Vaser UAL

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452 Fig. 45.25  (a) Layers of subcutaneous emulsification with Vaser UAL. (b) The thinner the subcutaenous fat, the greater the retraction achieved. UAL solid titanium probe works close to the dermis to thin the subcutaneous fat and achieve retraction

A. Di Giuseppe

a

b

In secondary surgeries, the experience of the surgeon plays a key factor. The surgeon must understand the previous surgeon’s mistakes or what was done incorrectly. Then, understand if the case is improvable and how (Figs. 45.27–45.32). For collecting fat, the

Tissue-Trans Mega 1,000 cl (Shippert, USA) is used for large volume fat transfer. The harvested fat is obtained in a sterile bag, unwanted fluid is removed by a luer lock syringe, and the final clear viable fat is obtained ready for injection.

45  Vaser-Assisted Liposculpture for Body Contouring Fig. 45.26  Fat thickness varies in different body areas

Fig. 45.27  Transforming a flat square buttock into a round harmonic buttock and improving gluteal cellulite with Vaser UAL and fat transfer

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Fig. 45.28  Transforming convexity into concave lines to recreate shape and natural contouring

a

Fig. 45.29  (a) Left: preoperative banana fold deformity. Right: postoperative following adjustment of minor irregularities of the banana fold and trochanter with a 2.2-mm probe and undermining and superficial sculpturing to thin the gluteus. Note postoperative upward rotation of the buttock. (b) Left: preoperative

banana fold deformity. Right: postoperative following adjustment of minor irregularities of the banana fold and trochanter with a 2.2-mm probe and undermining and superficial sculpturing to thin the gluteus. Note postoperative upward rotation of the buttock

45  Vaser-Assisted Liposculpture for Body Contouring Fig. 45.29  (continued)

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b

Fig. 45.30  Secondary banana fold deformity: Left: preoperative. Middle: planning. Right: postoperative after Vaser sculpting with 2.2 mm probe and thinning of all areas

456 Fig. 45.31  (a) Left: preoperative with asymmetrym bulges, fat deposits, lax skin, and cellulite. Right: plan with marking. (b) Left: preoperative. Right: postoperative following superficial and deep Vaser shaping and extensive fat grafting (arrows)

A. Di Giuseppe

a

b

45  Vaser-Assisted Liposculpture for Body Contouring

a

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Fig. 45.32  (a) Left: preoperative. Note depression (arrow). Right: planning. (b) Left: preoperative. Right: 1 year postoperative

Fig. 45.33  Large volume autologous fat transfer made easy

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Fig. 45.34  Harvested fat

Reference   1. Scuderi N, Devita R, D.Amdrea F, Vonella M. Nuove prospettive nella liposuzione la lipoemulsificazione. Giorn Chir Plast Ricostr Esthetica. 1987;2(1):33–9.

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Fig. 45.35  Drain unwanted fluid: Hang bag for fat and waste to separate. Drain unwanted fluid by opening the white clip. Drain unwanted fluid into a basin or attach a luer syringe and draw it off

Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring

46

Andrew T. Lyos

46.1 Introduction Today, preoccupation with fitness has made muscular definition in the female a sought-after goal [1, 2]. Wellproportioned arms and upper back with muscular development are the goal of today’s physically fit women and prominently featured in today’s fashion [3–5]. The increase in bariatric surgery for the morbidly obese has added to the group interested in aesthetic improvement of their arms. Rejuvenation of the upper arms continues to provide a challenge to both the surgeon and patient. Aging of the upper arm is extremely variable and depends on numerous factors, the most important of which appear to be genetics, the consistency of upper body toning exercises, obesity, and the variations of weight throughout life. The net result is an unaesthetic appearance with skin laxity and lipodystrophy of various degrees with the most severe form frequently designated the “batwing” deformity. Traditional liposuction of the upper arms has failed to meet the expectations of our patients. Commonly reported undesired sequelae of liposuction of the arms include worsening of skin laxity and wrinkling, central overresection on the inferior brachial border, and the lack of regional harmony [6–8]. Brachioplasty procedures improve contour, but are frequently unacceptable to our patients because of the undesired sequelae of widened, misplaced, or hypertrophic scars, contour irregularities, numbness, and skin necrosis [9–15]. Circumferential para-axillary superficial tumescent

A. T. Lyos Division of Plastic Surgery and Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, TX, USA e-mail: [email protected]

(CAST) liposuction alone or with minibrachioplasty has offered a reliable technique for arm contouring which maximizes retraction of the skin [3–5].

46.2 Technique Patient Classification. Patients are classified according to the scheme proposed by Teimourian and Malekzadeh (Table 46.1) (Fig. 46.1) [16]. Category 1: Minimal to moderate subcutaneous fat with minimal skin laxity: Patients generally have circumferential increase in fat volume, but adequate skin tone and elasticity. These patients do well with circumferential liposuction of the arm and para-axillary area. Relatively small amounts of fat are removed. Ultrasonic-assisted liposuction (UAL) is not required Category 2: Generalized accumulation of subcutaneous fat with moderate skin laxity: Patients generally have an increased volume of fatty tissue circumferentially as well as noticeable loss of skin elasticity with ptosis. Circumferential liposuction encourages skin tightening. Minibrachioplasty may be required. Ultrasonic energy can encourage enhanced skin retraction, frequently reducing the need for skin excision. Category 3: Generalized obesity and extensive skin laxity: Patients generally have more significant lipodystrophy and skin laxity. Obese patients typically accumulate a large volume of fat in the para-axillary region and upper arm. Ultrasonic-assisted circumferential liposuction maximizes the potential for adequate skin retraction. Minibrachioplasty confided to the axilla is frequently required for Group 3 individuals. The larger the volume of fat removal, the better the prognosis for skin retraction with CAST liposuction and the shorter the brachioplasty scar if required.

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_46, © Springer-Verlag Berlin Heidelberg 2010

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Table 46.1  Upper arm contouring classification Category 1

Minimal arm fat with good skin tone

Category 2

Moderate fat with moderate skin laxity

Category 3

Marked excess skin and fat

Category 4

Minimal to moderate fat and marked excess skin

Category 4: Minimal subcutaneous fat and extensive skin laxity: These individuals demonstrate marked skin laxity and depletion of subcutaneous fat. Full brachioplasty is capable of producing an aesthetically pleasing contour of the arm and straight inferior brachial boarder. The surgical scars can be detouring, particularly in those individuals who have Fitzpatrick III to VI skin type and those who scar poorly. CAST liposuction combined with a minibrachioplasty confined to the axillas can produce improvement of the upper arm with some residual skin laxity, particularly distally. As noted, the larger the volume of fat removed, the greater is the potential for skin retraction, thereby reducing the length of the brachioplasty scar.

46.3 Preoperative Marking Patients requesting arm reduction were marked in the preoperative area in the standing position. The arms were marked in the abducted position with 90° flexion a

c

Fig. 46.1  Upper arm contouring categories: (a) Category 1. (b) Category 2. (c) Category 3. (d) Category 4

at the elbow. Preoperative markings divide the arm and contiguous para-axillary regions into nine zones (Fig. 46.2). Distal forearm, upper back, deltoid, axilla, and lateral pectoral extensions are included for re­gional harmony. For individuals with excessive skin laxity, in addition to lipodystrophy, a minibrachioplasty is designed. Puncture sites are marked at the anterior and posterior axilla, medial and lateral distal arm 1.5 cm proximal to the olecranon. Infrequently a puncture site is marked in the middle third of the posterolateral arm. Preoperative marks were checked with the arms in the adducted relaxed position to ensure appropriate placement for minimal delectability.

46.4 Anesthesia CAST liposuction of the arms may be performed under local or general anesthesia. It is the author’s preference to treat the arms under general anesthesia while performing liposuction of multiple areas. Superwet or tumescent anesthesia is utilized for hemostasis, compartment magnification, and postoperative analgesia [17, 18]. A greater volume of infiltration is utilized to minimize the thermal effect if UAL is required [19]. For procedures performed under general anesthesia, to each three liters of lactated ringers are added 50 mL of 1% lidocaine (500 mg) and 3 mL of 1:1,000 epinephrine. For procedures performed under local anesthesia, b

d

46  Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring Fig. 46.2  Right arm para-axillary area with eight anatomical zones: (a) Anterior. (b) Posterior

a

the concentration of lidocaine may be increased by the addition of 150 mL of 1% lidocaine (1,500 mg) and 3 mL of 1:1,000 epinephrine. The surgeon must be aware of the dose of lidocaine being administered and keep the total lidocaine dose well below 35 mg/kg [17–22]. The volume of infiltrate is typically 800– 1,500 mL/arm.

46.5 Position Arm contouring in the lateral decubitus position is preferred. Although arm contouring can be performed in the prone and supine position, access to the para-axillary region is limited. The lateral decubitus position allows for circumferential treatment.

46.6 Technique Arm contouring is most frequently performed as part of total body contouring. When done so, the procedure is performed in an AAAA certified surgery center with the assistance of a board certified anesthesiologist. The patient is prepped in the standing positions to the level of the axilla. She is then placed on the operative table on a bean bag in the supine position. After achieving adequate general endotracheal anesthesia, she is draped in a sterile fashion. The patient is turned to the lateral decubitus position and an axillary roll is placed. The arm and upper forearm are prepped with Betadine and wrapped in a sterile towel from the elbow down, covering

461

b

intravenous (IV) tubing and anesthesia monitoring devices. The arm is then placed on a mayo stand padded with a pillow and covered with a sterile towel. The arm is freely mobile, offering the advantage of access to all incision sites. The incisions are made with an 11 blade. Tumescent fluid is infiltrated under pressure to achieve a peu de’orange appearance. In the lateral decubitus position, typically the back, hips, thighs, and buttocks are treated before the arms to allow additional time for vasoconstriction. The arm is conceptually divided into three regionsanteromedial, anterolateral, and posterolateral (Fig. 46.3). CAST liposuction of the arms is site specific with pretunneling and/or deep liposuction, superficial, or all-layer liposuction. Circumferential pretunneling is performed with a 3-mm Mercedes cannula through multiple access sites. UAL, when utilized, is performed with a Mentor Contour Genesis (Mentor Corp., Dallas, TX) utilizing a 20-mm solid tip cannula with a generator setting of 75. Treatment is limited to 2–3 min for the posterolateral and paraaxillary region utilizing the posterior axillary incision. Circumferential liposuction is performed most aggressively in the posterolateral one third, less aggressively in the anterolateral one third, and least aggressively in the anteromedial one third.

46.6.1 Anteromedial Pretunneling is performed from the olecranon and axillary sites longitudinally. If the pinch test is 10 mm or less, only pretunneling is done. No liposuction is performed

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Fig. 46.3  Cross-section of the left arm demonstrating three anatomical regions: medial, anterolateral, and posterolateral

Anterolateral

Anteromedial

Posterolateral

under thin, anteromedial skin due to the propensity for wrinkling, especially near the axilla. Cross tunneling and/ or deep suctioning is performed from the middle third of the arm to create a final pinch test of 10–15 mm.

overresection centrally (Zones 2 and 3) by checking the pinch test frequently.

46.6.4 Para-Axillary 46.6.2 Anterolateral Superficial liposuction from the anterior axillary site, dorsoradial arm, and mid arm is performed with a 3 × 20-mm Mercedes cannula. The final pinch test should be 9–14 mm.

46.6.3 Posterolateral Ultrasonic energy is delivered through the posterior axillary incision as described. All-layer liposuction is performed with deep, superficial, and subdermal liposuction frequently required. A 3 × 20-mm Mercedes cannula is used initially. For larger volume extractions, a 4 × 30-mm cannula enables access to the entire length of the posterolateral compartment. Avoid

UAL is particularly useful for the deltoid region and upper back (Zones 7 and 8). No ultrasonic energy is delivered to the axilla proper (Zone 6). The fat is evacuated with 3 and 4 mm Mercedes cannulas. More aggressive liposuction is performed with a 3 mm Gasparotti to encourage the formation of a confluent layer of collagen forming circumferentially around the arm connecting to the trunk. The axilla, deltoid, and lateral pectoral extensions are treated with a 3 mm Mercedes to minimize wrinkling. The suture sites are closed with a single 5-0 nylon suture

46.7 Postoperative Care Care is taken in applying Reston foam. The author prefers Reston foam to the nonadherent Lipofoam

46  Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring

for CAST liposuction of the arms. The adherent side to the Reston is covered with bacitracin ointment or vaseline to allow adherence, yet minimizing the risk of blistering. With the arm extended, the circulating nurse grasps the anterolateral skin to elevate the dependent posterolateral skin, and the sheet of Reston is placed under the posterolateral skin to redrape sagging skin smooth along the posterior arm. Wrinkling is directed anterolaterally. The arm is wrapped with a 4-inch ace wrap from the elbow proximally. Drains are no longer used as reported previously [3–5]. The Reston foam is removed the following day. Nonadherent Reston or Lipofoam is applied and a surgical compression garment that extends below the elbow is placed. The Reston may be kept in place for up to 1 week depending on the degree of skin laxity. The compression garment is worn at all times for­ 6 weeks. For more severe skin laxity, an additional 4 weeks of compression at least 12 h/day is recommended. The sutures are removed at 6–7 days. Frequent inspection for seromas is required for 6 weeks postoperatively. Persistent postoperative pain most frequently represents a seroma that should be treated with serial aspiration and compression. Painful bands or scar tissue or focal nodules representing fat necrosis are treated with message and microinjection of 0.2 mL triamcinolone (2 mg/mL). Injection is performed deep to avoid thinning of the skin. Limited range of motion of the shoulder due to axillary tightness is treated with message and range of motion exercises.

46.8 Minibrachioplasty Technique The minibrachiolasty incision is marked in the preoperative area with the arm abducted 90° from the trunk. The crease marking the junction of the medial arm with the axilla is located. The skin to be excised is marked with a symmetric ellipse of tissue measuring 4–6 by 12–15 cm in length. All attempts are made to confine the resulting scar to the axilla and avoid delectability, particularly posterior. The procedure can be performed in the lateral decubitus position; however, the author prefers to perform both minibrachioplasties in the supine position following the completion of the

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CAST liposuction. The demolipectomy is performed initially, leaving the superficial fascia intact to avoid injury of the vital structures located in the axilla. Metzenbaum scissors are then used spreading in the direction of the axillary vessels to identify the axillary vein. After locating the axillary vessels, superficial fascial system suspension sutures are placed of 2-0 Vicryl. Four to five sutures are preplaced and tagged prior to securing. Care is taken to incorporate the superficial layer of axillary fascia to prevent migration of the scar [13, 23–25]. Advancement is performed centrally to minimize standing cones. Standing cones are excised anteriorly if required. The subcutaneous tissue is closed with 3-0 Vicryl. A subcuticular suture of 4-0 clear PDS is placed. Interrupted 4-0 nylons sutures are placed to reinforce the inci­ sion and removed at 5–6 days. Postoperative care is similar to CAST liposuction of the arms with the exception that range of motion of the arms, particularly abduction, is limited for 4–6 weeks following surgery.

46.9 Results Between July 2001 and March 2009, 190 patients have undergone CAST liposuction alone (152) or with minibrachioplasty (38). Average age was 52.3 years (range, 20–71). Follow-up was 5–36 months (average, 16.2  months). There were 189 women and one man included in this series. One hundred and eighty nine patients underwent CAST Liposuction in combination with another cosmetic surgical procedure, most frequently liposuction of other regions. Represen­ tative before and after images are illustrated in Figs. 46.4–46.10. The following complications have been reported with liposuction of the arm with and without minibrachioplasty, but occurred infrequently in this series: Seroma, hematoma, pseudobursa, chronic pain, hypertrophic scarring, and wrinkling [1, 3–7, 16]. Use of ultrasonic liposuction, particularly time of use, and aggressive fat removal increase the likelihood of seroma. Aesthetic results were reviewed with the patients 6–12 months after the procedure. Secondary surgeries were offered at a reduced cost as outlined in the financial agreement discussed preoperatively.

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a1

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Fig. 46.4  Twenty-year-old female who underwent circumferential para-axillary superficial tumescent (CAST) liposuction with removal of 300 mL of fat from the right and 300 mL fat from the left: (a1, 2) Preoperative. (b1, 2) Five months postoperative

Residual skin flaccidity in Zone 4 proximal to the elbow and in Zone 1 anteromedial is relatively common in Category 3 and 4 patients, but is well accepted in lieu of the scars resulting from full brachioplasty. One patient who underwent CAST liposuction and minibrachioplasty requested revision on the posterior aspect of the incision due to visibility at the posterior axillary fold.

46.10 Discussion Requests for rejuvenation of the arms are increasing, particularly by young and middle aged women, who are frequently well-educated and physically fit. They receive a psychological boost from the appearance of

well-proportioned muscular arms. Early efforts to prevent, delay, or even halt skin degeneration and ptosis may include exercise, weight loss, and massage. It is only after these initial conservative efforts fail that individuals seek a consultation for surgical correction. Frequently, women are trying to prevent the development of “bat wing” deformity which they see in their mothers and grandmothers. There is evidence that early liposuction in these category 1 patients prevents the progressive lipodystrophy, which results in ptosis of the superficial fascia resulting in skin ptosis and flaccidity [1, 5]. The goal of CAST liposuction of the arm is to create regional harmony with a straight brachial border and minimal changes of skin quality, with minimal detectable scarring [3]. Correction of the upper arm utilizing traditional liposuction techniques has

46  Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring

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Fig. 46.5  Thirty-two-year-old female who underwent CAST liposuction with removal of 500 mL of fat from the right and 500 mL of fat from the left: (a1, 2) Preoperative. (b1, 2) Twelve months postoperative

presented a challenge with satisfaction rates for the arms significantly lower than other regions [1]. Caution has been advocated in the application of liposuction of the arm in patients over 50 years of age [8]. Traditional brachioplasty is capable of producing the improvement in arm shape that patients request, but most individuals are unwilling to accept the brachioplasty scar. Reported complication rates for traditional brachioplasty are up to 25% and revision rates of 12.5% [15]. CAST liposuction of the arms differs from traditional (standard) tumescent liposuction of the arms as follows. Traditional tumescent liposuction of the arms involves deep liposuction over the posterolateral arm feathering of anteromedially and anterolaterally without circumferential treatment and without ultrasonic energy. Standard tumescent liposuction has the potential to worsen skin laxity and sagging. CAST liposuction combines several

principles to obtain more predictable aesthetic results. Circumferential treatment of the upper arm and paraaxillary region creates a subcutaneous confluence (lattice) of collagen deposition during healing, which promotes regional harmony. Small cannulas (3–4 mm) are utilized to minimize the risk of contour irregularities. Liposuction is performed from multiple directions in a multilayered approach. Circumferential liposuction is performed most aggressively in the posterolateral one third, less aggressively in the anterolateral one third and least aggressively in the anteromedial one third. For this reason, the majority of the delivery of the ultrasonic energy and the extraction of fat are done in the lateral decubitus position through a puncture site in the posterolateral axillary fold [3–5]. Liposuction through the posterior axillary incision minimizes the risk of overresection posterolaterally in zones 2 and 3 and allows for excellent

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Fig. 46.6  Thirty-eight-year-old female who underwent CAST liposuction with removal of 600 mL of fat from the right and 550 mL of fat from the left: (a1, 2) Preoperative. (b1, 2) Seven months postoperative

access the axilla and para-axillary region (zones 6, 7, and 8). For individuals with moderate fat and moderate skin laxity (Category 2), the application of ultrasonic energy with tumescent infiltration allows for compartment magnification and greater fat removal. Extraction of the emulsion with small cannulas results in a smoother appearance and enhanced skin retraction. Extraction with small cannulas is done utilizing a multilevel, multidirectional approach. The majority of the liposuction is done in the posterolateral arm where there is generally the greatest adiposity. The skin of the posterior lateral arm is thickest and has the greatest potential for contraction. Care is taken in avoiding overresection in the thin-skinned areas of the anterolateral and anteromedial arm. This is particularly important in the individuals with photoaged Fitzpatrick

I and II skin types, to minimized worsening of wrinkles and ptosis in these areas. For individuals with marked excess of skin and fat (Category 3), CAST liposuction alone may provide the degree of correction. In general, the greater the amount of fat removal, the less likely skin excision will be required. Skin excision in the form of minibrachioplasty offers the advantage of tightening of the skin in Zones 1 and 2 in the anteromedial and posterolateral skin with an incision hidden in the axilla. Minibrachioplasty produces no improvement in the tightness of the skin in Zones 3 and 4. The scar of the minibrachioplasty is in general well tolerated as it rarely widens or becomes hypertrophic. Although additional skin can be excised, the dimension of the excised skin needs to be confined to the axilla, particularly posteriorly, to avoid visibility from behind. An

46  Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring

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Fig. 46.7  Forty-seven-year-old female who underwent CAST liposuction with removal of 450 mL of fat from the right and 400 mL of fat from the left: (a1, 2) Preoperative. (b1, 2) Four months postoperative

additional advantage is that excised skin reduces the hair baring skin of the axilla and reduces hydrosis. As the distal skin margin of the excision is longer than the proximal margin, early postoperative wrinkling is common, which improves within several months. Reported variations of modified brachioplasties or limited incision techniques leaving scars extending out of the axilla have been reported [1, 16, 23–25]. Extension may be in the form of a T or an L or may extend posteriorly on to the back. These reported techniques relied primarily on skin excision rather than liposuction. Individuals with minimal to moderate fat and marked excess of skin (Category 4) who are seeking arm rejuvenation are increasing due to the prevalence of bariatric surgery. Elderly women will invariably have wrinkling of the skin of their arms,

just as they will have wrinkling elsewhere. They will generally accept an imperfect result which appears natural. CAST liposuction provides improvement which the patients perceive as being more natural than the improvement resulting from a brachioplasty with anteromedial scarring of the arm. It is important to avoid overresection anteromedially in Zone 4, which results in wrinkling above the elbow. Performing CAST liposuction and minibrachioplasty does not obviate traditional brachioplasty in the future. For those with minimal to moderate fat and extreme skin laxity, traditional brachioplasty may provide the best alternative. Individuals wellsuited for traditional brachioplasty are those over the age of 60 years who are Fitzpatrick I or II skin types without personnel or family ­h istory of ­a bnormal scarring. Disadvantage of traditional

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Fig. 46.8  Twenty-year-old female who underwent CAST liposuction with removal of 450 mL of fat from the right and 450 mL of fat from the left: (a1, 2) Preoperative. (b1, 2) Four months postoperative

brachioplasty involves scarring, possible delayed healing, and numbness. Great care must be taken in the discussion of the risks involved in a traditional brachioplasty and in the informed consent process [13, 15]. Meticulous postoperative care is vital to obtaingood results. Compression is essential to achieve accurate redraping of the skin. Most frequently, the skin is loose and sagging posteriorly. Pulling the skin anterolaterally to smooth any wrinkles anterior medially and then fixing it with Reston foam facilitates ­re-draping and stabilization of the skin [3, 4, 7]. Weekly checks for seromas are required for the first 4 weeks. Seroma

formulation is decreased with re­duced duration of ultrasonic energy delivery and the use of a greater number of liposuction access sites. Postoperative compression is required for 6 weeks for optimal aesthetic results. The primary attraction of CAST liposuction with or without minibrachioplasty is enhanced skin retraction with minimal scarring compared to a traditional brachioplasty. Extensive preoperative educational is advisable. Realistic expectations should be stressed in terms of the amount of improvement which can be anticipated. Photographs of patients who have undergone liposuction, with and without minibrachioplasty,

46  Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring

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Fig. 46.9  Twenty-six-year-old female who underwent CAST liposuction with removal of 600 mL of fat from the right and 550 mL of fat from the left: (a1, 2) Preoperative. (b1, 2) Nine months postoperative

as well as full brachioplasty, should be available to demonstrate realistic results and sites of surgical scars. A financial policy should be spelled out prior to the procedure regarding financial obligations, should a secondary procedure be required.

46.11 Conclusions Liposuction of the arms in the patient with aged and flaccid skin has traditionally produced disappointing results. CAST liposuction was developed to maximize

skin retraction can regional harmony by compartment magnification followed by circumferential treatment of the arm and adjacent aesthetic units. Rigorous patient selection and education are essential as the goal of CAST liposuction is improvement, not perfection. The postoperative care is demanding in order to achieve accurate skin redraping requiring complete patient compliance. Minor complications including seromas and wrinkling are not uncommon. The patient must be aware that there may be the need for a secondary surgical procedure in the form of a modified brachioplasty to treat redundant skin in the axilla and upper arm.

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Fig. 46.10  Fifty-five-year-old female who underwent CAST liposuction with removal of 800 mL of fat from the right and 800 mL of fat from the left combined with minibrachioplasty. (a1, 2) Preoperative. (b1, 2) Five months postoperative

References   1. Vogt PA, Baroudi R. Brachioplasty and brachial suctionassisted lipectomy. In: Cohen M, editor. Mastery of plastic and reconstructive surgery. 1st ed. Boston: Little Brown; 1994. p. 2219–36.   2. Lillis PJ. Liposuction of the arms. Dermatol Clin. 1999; 17(4):783–97.   3. Gilliland MD, Lyos AT. CAST liposuction of the arm improves aesthetic results. Aesthetic Plast Surg. 1997;21(4): 225–9.   4. Gilliland MD, Lyos AT. CAST liposuction: an alternative to brachioplasty. Aesthetic Plast Surg. 1997;21(6):398–402.   5. Gilliland MD. Ultrasound-assisted circumferential paraaxillary superficial liposuction effect on arm contour. Oper Tech Plast Reconstr Surg. 2002;8(2):60–6.   6. Illouz YG, DeVillers YT. Body sculpting by lipoplasty. Edinburg: Churchilll Livingstone; 1989. p. 279–81.   7. Schlesinger L. Suction assisted lipectomy of the upper arm: a four cannula technique. Aesthetic Plast Surg. 1990; 14(4):271–4.   8. Grazer FM. Atlas of suction assisted lipectomy. New York: Churchill Livingstone; 1992. p. 139–40.

  9. Correa-Iturraspe M, Fernandez JC. Dermolipectomia brachuial. Prensa Med Argent. 1954;41(34):2432–6. 10. Baroudi R. Dermolipectomy of the upper arm. Clin Plast Surg. 1975;2(3):485–94. 11. Guerrero-Santos J. Brachioplasty V. Aesthetic Surg J. 2004;24:1616–9. 12. Pitanguy I. Aesthetic plastic surgery of the upper and lower limbs. Aesthetic Plast Surg. 1980;4:363–72. 13. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(4):912–20. 14. Pascal JF, Le Louarn C. Brachioplasty. Aesthetic Plast Surg. 2005;29(5):423–9. 15. Knoetgen J, Moran SL. Long-term outcomes and complications associated with brachioplasty: a retrospective review and cadaveric study. Plast Reconstr Surg. 2006;117(7): 2219–23. 16. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102(2):545–51. 17. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990;16(3):248–63. 18. Rohrich RJ, Beran SJ, Fodor PB. The role of subcutaneous infiltration in suction assisted lipoplasty. Plast Reconstr Surg. 1997;99(2):51.4–9.

46  Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring 19. Kenkel JM, Robinson JB, Beran SJ, Tan J, Howard BK, Zocchi ML, Rohrich RJ. The tissue effects of ultrasound assisted lipoplasty. Plast Reconstr Surg. 1998;102(1): 213–20. 20. Pitman GH. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg. 1993;92:1099–100. 21. Matarasso A. Lidocaine in ultrasound assisted lipoplasty. Clin Plast Surg. 1999;26(3):431–9.

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22. Samdahl F, Amland PF, Bugge JF. Plasma lidocaine levels during suction assisted lipectomy using dilute lidocaine. Plast Reconstr Surg. 1994;93(6):1217–23. 23. Richards ME. Minimal incision brachioplasty: a first choice option in arm reduction. Aesthetic Surg J. 2001;21:301–8. 24. Richards ME. Reassessing minimal-incision brachioplasty. Aesthetic Surg J. 2004;25:175–9. 25. Abramson DL. Minibrachioplasty: minimizing scars while maximizing results. Plast Reconstr Surg. 2004;114(6):1631–7.

Body Contouring with Focused Ultrasound

47

Javier Moreno-Moraga and Josefina Royo de la Torre

47.1 Introduction Demand for nonsurgical body weight control ­treatments has increased in the last few years. Despite offering less corrective results than traditional cosmetic surgery for body contouring (liposuction, crural and brachial lifts and abdominoplasty), nonsurgical treatments have gradually gained ground in the reduction of localized fat and improvement of the skin’s appearance and texture [1–3]. Diet, exercise, and genetics are all important influencing factors in the appearance of indentations in the skin, which are hard to conceal at any age. Demand for nonsurgical, nonablative cellulite treatments have lead many manufacturers to invest in a new generation of sophisticated devices and therapies to repair the skin and improve body shape. A number of these options have a proven softening effect (after multiple treatment sessions).

47.2 General Considerations 47.2.1 Subcutaneous Adipose Tissue Anatomic and physiologic studies on the adipose tissue have been focused on in vivo studies of individual adipocytes or in vivo studies with functional and minimally invasive methods [4–6]. Traditionally, the subcutaneous adipose tissue has been considered as insulation and a source of stored energy. More recently, there has been greater interest in

J. Moreno-Moraga (*) Instituto Medico Laser, General Martinez-Campos 33, 28010 Madrid, Spain e-mail: [email protected]

the distribution and composition of the adipose ­tissue in relation to health and morbidity. The actual concepts of the adipose tissue’s anatomy are derived from the histological studies of Nurnberger and Muller, who analyzed samples of healthy men and women’s adipose tissue and of women with cellulite [7]. They reported indentations into the deep adipose tissue through the dermis on women, but not in men. They also described modifications on the fibrous septae architecture oriented perpendicular to the cutaneous surface on women and in a criss–cross pattern on men.

47.2.2 Histological Characteristics of Subcutaneous Adipose Tissue The histology of subcutaneous adipose tissue has been thoroughly investigated. There are macroscopic and microscopic differences between skin of men and woman without alterations and on women with celulite [8]. The macroscopic examination of the specimens of full thickness proved the complexity of the 3-dimensional (3-D) net formed by the fibrous bands, which are born from the hypodermis. Pierard felt that there were no continuous layers of connective tissue that may be called septae between the lobules of adipose tissue in women with cellulite, even though the microscopic examination of thigh skin in men shows a dermalhypodermic leveled interface without any clinical signs of cellulite. In contrast, the dermal-hypodermic interface of women’s thigh skin (even without cellulite) demonstrates that the adipose lobules have a granular aspect, which protrudes into the dermis [5]. The lobules rise as valleys and hills under the dermal surface. In some cases, the sweat glands are trapped in these fat lobules. There is no correlation between the extent of this finding and

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the clinical type and severity of cellulite. A more undulated dermis hypodermic interface on women, which corresponds to the fibrous bands observed in the macroscopic studies on corpses, has been confirmed using high-resolution ultrasound (US) images [6]. Recently, the architecture of the fibrous septae net has been visualized through 3-D magnetic resonance imaging (MRI), as well as with a high-resolution ultrasound. Camper’s fascia can clearly be observed as a thin flat structure more or less parallel to the cutaneous surface. Other septae were detected as thin structures oriented like pillars in three directions: perpendicular, parallel, and with a 45° angle. In women with cellulite, there are a higher percentage of perpendicular fibers in comparison with women (and men) who do not have cellulite. As for the fibers in other directions, women with cellulite have a lower percentage of parallel septae to the skin and a higher percentage of angled septae. Furthermore, an MRI study on adipose tissue comparing young and mature women found a higher content of water within the dermis in the older group. A larger amount of free water between the dermis has been related to collagen architecture degradation during the aging process, leaving less interaction sites between water and macromolecules [5, 6]. Skin aging is a process that can be classified into two groups: intrinsic aging and photo aging. These are considered different processes with the first caused by the passage of time and the second due to continuous exposure to the ultraviolet rays from the sun. In both types of aging, the most dramatic histological changes are found in the dermis. Collagen alterations, the main skin component, have been identified as the cause of the changes observed. The dermis contains mainly collagen type I (85–90%) and less collagen type III (10–15%). The dermal fibroblasts synthesize the individual chains of polypeptide procollagen I and II, precursors of collagen type II and type III that are formerly polymerized in the carboxylic rings and amino terminals to form the triple helixes. Skin that is not normally exposed to the sun’s ultraviolet radiation, such as the thighs and buttocks, mainly goes through the intrinsic aging process. In a study about collagen metabolism in the aging process, it was observed that in the areas not exposed to sun, the synthesis of collagen diminishes as the aging process goes on, maintaining a negative balance between synthesis and collagen degradation. Since the buttocks and thighs undergo a lesser degree of photo aging, they are ideal anatomical areas to

J. Moreno-Moraga and J. R. de la Torre

observe the effect of RF energy on the chronologically aged collagen in the adipose tissue [6].

47.2.3 Cellulite Cellulite is a type of lipodystrophy considered by many to be an aesthetic disorder in which the alteration is a morphological constitutional disposition with no significant histological or biological alterations of the adipose tissue [7]. It affects females almost exclusively, and appears around puberty. Approximately 90% of the female population have some degree of cellulite. It is common to confuse cellulite appearance with obesity, even though it is a different condition. Obesity is a generalized condition in which the adipocytes increase in number and size. Cellulite is localized to specific sites with characteristic structural changes (lipodystrophy). Cellulite is mainly located on the lateral aspects of the thighs and buttocks and is highly related to hormonal changes in females. Cellulite differs from the fat on the abdominal wall, which is more dependent on metabolism and diet, and is more easily removed. Skin with cellulite is rough to the touch. When it is pinched, it has the appearance of orange skin, and is often associated with a painful sensation.

47.2.4 Cellulite Pathogenesis In the gynoid zones (thighs, hips, and buttocks), women have adipocytes five times greater than in other body zones. The cutaneous microcirculation has certain special characteristics that deposit more fat and retain more interstitial fluids. The fat is kept in the adipocytes that are found between the skin and muscles and divided by fibrous tissue bands. These fibrous bands give the adipose tissue a wall-like aspect between the skin and muscles which slow down the lymphatic drainage.

47.2.5 Ultrasound (US) in the Study of Cellulite It is complicated to study the RF thermal effect on the subcutaneous tissue in large areas like the thighs and buttocks. A biopsy may cause trauma to the tissue,

47  Body Contouring with Focused Ultrasound

which would modify the next sample by leaving scar tissue that would alter the histological morphology of the study zone. It is technically difficult to take the whole thickness of healthy adipose tissue without causing a deformity during extraction or processing. It was determined that in vivo observation in real time with noninvasive methods, like the ultrasound, would allow us to register changes on large anatomical zones, quantify them, and keep the records of what could happen when heating the tissue with RF. The Real Time Scanning Compound Image (RTSCI) ultrasound has a great variety of medical applications including blood vessels, the musculoskeletal system, gynaecological and abdominal exams, and so forth. However, its use for the study of skin and subcutaneous tissue is not well known [6].

47.3 Ultrasound Ultrasound has been widely applied in varied fields of medicine. A number of companies have put new devices on the market aimed at destroying the subcutaneous adipose tissue, thereby achieving body shape reduction and remodeling. A variety of pressure waves designed for therapeutic effects are available as follows: 1. Generation of mechanical pressure waves [8–10] 2. Electromagnetic radiation: • Lasers, IPL, Radio Frequency devices • Highly absorbed by human tissue • Superficial penetration 3. Focused ultrasound: • 2–10 MHz ultrasound • Very long wavelengths • Minimal relative absorption in tissue • Ability to penetrate deeply into tissue • Ultrasound energy is attenuated as it passes through tissue at approximately 1 dB/cm at 2 MHz.

47.3.1 Methods of Attenuation Absorption • Acoustic energy is converted to heat • Primary factor of attenuation Reflection • Echoes (imaging)

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Scattering • Change of direction The approach of using noninvasive focused ultrasound for tissue disruption differs from other therapeutic ultrasound devices in important ways (Fig. 47.1). The first and most obvious distinction is between invasive therapeutic ultrasound, such as is used in internal ultrasound-assisted liposuction (UAL), and external therapeutic ultrasound of various types. Among external ultrasound treatments, the approach of tissue or substance destruction should be distinguished from tissue warming [11–14]. As a rough generalization of currently marketed systems (which are predominantly for nonaesthetic applications), most noninvasive destructive or disruptive ultrasound devices use focused ultrasound , whereas devices that warm the tissue are nonfocused. For example, shock wave treatments (extracorporeal lithotripsy for renal calculi, orthopaedic treatments for calcifying tendonitis and heel spurs) operate by focusing single, very intense pulses of ultrasound energy onto their target and deliver mechanical (rather than thermal) action [10, 14]. They can be very painful and require sedation and/or anesthesia, but their effect (destruction of a substance) is long lasting. In contrast, thermal treatments, which are very commonly used in physiotherapy, are very well tolerated. Such thermal treatments induce temporary vasodilation and increase blood flow, and this mechanism has been proposed to explain their beneficial effects in temporary relief or muscle and joint pain (Fig. 47.1).

Therapeutic ultrasound

Noninvasive

Invasive Internal UAL Focused

Tissue disruption Durable effect Examples: UltraShapeTM Contour 1 Tumor ablation (prostate, uterine myomas) Cardiac ablation (A Fib) Shock wave therapy (renal calculi, calcifying tendonitis, heel spurs)

Fig. 47.1  Ultrasound used in medicine

Non-focused Tissue warming Nonablative Usually temporary effect Examples: Physiotherapy External UAL

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47.3.2 High Intensity Focused Ultrasound (HIFU) Mechanism Action The HIFU procedure produces its desired effects by presumably rupturing the adipocytes membrane [10]. A nonablative thermal treatment would not be expected to have a significant or durable effect on fat. In fact, external nonfocused therapeutic ultrasound has been applied to body contouring, but was found to be effective only as an adjunct to liposuction, where it is postulated that treatment with external ultrasound after infiltration with tumescent solution improves tissue hydration and distribution of the tumescent solution. Other devices currently marketed for body aesthetics claims (such as temporary cellulite improvement), which act by heating, require numerous treatments (six or more) and generally have short-term effects. In the context of the benefits and drawbacks of previously available therapeutic ultrasound approaches described above, the HIFU body contouring devices were designed to be noninvasive (to improve upon the risks of UAL) and focused (to provide a destructive effect, with an expected longer-lasting effect), but well-tolerated, for office-based use without the need for any sedation or anesthesia, downtime or recovery period. Ultrasound is mechanical pressure waves that spread out through the treated tissue. HIFU is focused ultrasound. Focusing means centering the sum of energies in a single point; thus as it pierces the skin without a build-up effect, it is respected and becomes more effective on the focal point. Focusing depends on the frequency (f) and the ultrasound wavelength (l). Ultrasound is generated in a piezoelectric crystal excited by an electric current. The frequency depends on the crystal’s characteristics and is constant for any ultrasound device. Focusing precision is improved as frequency is increased. Most devices deliver pulsed energy which allows for peaks of maximum intensity in each pulse [6, 9]. HIFU works under the same principles as the ultrasound diagnosis system, although as the very name implies, the levels of therapeutic energy are great in the case of HIFU. HIFU focuses energy in the treated tissue much more than sun rays concentrated through a crystal (magnifying glass) on a specific point. Energy on a focal point is sufficient to cause damage, but outside of this point, solar energy is not concentrated enough to damage tissue. HIFU acts in the same way.

J. Moreno-Moraga and J. R. de la Torre

The therapeutic US emission window is focused on a specific point, known as focal point. This concentration of energy on a specific spot creates thermomechanical damage in the adipose tissue and also affects a small area around the focal point. Actually, the compression/decompression waves exit lineally, but the lineality is inverted on contact with the focal point. This causes bubbles to form due to the abrupt fall in pressure of the inversion. These bubbles rub against each other and the sudden rise in pressure due to lack of lineality generates a large amount of heat energy. The heat is so intense that coagulative necrosis sets in at the focal point [10–13]. Therefore, adipose cells are affected by two mechanisms: mechanical and hyperthermic forces. One cannot occur without the other. Although, according to the type of device used, either the thermal or mechanical effect will be predominant over the other. HIFUs of high and low frequency must be distinguished (Fig. 47.2) as follows: 1. Low frequency (0.1–1 MHz): (a)  Lower absorption in tissue (b)  Achieves limited thermo effects (c)  Slower delivery into tissue (d)  Does not tighten collagen (e) Difficult to tightly focus due to longer wavelengths (f)  Ultrashape® is an example of this device 2 High frequency (1–10 MHz): (a)  More highly absorbed in tissue (b)  Achieves thermo-mechanical effects (c)  More efficient rapid delivery into tissue. (d)  Achieves collagen tightening (e) Can achieve very precise focus due to frequency used (f) It respects the vessels and nerves to a lesser degree, causing haematomas and postprocedural pain in the majority of cases. (g)  Lipsonix® is an example of this device

47.3.3 Nonfocused Ultrasound Mechanism Action (Cavitation) Physical phenomenon based on the effect of ultrasounds on liquids that causes the repeated creation of micro vapor bubbles due to the fast oscillation in

47  Body Contouring with Focused Ultrasound Fig. 47.2  Ultrasound absorption vs. frequency at 2 cm

477 Ultrasound absorption versus frequency at 2 cm

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pressure. It can be created by mechanical movements (turbines, propellers, and ultrasounds). This technique is well known but not very useful given its instability and shallow penetration, as well as the drawbacks caused by the high temperatures created by molecular friction generated by the ultrasounds at 1 or 3 MHz. These techniques were used in surgery for hydrolipochalasis, rendering irregular results [10]. With the development of specific last generation devices, a true capacity of permanent treatment of lipodystrophies or localized fat is available. In contradistinction to previous ultrasound devices, greater penetration frequencies are applied using higher compression capacity and a lower thermal effect. This generates stable cavitation fields that create larger micro vapor bubbles continuously and in a controlled manner, allowing for greater capacity and effectiveness. The bubbles created accumulate energy to the point of implosion and collapse. This process liberates energy over 100 kg/cm2. As this phenomenon is recreated in the interstitial fluid contained in the adipose tissue, the adipose cells are exposed to exceedingly high pressure that causes the separation of the fat nodule parcels and the rupturing of cell walls or membranes. This causes the selective and bloodless

destruction of the adipose cell. In turn, as such a large bubble implodes; it launches a high pressure micro jet against the adipocytes, thereby increasing the action even more. This implosion favors the break up of fats liberated from their membranes into shorter chains than fatty acids that stimulate their metabolism and natural elimination. This principle of physics had not been previously used in cosmetic medicine and is the basis of ultracavitation [10–12]. The destruction of adipocytes can be observed without injury to the blood vessels that are resilient, and therefore, can absorb the high pressure without breaking. As the membranes are destroyed, fat is dispersed in the hypodermic interstitial fluid. As the bubbles implode, they generate high temperatures which stimulate fat rupture into shorter fatty acids chains, favoring absorption. The high temperatures created in the tissue favor neocollagenesis, which aid in improving dermis elasticity. It is vital that the emitted frequency spectrum coincides with the absorbed frequency in each tissue for stable cavitation. This will depend on the density, depth, and shape of the cavity it is contained in. So, it is extremely important that the relation between ­emitted and absorbed frequency be maximum. The

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Fig. 47.3  Ultrasounds for lipolysis

ULTRASOUNDS FOR LIPOSYSIS NONFOCUSED US: . Thermal and vibratory effect . Less lipolysis capacity . Numerous sessions . Infiltration needed for hypoosmolar solutions

FOCUSED US (HIFU): . Few sessions . No infiltration needed . Greater lipolysis

LOW FREQUENCY FOCUSED US (HIFU)

HIGH FREQUENCY FOCUSED US (HIFU)

. . . .

. . . .

Lower absorption Less focalisation Safe, no postoperative Good results in a number of cases

NovaShape® Adjust and Rate functions aid in finding the appropriate frequencies for each area and type of adipose tissue. The device’s ability to focalize emissions allows for selection of wave penetration to more or less depth depending on where the adipose panniculus is located. Once the adipocytes are destroyed with any type of ultrasound , the human body’s healing mechanism sets off. Macrophages act in the damaged area eliminating the cell content, including the fat molecules. Lipids are metabolized by the regular methods. As time goes by, the cell matrix treated is destroyed and remodeling takes place with reduction of the fat layer thickness. The amount of free lipids born out of this procedure is within the body’s metabolism capabilities of adipose tissue. In fact, the indexes obtained by the analysis of fat content in the blood after HIFU treatment are within the normal parameters without observing significant increases in FFA (free fatty acids), HDL, LDL, triglycerides, or total cholesterol [15–18]. A comparative summary of the ultrasounds used for lipolysis is related in Fig. 47.3.

47.3.4 Histopathology The energy deposited in the target (adipose tissue) causes cell death through thermal coagulation of the tissue, ultracavitation, or mechanical vibratory stimulation. Slight bleeding through capillarity is observed. This is translated into ecchymosis in some cases, although the energy protocols worked with render

Higher absorption Better focalisation Postoperative pain and haematoma Application limited to abdomen

ecchymosis unlikely, except in patients with ­coagulation disorders. After disrupting the adipocyte membranes, inflammation with the emergence of macrophages is apparent along with a fine line of fibrosis after 8 weeks. Calcification, abscesses, or fistulas have not been detected.

47.3.5 Applications Destruction of fat deposits requires a thick enough fat layer to allow to limit the ultrasound action on the adipose tissue without injuring other body structures.

47.3.6 Contraindications 1. Female patients who are or may be pregnant. 2. The patient who has less than 1 cm of adipose tissue thickness beyond the selected focal depth in the area to be treated. 3. The patient who has been diagnosed with a coagulation disorder or is receiving anticoagulant therapy. 4. The patient who has a history of liposuction, any injection lipolysis therapy, abdominoplasty, or surgery (open or laparoscopic) in the area to be treated. 5. Presence of an implantable electrical device, e.g., pacemaker, defibrillator, or neurostimulator.

47  Body Contouring with Focused Ultrasound

6. Presence of neurosurgical cerebrospinal shunt in the area to be treated. 7. Presence of cancer, hernia, sensory loss or dysesthesia, scars or wounds in treatment area. 8. The patient who is under the care of a physician for known or suspected systemic disease of any type, or takes prescription drugs for a chronic condition. 9. Redundant skin folds or poor skin elasticity. Use in such patients may not produce the desired aesthetic effect.

47.4 Clinical Procedure Protocol The procedure should start with a visual study of the area to be treated; an ultrasound will provide a good image of the adipose tissue thickness and safety of the treatment [19] (Fig. 47.4). In order to obtain good results, the area to be treated should not be tense and any protrusion of bone structures avoided, such as in the case of the trochanteric region. This requires the use of gadgets such as foam pillows to place the areas in a comfortable position free from tension. This is important as one of the drawbacks of the procedure is its duration. The fat must be compacted in the treated area using bandages

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Fig. 47.4  (a) Ultrasound image before the treatment. (b) Ultrasound image after treatment

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or corsets. It is important to always keep the surface covered in a layer of oil to avoid the very rare chance of burning (Figs. 47.5 and 47.6). The stability of the circulating fat profile and the absence of steatorrhoeic hepatosis during treatment assure that this procedure is safe, with no repercussions on the organism due to its ability to handle large amounts of triglycerides (as in the case of the postprandial stage), which are never exceeded in a sole session of ultra liposculpture. Maintaining body weight confirms that the reduction in volume is exclusively due to the loss of adipose tissue in the treated areas.

47.4.1 Results Reduction in the adipose panniculus has been observed, to a greater or lesser degree, in every patient treated using the three systems. Figure 47.7 shows the results obtained with NovaShape®. Figures 47.8 and 47.9 show UltraShape® and Liposonix® results, respectively. At least 20% of the patients had less than 1 cm of reduction in treated fat height, which displays the poor aesthetic result. The flanks and internal part of the thighs and knees are the areas with the greatest aesthetic failure rate.

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480 Fig. 47.5  Compacted fat in the treated area using bandages and cushion

Fig. 47.6  Ultrasound image with and without bandages and cushions

J. Moreno-Moraga and J. R. de la Torre

47  Body Contouring with Focused Ultrasound Fig. 47.7  (Left) Before treatment. (Right) After treatment with Novashape™

Fig. 47.8  (Left) Before treatment. (Right) After treatment with Ultrashape™

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Fig. 47.9  (Left) Before treatment. (Right) After treatment with Liposonix™

elastocompression apparel) and the good tolerance level of clinical procedures (painless and outpatient) have increased social demand for this type of unwanted fat accumulation treatment.

47.5 Conclusions

Fig. 47.10  Burn after treatment with Ultrashape™

All three devices have caused burns, which in some cases were significant (Fig. 47.10). In most cases, this is due to poor contact of the handpiece with the body area. The discomfort and risks of invasive techniques (hospitalization, anesthesia, postoperative, use of

This is a procedure with minimally undesirable effects, most of which avoidable. It has no repercussion on the organism’s general state and is very well tolerated by patients. It is also believed that the aesthetic results reached, although improvable, are markedly satisfactory.

References   1. Commons GW, Halperin B, Chang CC. Large volumes liposuction: review of 631 consecutive cases over 12 years. Plast Reconstr Surg. 2001;108(6):1753–63.

47  Body Contouring with Focused Ultrasound   2. Ross AB, Vergnanini AL. Cellulite: a review. J Eur Acad Dermatol Venereol. 2000;14(4):251–62.   3. Nürnberger A, Müller G. So-called cellulite an invented disease. J Dermatol Surg Oncol. 1978;4(3):221–9.   4. Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. Plast Reconstr Surg. 2006;117(6):1797–808.   5. Querleux B, Cornillon C, Jolivet O, Bittoun J. Anatomy and physiology of subcutaneous adipose tissue by in vivo magnetic resonance imaging and spectroscopy: relationship with sex and presence of cellulite. Skin Res Technol. 2002;8(2):118–24.   6. Kennedy J, Ter Haar GR, Cranston D. High intensity focused ultrasound: surgery of the future? Br J Radiol. 2003; 76(909):590–99.   7. Grazer FM, Jong RH. Fatal outcome from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg. 2000;105(1):436–46.   8. del Pino ME, Rosado RH, Azuela A, Graciela Guzman M, Arguelles D, Rodriguez C, Rosado GM. Effect of controlled volumetric tissue heating with radiofrequency on cellulite and the subcutaneous tissue of buttocks and thighs. J Drugs Dermatol. 2006;5(8):714–22.   9. Haar GT, Coussios C. High intensity focused ultrasound: past, present and future. Int J Hyperthermia. 2007;23(2):85–7. 10. Coussios C, Farny CH, Haar GT, Roy RA. Role of acoustic cavitation in the delivery and monitoring of cancer treatment by high-intensity focused ultrasound (HIFU). Int J Hyper­ thermia. 2007;23(2):105–20. 11. Leslie TA, Kennedy JE. High intensity focused ultrasound in the treatment of abdominal and gynaecological disease. Int J Hyperthermia. 2007;23(2):173–82. 12. Wu F, Wang ZB, Chen WZ, Zou JZ, Bai J, Zhu H, Li KQ, Xie FL, Jin CB, Su HB, Gao, GW. Extracorporeal focused ultrasound surgery for treatment of human solid carcinomas:

483 early Chinese clinical experience. Ultrasound Med Biol. 2004;30(2):245–60. 13. Haar GT, Coussios C. High intensity focused ultrasound: physical principles and devices. Int J Hyperthermia. 2007;23(2):89–104. 14. Lafon C, Melodelima D, Salomir R, Chapelon JY. Interstitial devices for minimally invasive thermal ablation by highintenstiy ultrasound. Int J Hyperthermia. 2007;­23(2): 153–63. 15. Miles JM, Park YS, Walewicz D, Russell-López C, Windsor S, Isley WL, Coppack SW, Harris WS. Systemic and forearm triglyceride metabolism: fate of lipoprotein lipase-generated glycerol and free fatty acids. Diabetes 2004;53(3): 521–7. 16. Garcia-Murray E, Adan Rivas O, Stecco K, Desilets Ch, Kunz L. The use and mechanism of action of high-intensity focused ultrasound for adipose tissue removal and non-invasive body sculpting, Abstract. Am Soc Plast Surg Meeting Chicago, Illinois: September 2006. 17. Smoller BR, Garcia-Murray E, Adan Rivas OE, Stecco KA, Desilets CS, Fodor PB. The histopathological changes from the use of high-intensity focused ultrasound (HIFU) in adipose tissue, Abstract. Am Acad Dermatol Meeting, San Francisco: March 2006. 18. García- Murray E, Fodor PB, Smoller BR, Stecco KA, Desilets CS. Evaluation of the acute and chronic systemic and metabolic effects from the use of high-intensity focused ultrasound for adipose tissue removal and non-invasive body sculpting, Abstract. Am Soc Plast Surg Meeting, Chicago, Illinois: September 2005. 19. Moreno-Moraga J, Valero-Altés T, Riquelme AM, IssariaMarcosy MI, de la Torre JR. Body contouring by non-invasive transdermal focused ultrasound. Laser Surg Med. 2007;39(4):315–23.

Focus Ultrasound on Limited Lipodystrophies

48

Michele Cataldo, Luca Grassetti, and David E. Talevi

48.1 Introduction Localized fat deposit in man and woman represents one of the main causes of dissatisfaction of the body image in this millennium, where the consideration for a slim and pleasant proportioned body has taken the place of the fat woman of the middle ages at the beginning of 1900. New models introduced by the media and imaging have pushed the population to follow diet and regime to try to be on shape, and for most of the lifetime, struggling against the temptations of good food and lazy life. Healthy food, gymnastics, exercise, and running are all types of new trends of life scenario that have been introduced in the last 20 years and have revolutionized our lifestyle. Despite all these attempts, fat deposits in women and men have remained unchanged. This is mainly because of hereditary disturbance of constitution and hormonal change mostly in woman, rather than for the difficulty of most races, such as Black and Arab, to change their style of life and nutrition through the ages. The new generation is very focused on the aspects of the body, aiming to be slim and sexy and devote great attention to nutrition, exercise, and body enhancement. For limited areas of fat accumulation, what we generally call lipodystrophies, a new treatment has been introduced recently following the previous experience of internal and external ultrasound energy.

M. Cataldo (*) via Turati 4, 20060 Trezzano Rosa, Milano, Italy e-mail: [email protected]

48.2 History of Medial Applications of Ultrasound Ultrasonic medical devices have been used as a diagnostic and therapeutic tool for a number of years and have proven to be effective, useful, and safe. Ultrasound has been used by plastic and cosmetic surgeons postoperatively to reduce swelling after liposculpture and, since 1991, has been applied preoperatively and intraoperatively as well. After the development of tumescent liposculpture, the application of ultrasound to liposuction surgery became a possibility because ultrasonic energy requires a fluid medium to be transmitted and the tumescent fluid provides such a medium. So ultrasound may be very effective in the attempt to emulsify body fat and may be applied either internally or externally [1]. Internal ultrasound utilizes a special probe that is connected to an ultrasound generator and a handpiece that converts electric energy into ultrasound energy that transmits through a ceramic handpiece. The probe is inserted into the body through the same incisions as liposuction and the sound wave progressively emulsifies the target fat. Thus, internal ultrasound is applied and replaces the actual liposuction procedure. External ultrasound uses a flat round transducer that is held against the skin in the area to be treated. External ultrasound may be used on tumesced areas immediately before liposuction to facilitate the procedure or on follow-up visits during the postoperative period to speed healing [2, 3]. The application of ultrasonic energy to adipose tissue effectively liquefies the fat, releasing a combination of triglycerides, normal interstitial fluid, and the infused tumescent solution. These components form an emulsion that can be removed using vacuum suction. Because of the predilection of the ultrasound waves for low density tissue such as fat, there is felt to

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be a selective targeting of the fat cells without ­affecting the intervening connective tissue and neurovascular structures. The depth of the penetration is inversely proportional to the frequency used [4]. It is felt that ultrasonic energy affects the adipose tissue via several mechanisms thermally, micromechanically, and through the phenomenon of cavitation. Internal ultrasonic liposuction mainly utilizes the principles of cavitation. The mechanism through which external ultrasound affects fatty tissues is felt to be a micromechanical effect.

48.3 Infiltration Infusion Before being treated with ultrasound, external as well as focus ultrasound, the area of body to be treated should be infiltrated with tumescent solution to provide a medium for the conduction of the ultrasonic waves. The presence of fluid reduces the density of the tissue, thereby facilitating the emulsification process of the tissues. The authors use the solution containing lidocaine (2%) 200  mg in 100  mL of saline solution and 10 mEq disodium bicarbonate. The total solution infiltrated never exceeds 100 ml (Fig. 48.1).

48.4 Focus Ultrasound on Small Fat Deposits The authors investigated the potential of focus ultrasound on small fat deposits of the body in terms of fat emulsification and selective destruction of the target fat deposit. All the patients were submitted to multiple staged treatments. The fat compartments treated were: 1. Abdominal periumbilical area 2. Flanks 3. Trochanter All the patients had pretreatment assessment, cholesterol, triglycerides, liver, and renal function and postoperative check. Other studies have concluded that external and focus ultrasound, when a limited area of the body is treated and a limited quantity of fat is emulsified, does not present any alteration to the renal and liver function. Also the authors’ study arrived at the

Fig. 48.1  Focus ultrasound: The handpiece and the concentrated action of the ultrasound wave on superficial fat 1.5 cm deep from the skin surface

same conclusion. The progressive absorption of the emulsified fat arrives through the renal system, but without failure in the reduction of functionality. The area of the target was 10 by 10 cm2 on the abdomen, the flank, and the trochanter. The depth of the infiltration advised is 1.5  cm at least in the target area. The energy was applied in adipose tissue as thick as 2 cm minimum. The focus ultrasound does concentrate the energy at 1.5 cm of depth. If by mistake the ultrasound energy is directed deeper, the potential for intestine perforation, bowel bleeding, and bone perforation could be reached. The authors assessed the thinning of the fat layers that undergo treatments with the focus ultrasound device. It is necessary to distinguish pure fat reduction from the loss of intracellular fluids, which is clearly temporary and ineffective for a constant volume reduction effect. The number of treatments for each body

48  Focus Ultrasound on Limited Lipodystrophies

Fig. 48.2  (a) Infiltration of the gluteal crease prior to tumescent fluid injection. (b) The infiltration stays no deeper than 2 cm from the surface. (c) Needle in the superficial fat is 2 cm maximum from the surface. Infiltration is concentrated in this layer

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area has never been more than four. Only localized lipodystrophies have been considered. Each treatment was performed with the infiltration of a maximum dose of 100 mL of solution, with lidocaine and sodium bicarbonate, in a 10 by 10-cm2 area. If two areas were to be treated, 50 mL of solution was infiltrated for each side (Fig. 48.2). Tumescent solution has three purposes: 1. Increases the thickness of the adipose tissue, thereby protecting the underlying deep layers. 2. Diminishes the consistency of fat, making the emulsification process easier. 3. Helps ultrasound wave to create the cavitation effect which is the key for adipocyte selective destruction. Prior to infiltration, an 18 gauge needle is utilized to administrate local anesthesia. Then a blunt needle with multiple holes is helpful for infiltration of the tumescent solution. The area to be treated is always marked with a permanent pen and infiltration should be quite

superficial, never deeper than 2 cm from the skin surface. Contrary to classic mesotherapy, where the tissue can be infiltrated as deep as 4 cm in the fat layers, focus ultrasound concentrates its effect on the medium layer fat, 1.5 cm in depth. The focus ultrasound device utilized is named Lipothermae by Genex (Fig. 48.3). The energy applied is 3  MHz, and the handpiece has a 5-cm diameter. Time of treatment is around 30 min for each area. The method is the classic slow massage with a constant action, protecting the skin with a gel. There is a continuous round movement in a circular fashion without pressure on the tissue. The patient hears a fine whistle determined by the cavitation effect in the adipose tissue. This is the first noticeable effect of focus ultrasound compared to the classic external ultrasound. After 15–20  min of action, a spreading erythema appears, the underlying tissue appears progressively less dense and mobile. It softens progressively without pain or discomfort for the patient.

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Fig. 48.4  Erythema following treatment

48.6 Clinical Case

Fig. 48.3  (a) Lipothermae by Genex. (b) Handpiece in action with gel applied to protect the skin

The tool has a power set up that is normally at 75% of the total. If the erythema is soft, it is even possible to increase the power, thereby increasing the cavitation effect of the system (Fig. 48.4). After treatment, the patient wears a compressive garment in order to increase tissue drainage. The patient is also encouraged to increase hydration for dilution of emulsified fat in the blood system and a quicker metabolizing at the liver level and elimination at renal system.

48.5 Complications No complications were encountered in the 25 patients treated.

A 25-year-old patient was treated in multiple areas of the body including the flanks, abdomen, and trochanter. The consistency of the fat reduction was measured with a plicometer, with ultrasound sonography, with digital photos in standard position, and with double blind assessment by two different doctors not involved into the treatment. The medium circumferential reduction of the area treated was of 4.5 cm (Figs. 48.5 and 48.6). The minimum interval between sessions is 15 days. Limits of the technique are represented by the amount of fat reduction for area, the minimum thickness of fat necessary for treatment to allow the action of focus ultrasound (1.5 cm, which is contraindicated in certain areas such as the neck), and the interval time from session to session. No hematoma and no ecchymosis were found in the patients treated. The treatment is well tolerated by the patient and is safe if performed in the correct way by an experienced physician. The degree of satisfaction from the patients was really high.

48.7 Discussion Requests for aesthetic procedures in the last years have really boomed all over the world, but not so much of the surgical procedures, but of less aggressive techniques such as botulinum toxin and fillers. Now, focus ultrasound promises to be really an effective alternative so that surgical treatment of localized fat deposit may not be necessary. This method does not substitute

48  Focus Ultrasound on Limited Lipodystrophies Fig. 48.5  A 23-year-old patient. (a1,2) Preoperative. (b1,2) Following treatment with focus ultrasound on the trochanter and anterior thigh with 4.5 cm reduction at the thigh

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Fig. 48.6  A 30-year-old patient. (a1–3) Preoperative. (b1–3) After four treatments of focus ultrasound

liposculpture, which really can model a body in multiple areas at the same time [5]. However, it can be the first choice in many patients who are afraid of surgery, who cannot take time off

from their work, who do not have money to pay a liposculpture, and who radically refuse the idea of a surgical procedure for their body, considering it too aggressive, too risky, or too invasive.

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References   1. Suslick KS. The chemistry of ultrasound. The yearbook of science and the future 1994 encyclopedia. Chicago: Britannica; 1994. p. 138–55.   2. Pignatelli V, Ceccarelli M, Bartoletti CA. Idrolipoclasia ultrasonica nel trattamento della adiposita’ localizzata in

491 eccesso: una modifica del protocollo e ulteriori valutazioni. Medicina Estetic. 1994;18.   3. Ceccarelli M, Bartoletti CA. Adiposita’ localizzata ed idrolipoclasia ultrasonica. Medicina Estetic. 1992;16.   4. Cimino WW. Ultrasonic energy: power quantification, and efficiency optimization. Aesthetic Surg J. 2001;21(3):233–41.   5. Di Giuseppe A. Ultrasonic assisted liposculpture. Presented at World Congress on Liposuction. Dubai: 2007.

Aesthetic Body Contouring of the Posterior Trunk and Buttocks Using Third Generation Pulsed Solid Probe Internal Ultrasound-Assisted Lipoplasty

49

Onelio Garcia Jr.

49.1 Introduction The trunk is one of the most common areas for which patients seek lipoplasty [1]. With the exception of minor contouring of a small surface area, it has been my experience that major contouring of the trunk is best performed circumferentially. That personal experience is derived from thousands of lipoplasty cases over a 25-year period. Circumferential contouring of the trunk requires a prone position followed by supine position on the operating table, and since most of these cases require extensive fat removal over a large ­s urface area, they are performed under general anesthesia. The posterior trunk and flank areas have traditionally been one of the most challenging anatomical areas to properly contour by means of lipoplasty. Although the back dermis is relatively thick, forgiving and capable of camouflaging minor irregularities, the back fat is dense, fibrous, and difficult to extract by means of traditional lipoplasty (SAL). Elimination of the back rolls, in particular, using SAL has been extremely difficult and associated with significant blood loss. Soon after its introduction in this country, “dry lipoplasty” was associated with blood loss of 20–45% of the volume aspirated [2–4] and one can assume that the higher 45% figure was asso­­ciated with cases involving the posterior trunk. The significant tissue trauma associated with using large

O. Garcia Jr. Division of Plastic Surgery, University of Miami, Miller School of Medicine, 3850 Bird Road, Suite 102, Miami, FL 33146, USA e-mail: [email protected]

diameter suction cannulas for “dry lipoplasty” of these dense areas resulted in extremely bloody aspirate and the inability to properly evacuate fat in volumes that would yield a significant difference in contour. Early attempts to contour the posterior trunk using “dry lipoplasty” were extremely disappointing. The advent of wetting solutions with epinephrine further decreased the blood loss in these procedures [3–6] and made it somewhat easier to extract fat from the back; however, the process was still quite cumbersome and did not yield the ideal back contours due to residual fibrous back fat that could not be extracted. The use of internal ultrasound-assisted lipoplasty (UAL) further decreased lipoplasty blood loss [7–10] and made it significantly easier to extract dense, fibrous fat from the back at the expense of greater potential complications with the early UAL devices [11–14]. The creation of the third generation internal UAL devices has addressed many of the complications associated with the early UAL devices [15, 16]. Recently, Garcia and Nathan [17] performed a series of large volume, posterior trunk lipoplasties using the VASER (Sound Surgical Technologies, Louisville, Co.), a third generation pulsed solid probe internal ultrasound device, and compared them to a similar group treated with traditional superwet suctionassisted lipoplasty (SAL). They reported the average blood loss from the posterior trunk to be approximately seven times greater in the SAL group than in the VASER group. Furthermore, they were able to extract three times more fat from the back in the VASER group when compared to the SAL patients prior to obtaining bloody aspirate. It is as a result of these studies that the author strongly recommends the use of third generation internal ultrasound for all posterior trunk lipoplasties.

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Moderate to large volume lipoplasty procedures impact a significant surgical insult on the patient and are reserved only for those individuals in relatively good state of health. It is important to note during the medical history any of the common medications that may interfere with platelet function such as aspirin and stop their use at least a week in advance of the surgery. Our routine preoperative laboratory work includes a complete blood count, electrolytes, clotting studies, and urine analysis. A pregnancy test is obtained when warranted. The author’s preoperative photography protocol for posterior trunk lipoplasty includes straight view of the back and hips, as well as left and right oblique views against a medium blue background. Preoperative markings are performed in the standing position using a black or dark blue marker and include areas to be contoured as well as the access incision sites. It is the author’s preference, whenever possible, to perform the preoperative markings in the afternoon on the day prior to surgery and digitally photograph the markings. This allows the surgeon to review the markings with the patient on the computer screen. It has been my experience that this preoperative review gives the patient a better understanding of the surgical plan and possibly avoids misunderstandings, such as

the placement of the access incisions or the exact ­boundaries of the areas to be contoured. This is of particular importance when the surgery involves the posterior trunk since the patient cannot easily visualize the treatment area. On the day of surgery, prophylactic antibiotics are administered while the patient is in the holding area and sequential pneumatic compression stockings are applied. Major lipoplasties that include the posterior trunk and involve placing the patient in the prone position are performed by the author under general endotracheal anesthesia. Frequently a foley catheter is placed at the start of the operation to monitor urine output in the higher volume lipoplasties where the patient is exposed to large volumes of infiltrating solutions and intravenous fluids. When placing the patient in the prone position, it is preferable to place the arms on arm boards away from the operative site. A roll is placed under the pelvis extending between the iliac crests to elevate the hips off the operating table (Fig. 49.1), two longitudinal rolls are placed under the chest for support, and a foam face protector is used to pad the face. Slightly flexing the operating table into a jackknife position provides easier access for the UAL probes and suction cannulas into the posterior trunk. Patients undergoing lipoplasty of the trunk have large body surface areas containing wetting solutions exposed, making them susceptible to hypothermia. As a preventive measure against hypothermia, a Bair Hugger is used over the nonoperative sites and the intravenous fluids are warmed.

Fig. 49.1  The prone position provides good access for lipoplasty contouring of the posterior trunk, particularly the back, and has the advantage of providing simultaneous visual comparison between the two sides. The arms are on padded arm

boards away from the surgery site, the body is supported by two longitudinal rolls, the face lies on a foam face protector, and a horizontal roll between the iliac crests slightly elevates the hips from the operating table

49.2.1 General Considerations

49  Aesthetic Body Contouring of the Posterior Trunk and Buttocks

The small access incisions are easily performed with a #11 scapel blade. Rohrich, Beran, and Kenkel suggest that the access incisions be placed asymmetrically to give a less “surgical” appearance [18]. The areas to be treated are infiltrated with the wetting solution (1  mg epinephrine 1:1,000/L Ringer’s lactate) using a subcutaneous infiltration pump. For tight, fibrous areas such as the back, the author runs the infiltration pump at 400 mL/min. The author has found that solid probe UAL performs more efficiently in a very “wet” environment. The original recommendation of a 1:1 ratio of infiltrate to expected aspirate does not provide enough fluid in the tissues, particularly in the posterior trunk. The author currently uses approximately a 3:1–4:1 ratio of infiltrate to expected aspirate. This large amount of wetting solution in the tissues makes the fat emulsification process more efficient and also provides a greater safeguard against thermal injury by the UAL probe. Allow approximately 12 min following the fluid infiltration for the vasoconstrictive effect of the epinephrine to take place. The UAL treatment employed by the author involves a third generation solid probe internal ultrasound device, (VASER). The energy levels used in the posterior trunk are generally higher than for other anatomical areas. The posterior flanks are usually treated at 80–90% energy levels in the pulsed mode using a 3-ring or 2-ring probe. The back is treated at 90% energy level usually in continuous mode with a 2-ring probe. On occasion, tight back rolls are treated with 100% energy levels in continuous mode for brief periods using a 1-ring probe. Extra wetting solution is infiltrated into these areas prior to this aggressive treatment. While applying the internal ultrasound to the tissues, it is important not to push down on the skin in the area where the probe tip is located. This technique may be helpful during the suction phase to stabilize the suction cannula, but during the ultrasound phase it actually disperses fluid away from the probe tip (Fig. 49.2). Forcefully pushing down on the skin can actually cause a vacuum effect creating a “dry spot” near the tip, which potentially increases the risk for thermal injury. When running high ultra­sound energy levels for longer periods such as under very tight, fibrous back areas, it may be helpful to gently work the surrounding tissue fluid toward the probe tip (Fig. 49.3). Most of the suction phase is performed using 3.0-mm and 3.7-mm Ventx cannulas (Sound Surgical Technologies, Louisville, Co.). Other than for the deep fat layer, the author performs the majority of the suction using the 3-mm Ventx cannula. Following proper fat

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Fig. 49.2  During the ultrasound phase, the surgeon should not push down on the tissues over the ultrasound probe. This maneuver pushes fluid away from the tip of the probe creating a “dry spot” near the tip and potentially increasing the risk of thermal injury

Fig. 49.3  Maneuvering adjacent tissue fluids toward the ultrasound probe tip can be helpful when employing higher energy levels for increased periods of time such as when contouring tight, fibrous back rolls

emulsification extraction is very quick and precise with the 3-mm cannula. The small access incisions are closed with one simple absorbable suture of 5–0 plain. Contoured foam is placed over the treated areas under the compressive garment. The initial garment with side zippers is used immediately after surgery since

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Fig. 49.4  Thirty-year-old female with a total volume of 5,400 mL extracted. The posterior trunk (shaded color areas) yielded 2,600 mL of aspirate. Left: areas of liposuction with direction of tunnels. Middle: preoperative. Right: postoperative

Fig. 49.5  Twenty-year-old female with a total volume of 6,200 mL extracted. The posterior trunk (shaded color areas) yielded 2,400 mL of aspirate. Left: areas of liposuction with direction of

tunnels. Middle: preoperative. Right: postoperative. Note high definition contouring of the posterior flanks

it is easier to apply over the foam while the patient is still on the operating table under anesthesia. Several days later, the patient changes to a secondary compression garment without zippers. Massaging the treated areas with a moisturizer is recommended several times a day as soon as the patient can tolerate the discomfort. In high-volume cases the author has found that several sessions of endermologie treatments to the lipoplasty areas are helpful in loosening adhesions and decreasing edema. Our protocol consists of six treatments over a 3-week period beginning as soon as the echymosis disappears. The author performed lipoplasty contouring of the posterior trunk on a large series of female patients [17]. The average age was approximately 37 years and

the average body mass index (BMI) was approximately 25. Since it is preferable to contour the trunk in a circumferential manner, these patients also undergo lipoplasty of the abdomen and anterior hips at a minimum, with other areas such as thighs and arms frequently contoured at the same operation (Figs. 49.4–49.6). The average total aspirate from these patients was ­approximately 5,700 mL with approximately 2,450 mL extracted from the posterior trunk. The third generation solid probe UAL devices have allowed us to perform high-volume body contouring in selected patients with minimal associated morbidity [19] (Figs. 49.7–49.9). Patients are kept overnight for postoperative recovery as well as monitoring of fluid intake and urine output.

49  Aesthetic Body Contouring of the Posterior Trunk and Buttocks Fig. 49.6  Thirty-seven-year-old female with a total volume of 5,750 mL extracted. The posterior trunk (shaded color areas) yielded 2,200 mL of aspirate. (a) Areas of liposuction with direction of tunnels. (b) Left: preoperative. Right: postoperative. Note high definition contouring of the posterior flanks

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The third generation of UAL devices has made it possible to offer more aggressive body contouring to older patients particularly in the posterior trunk (Fig. 49.10). It is important to create realistic expectations in these patients since their skin elasticity may present limitations on the volumes extracted and the postoperative result may be an improvement over the preoperative appearance, but not necessarily the ideal contour.

49.3 Contouring of the Buttocks Using Third Generation Pulsed Solid Probe UAL The ideal female buttocks have a rounded appearance and merge into the fat of the lateral thigh. Excess fat in the posterior flanks, lateral thighs, and subgluteal area (banana roll) creates a “trapezoid” shape.

Although buttock fat grafting is sometimes necessary to achieve the ideal round shape in extremely flat buttocks, UAL contouring of the posterior flanks, lateral thighs, and subgluteal rolls can often provide aesthetically pleasing buttocks. While contouring these areas, it is important to pay special attention to avoiding the zones of adherence over the tensor fascia lata area of the distal lateral thigh, the posterior thigh (inferior to the subgluteal roll), the lateral gluteal depression (between the flanks and lateral thigh rolls), the gluteal crease, and a small area of the midmedial thigh above the fatty deposit of the medial knee (Fig. 49.11). It is imperative that the gluteal fold is not crossed with either UAL probes or suction cannulas! Third generation solid probe UAL has made it possible to precisely contour these areas with minimal morbidity. Patients have significant improvement in gluteal definition with only fat extraction (Figs. 49.11– 49.13). The author has found that fat grafting is not necessary to improve buttock contour in the majority of patients.

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Fig. 49.7  Twenty-three-year-old female with a total volume of 11,500 mL extracted. The posterior trunk (shaded color areas) yielded 4,200 mL of aspirate. (a) Left: areas of liposuction with direction of tunnels. Middle: preoperative. Right: postoperative.

(b) Buttocks. Left: preoperative. Right: postoperative. Note improved definition of the buttocks obtained following aggressive contouring of the posterior flanks

Fig. 49.8  Forty-year-old female with a total volume of 9,200 mL extracted. The posterior trunk (shaded color areas) yielded 3,700 mL of aspirate. Left: areas of liposuction with direction of tunnels. Middle: preoperative. Right: postoperative

49  Aesthetic Body Contouring of the Posterior Trunk and Buttocks

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Fig. 49.9  Twenty-seven-year-old female with a total volume of 8,400 mL extracted. The posterior trunk (shaded color areas) yielded 2,900 mL of aspirate. Left: areas of liposuction with direction of tunnels. Middle: preoperative. Right: postoperative

Fig. 49.10  Sixty-two-year-old female with a total volume of 4,800 mL extracted. The posterior trunk (shaded color areas) yielded 2,200 mL of aspirate. Left: areas of liposuction with direction of tunnels. Middle: preoperative. Right: postoperative

49.4 Fat Grafting for Gluteal Enhancement Patients who exhibit very flat buttocks with poor definition (the trapezoid shape) may be candidates for gluteal contouring with fat extraction from the posterior flanks, lateral thighs, and subgluteal rolls plus fat grafting. Mendieta [20, 21] has described a simple and effective technique for gluteal enhancement that involves aggressive UAL contouring of the  perigluteal areas with grafting of the strained harvested

supernatant aspirate into the gluteus. He described 10 aesthetic units to the posterior region and how six of these zones define the buttocks (Fig.  49.14). Following solid probe UAL using the VASER device for the fat emulsification and extraction, Mendieta uses a simple technique for preparation of the harvested fat. The aspirate is placed in a large metal kitchen strainer which allows the tumescent fluid, blood, and oil lipid layer to flow through into an open container, leaving the supernatant fat in the strainer (Fig.  49.15). This harvested fat is then cleansed in antibiotic solution (Clindamycin 600 mg in 20 mL of

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O. Garcia Jr.

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Fig. 49.11  (a) Left: twenty-year-old female with a total volume of 4,200 mL extracted. The posterior flanks, lateral thigh, and subgluteal roll (shaded color areas) yielded 1,800 mL of aspi-

rate. The zones of adherence to be avoided are marked in red. Middle: preoperative. Right: postoperative. (b) Buttocks. Left: preoperative. Right: postoperative

Fig. 49.12  Twenty-two-year-old female with a total volume of 4,800 mL extracted. The shaded color areas yielded 2,000 mL of aspirate. (a) Left: areas of liposuction with direction of tunnels. Middle: preoperative. Right: postoperative (b) Left: preoperative. Right: postoperative

49  Aesthetic Body Contouring of the Posterior Trunk and Buttocks Fig. 49.12  (continued)

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Fig. 49.13  Twenty-seven-year-old female with a total volume of 4,800 mL extracted. The shaded color areas yielded 2,000 of aspirate. (a) Left: areas of liposuction with direction of tunnels.

Middle: preoperative. Right: postoperative. (b) Left: preoperative. Right: postoperative

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Fig. 49.14  The 10 Aesthetic units/zones of the posterior region as described by Mendieta. Left: (1) Sacrum V-zone. (2) Flank. (3) Upper buttock. (4) Lower back. (5) Outer leg. (6) Gluteus. (7) Diamond zone: inner gluteal/leg junction. (8) Mid-lateral buttock point C. (9) Inferior gluteal/posterior leg junction. (10)

Fig. 49.15  The fat is harvested by placing the aspirate in a large kitchen strainer allowing the tumescent fluid, blood, and oil lipid layer to flow through into an open container, leaving the supernatant fat in the strainer. Reproduced with permission of American Society for Aesthetic Plastic Surgery and Aesthetic Surgery Journal

O. Garcia Jr.

Upper back. Middle: six important zones truly define the buttock frame/shape. Right: Zone 8 is the only zone that may require fat transfer to smooth the contour. Reproduced with permission of American Society for Aesthetic Plastic Surgery and Aesthetic Surgery Journal

saline solution and loaded into 60 and 10-mL luerlock syringes). The fat injected intramuscularly with the 60-mL syringes and 3-mm cannulas provide volume and the fat injected subcutaneously with the 10-mL syringes and 2.4-mm cannulas provide contour (Fig. 49.16). Fat grafting of the gluteal area following lipoplasty contouring of the buttocks is a simple, cost effective technique. Mendieta believes that 80–85% of the injected fat is viable at 2 years and that the use of solid probe UAL (VASER) to extract the fat does not affect its survival [20] (Fig. 49.17). The author agrees with Mendieta that contouring the buttocks into an aesthetically pleasing round shape requires aggressive fat extraction from the posterior flank, lateral thigh, inferior gluteal roll, and sacral areas with or without fat grafting.

49  Aesthetic Body Contouring of the Posterior Trunk and Buttocks

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Fig. 49.16  Buttocks. Left: preoperative. Right: postoperative following fat grafting using the Mendieta “gluteal reshaping” technique. Reproduced with permission of American Society for Aesthetic Plastic Surgery and Aesthetic Surgery Journal

a

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Fig. 49.17  Twenty-sevenyear-old female patient who underwent contouring of the sacrum and flanks plus 750 mL fat injections into each buttock using the Mendieta “gluteal reshaping” technique. Left: preoperative. Right: postoperative. Reproduced with permission of American Society for Aesthetic Plastic Surgery and Aesthetic Surgery Journal

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References   1. The American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank, Procedural Statistics; 2007.   2. Illouz YG. Refinements in the lipoplasty technique. Clin Plast Surg. 1989;16(2):217–33.   3. Rohrich RJ, Beran SJ, Fodor PB. The role of subcutaneous infiltration in suction-assisted lipoplasty: a review. Plast Reconstr Surg. 1997;99(2):514–9.   4. Rohrich RJ, Beran SJ, Kenkel JM. Anesthetic considerations. In: Rohrich RJ, Beran SJ, Kenkel JM, editors. Ultrasound-assisted liposuction. 1st ed. St. Louis: Quality Medical Publishing; 1998. p. 69–84.   5. Hetter GP. The effect of low-dose epinephrine on the hematocrit drop following lipolysis. Aesthetic Plast Surg. 1984;8(1):19–21.   6. Fodor PB, Watson JP. Wetting solutions in ultrasoundassisted lipoplasty. Clin Plast Surg. 1999;26(2):289–93.   7. Fodor PB, Watson J. Personal experience with ­ultrasound-assisted lipoplasty: a pilot study comparing ultrasound-assisted lipoplasty with traditional lipoplasty. Plast Reconstr Surg. 1998;101(4):1103–16.   8. Kloehn R. Liposuction with “sonic sculpture”: six years’ experience with more than 6000 patients. Aesthetic Surg Q. 1996;16:123.   9. Scheflan M, Tazi H. Ultrasonically assisted body contouring. Aesthetic Surg Q. 1996;16:117. 10. Zocchi ML. Ultrasonic-assisted lipoplasty. Clin Plast Surg. 1996;23:575. 11. Rohrich RJ, Beran SJ, Kenkel JM, Adams WP Jr, DiSpaltro F. Extending the role of liposuction in body contouring with ultrasound-assisted liposuction. Plast Reconstr Surg. 1998; 101(4):1090–102.

O. Garcia Jr. 12. Rohrich RJ, Beran SJ, Kenkel JM. Complications. In: Rohrich RJ, Beran SJ, Kenkel JM, editors. Ultrasound-assisted liposuction. 1st ed. St. Louis: Quality Medical Publishing; 1998. p. 347–62. 13. Young VL, Schorr MW. Report from the conference on ultrasound-assisted liposuction safety and effects. Clin Plast Surg. 1999;26(3):481–524. 14. Mladick RA. Personal experience with ultrasound-assisted lipoplasty: a pilot study comparing ultrasound-assisted lipoplasty with traditional lipoplasty (discussion). Plast Reconstr Surg. 1998;101(4):1117–9. 15. de Souza Pinto EB, Abdala PC, Maciel CM, dos Santos fde P, de Souza RP. Liposuction and VASER. Clin Plast Surg. 2006;33(1):107–15. 16. Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari MA. Clinical application of VASER-assisted lipoplasty: a pilot study. Aesthetic Surg J. 2002;22:131–46. 17. Garcia O, Nathan N. Comparative analysis of blood loss in suction – assisted lipoplasty and third generation internal ultrasound-assisted lipoplasty. Aesthetic Surg J. 2008; 28:430–5. 18. Rohrich RJ, Beran SJ, Kenkel JM. Back and arms. In: Rohrich RJ, Beran SJ, Kenkel JM, editors. Ultrasound-assisted liposuction. 1st ed. St. Louis: Quality Medical Publishing; 1998. p. 231–52. 19. Scuderi N, Paolini G, Grippaudo FR, Tenna S. Comparative evaluation of traditional, ultrasonic and pneumatic-assis­ ted lipoplasty: analysis of local and systemic effects, efficacy and costs of these methods. Aesthetic Plast Surg. 2000;24(6):395–400. 20. Mendieta CG. Gluteal reshaping. Aesthetic Surg J. 2007; 27(6):641–55. 21. Mendieta CG. Intramuscular gluteal augmentation technique. Clin Plast Surg. 2006;33(3):423–34.

Treatment Options in Benign Symmetric Lipomatosis

50

Madelung’s Disease Anthony P. Sclafani, Kenneth Rosenstein, and Joseph J. Rousso

50.1 Introduction Benign symmetric lipomatosis (BSL) is a rarely encountered disease first described by Brodie in 1846 [1]. Brodie’s description was that of a single patient with symmetric cervical fat deposition. It was not until 1898 that Madelung [2], in a study involving 35 patients, described a classic distribution of fat, including a cervical “horse collar” distribution. Launoise and Bensaude, in 1898 [3], in an extensive review of 65 patients gave a more complete description of the entity as being diffuse and disseminated with characteristic fatty neck deposits. Several forms of the disease have been described; however, Type I is the most common presentation, with a specific fat collar composed of tissue that ­accumulates in the upper back and neck (Fig.  50.1). This form typically affects middle-aged men of Mediterranean heritage. Cosmetic deformity and limitation of mobility due to swelling of the neck are usually the first presentations of lipomatosis [4]. More advanced deposits of fat can cause extrathoracic airway obstruction and dysphagia. Sixty to ninety percent of patients with Type I BSL have a strong history of alcohol abuse and dependence [5]. Type 2 has characteristic adipose tissue deposition in the upper back, deltoid area, hips, and thighs, and exhibits equivalent male and female prevalence. Type 2 BSL results in a body habitus referred to as “pseudo-

A. P. Sclafani (*) Department of Otolaryngology, Division of Facial Plastic Surgery, The New York Eye and Ear Infirmary, 310 East 14th Street, North Building, New York, NY 10003, USA e-mail: [email protected]

athletic syndrome,” due to the patchy areas of fatty deposition mirroring an overdeveloped physique. Busetto et  al. [6] have proposed that type 2 is often unrecognized and has led to underdiagnosis of this phenomenon in females.

50.2 Disease Features Several hypotheses exist regarding the pathogenesis of BSL, but the cause, thus far, remains unknown. The clinical presentation and anatomic distribution of fat unique to BSL remains the defining feature of the disease. In stark contrast to typical lipomas, the adipose tissue of patients with BSL is nonencapsulated allowing it access to anatomical spaces via deep ingrowth of soft tissue [7]. As the disease is primarily a clinical diagnosis, various other lipodystrophies and neck masses must be considered in the evaluation. An exhaustive differential diagnosis of rare neck masses and tumors is possible, although Cushingoid diseases, goiters, and protease inhibitor-associated lipodystrophy are more common considerations [8]. Radiologic assessment and a thoughtful history and physical examination are often adequate to diagnose BSL. Radiographic ­imaging is essential in diagnosis and treatment ­planning, as it best illustrates the defining feature of BSL: infiltrative, unencapsulated fatty proliferation (Fig. 50.1). Zhang et al. [5] performed CT and MRI studies on sixteen subjects to further characterize the insidious growth pattern of lipomatosis in BSL. In addition to superficial fat deposits, their analysis revealed strikingly deep extension involving and often displacing the sternocleidomastoid, trapezius, paraspinal muscles,

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_50, © Springer-Verlag Berlin Heidelberg 2010

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506 Fig. 50.1  (a) Patient with Madelung’s disease, showing diffuse fatty accumulation in the cervical area. (b) Two and one half years later with progression of fatty accumulation despite cervical liposuction during that period. The patient ultimately required an open procedure. (c) Lateral view of patient demonstrating posterior neck disease, as well as anterior neck and submental involvement. (d) T1-weighted sagittal MRI image demonstrating infiltrative nature of fat in the submental and posterior neck

A. P. Sclafani et al.

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as well as salivary glands, larynx, and deep vessels (Fig. 50.2). It is this insidious growth pattern that is the most clinically relevant factor in determining the need and extent of intervention. Patients with BSL often present with symptoms directly related to the anatomic structures affected by the deep ingrowth of fat. Paratracheal, mediastinal, and laryngeal involvement can cause compressive upper airway symptoms. Involvement of the submental triangle

and parapharyngeal spaces may cause disruption in salivary function. Compression, and later, secondary atrophy of neck musculature may severely limit neck mobility. Involvement of nerves and parapharyngeal musculature may cause dysphagia. Rarely, encasement or stricturing of venous drainage may cause cephalad venous congestion. Each of these potential functional deficits necessitates surgical intervention beyond cosmesis [7–9].

50  Treatment Options in Benign Symmetric Lipomatosis

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Fig. 50.2  Histology demonstrates the invasive nature of fat in Madelung’s disease. Hematoxylin and eosin stains show relatively normal-appearing fat surrounding and invading skeletal muscle. (a) 10×. (b) 20×

Although MRI analysis revealed these pathological fat deposits to have equivalent signal intensity to that of normal fat, the pattern of aggressively deep extension has warranted study into the cellular and biochemical origin of these lesions. Although no definitive etiological factor has been identified, the potential metabolic and neoplastic factors affecting lipomatosis in BSL have begun to be elucidated [5, 10].

50.3 Pathophysiology Many investigations have searched for the inciting factor in the accumulation of fatty deposits in BSL. The disease’s unique histology, genetic correlates, and association with alcoholism and glucose intolerance have aided researchers in defining many of the forces at play. Unfortunately, no clear etiology has yet been elucidated and the condition may prove to be a final common pathway for a composite of pathological changes within these patients [11]. Nisoli et  al. [12] proposed that the unusual fat deposits may be a result of a neoplastic proliferation of defective brown adipocytes. Activation of the UCP-1 gene in the pathologically located fat (as opposed to that of normally located fat) has been documented in patients with BSL. This gene confers an increase propensity for lipogenicity [8]. The fat growth pattern is often described as hypertrophic, with an increase in the overall number of small adipocytes [11]. In contrast,

typical visceral fat exhibits a hyperplastic growth pattern where adipocytes increase in size and storage capability. In obesity-associated diabetes mellitus, the storage capacity of these fat cells is overwhelmed, lipids accumulate in the liver and pancreas, and insulin resistance develops. Although an increased incidence of glucose intolerance has been reported in patients with BSL, no clear association between fatty accumulation and metabolic abnormalities has been elucidated independent of comorbid conditions. Interestingly, some studies have shown a relative insulin sensitivity as the fatty proliferation removes elevated lipids and fatty acids from the systemic circulation and stores them away from visceral fat [11]. A pharmacologic correlate has been identified in the treatment of diabetes with thiazolidinediones, where improved glycemics and insulin sensitivity is accompanied by a deposition of subcutaneous fat [13]. Although some evidence exists that patients with BSL have relatively benign obesity-associated metabolic comorbidites, the high prevalence of alcohol-related hepatopathy and its sequalae are often of more significant concern [9]. Despite a known increase in fatty proliferation and storage, a failure in lipolytic pathways has also been implicated in the etiology of BSL. A familial form of the disease characterized by defective mitochondrial function has been identified. The A8344G mutation confers decreased activity of respiratory function enzymes inciting depressed lipolytic function [8].

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Additionally, chronic alcohol ingestion depresses catecholamine-induced lipolysis by direct depression of catecholamine receptors on brown adipocytes and may also affect mitochondrial function [8]. Finally, there is clear epidemiologic evidence that alcohol abuse predisposes patients to the development of BSL. Alcohol induced liver disease limits the ability of the organ to process lipids, and it is postulated that BSL patients respond with an increase in lipogenesis [13].

50.4 Palliation and Treatment Medical intervention with the use of the beta-2 agonist salbutamol and intralesional low molecular weight heparin injections have been studied and found to be inconclusive at best [14]. Decreasing alcohol intake, weight loss, control of endocrine disorders such as diabetes and hypothyroidism are all advocated, but have not been shown to halt or reverse the disease once it is present [15]. The natural course of the disease is characterized by a period of rapid initial growth followed by a prolonged phase of slow growth of lesions. No medical treatment has shown to affect growth suppression or involution. Due to the failure of medical treatments, surgical intervention is crucial to decreasing morbidity and mortality in patients suffering from BSL. In addition to the severe cosmetic deformities that the disease can cause, there has been several case reports of compressive symptoms related to the location of the lesions. Lesions can cause aero-digestive tract obstruction, sleep apnea, dysphagia, neuropathy, and cardiac pathology secondary to mediastinal compression [16]. Furthermore, Chan et  al. [17], in a study of eight patients with BSL, believe that there is a correlation between the development of head and neck cancers and the presence of BSL. The correlation may simply be the synergistic effect of both smoking and alcohol abuse for the development of both BSL and head and neck cancers. In the appropriate circumstances, screening aero-digestive tract panendoscopy should be considered. The two most accepted surgical interventions are liposuction and open surgical excision of lesions with the removal of redundant skin. Liposuction is advantageous in smaller lesions and can be performed under local anesthesia. However, larger lesions and those

A. P. Sclafani et al.

with deep infiltration of vital structures are not ­amenable to liposuction and will require careful excision. Because of the nonencapsulated nature of the lesions and profound vascularity, it can be nearly impossible to remove the entire mass, particularly if it places essential structures at risk. Neurovascular, phonatory, and gustatory postoperative deficits are unacceptable in the resection of benign disease. Simple debulking is acceptable since it is difficult to determine what is part of the pathology and what is normal fat [18]. As the vast majority of patients typically present with only cosmetic concerns, the initial step in surgical planning is evaluation of operative risk. The two major concerns in this patient population are difficulties in airway management due to severely limited neck mobility and increased frequency of postoperative bleeding. The high incidence of alcoholism has led to a higher prevalence of liver disease and associated coagulopathies [9]. Comprehensive medical clearance and evaluation by anesthesiology is essential to ensure the safety of patients undergoing these procedures, the majority of which are elective in nature [19]. The surgical planning phase is also the appropriate time to tailor an approach to the individual patient. Several approaches have been used to address cervicofacial lipomatous tumors of BSL. These include primary liposuction, multiple incisions, and local excisions, as well as apron incisions and flap elevation for improved access and gross debulking [18]. Both patient-specific and site-specific surgical risks need to be addressed at this time and the patients counseled on potential complications and sequelae of treatment. If the submental area requires surgical excision, care must be taken to preserve the muscular floor of mouth and salivary glands and associated ducts. Occasionally, the submandibular glands may be sacrificed as they may be deeply infiltrated by tumor [18]. For optimal contouring of submental, submandibular, and occipital involvement, a staged procedure involving primary lipectomy followed by “wet” or “super-wet” liposuction several months later has been described. This strategy reduces blood loss and improves cervicofacial contouring when compared to the “dry” technique [20]. Other case reports reveal a similar limited use of liposuction for refinement and contouring following a necessary open excision [21]. Despite its limitations, tumescent liposuction is considered a conservative approach, accepted by many

50  Treatment Options in Benign Symmetric Lipomatosis

as the cosmetic treatment of choice in mild to mode­ rate cases of BSL, or when patients refuse an open approach. Despite minimizing surgical risk, the patients’ medical status leads to one concerning ramification. Many of these patients have impaired liver function secondary to their history of ethanol- induced hepatic cirrhosis; this leads to risks of a decrease in the cytochrome P450 3A4 enzymes and their ability to metabolize lidocaine [22]. Several authors recommend minor sessions of tumescent liposuction with lidocaine amounts of up to half of the recommended dosage of patients with

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Fig. 50.3  Patient with advanced form of Madelung’s disease at presentation. Despite the striking appearance, this patient only recently had developed dysphagia as his only functional complaint. (a1,2) Preoperative patient with large “horse collar”

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normal liver function [9]. Some researchers have also experienced a high incidence of postoperative ­hematoma in this population [18]. These patients need to be monitored for at least 24 h after the administration of local anesthesia. Furthermore, Grassegger et al. [23] recommend peri-operative use of Azithromycin for antibacterial prophylaxis since it is not metabolized via the cytochrome P450 3A4 pathway. In levels II through V of the deep neck, surgery typically involves incision and dissection analogous to modified neck dissection (Fig. 50.3). Wong et al. [18] propose that one larger apron incision with elevation

b3

deformity. (b1–3) Postoperative after debulking of the anterolateral neck fat and redundant skin through an apron incision. The patient was offered second stage posterior neck debulking, but failed to follow-up

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of subplatysmal flaps allows for optimal excision. By this method, a larger and more targeted debulking, as well as more symmetric postoperative contour, can be achieved. Additionally, involvement of the great vessels, nerves, thyroid and parathyroids, and musculature of the neck can be safely assessed and addressed. The fatty infiltration of local tissues may distort the normal cervical anatomy, and following standard neck dissection planes may aid in the identification of vital structures. With adherent infiltrative disease, the surgeon must prefer leaving benign disease in the neck to any risk of vital structures. Preservation of parotid structures and branches of the facial nerve becomes paramount if the resection must precede superolaterally onto the face and the need for adequate debulking here precludes liposuction [9]. Rare involvement of the tongue requires debulking to restore speech, swallowing, and improve airway caliber; however, cautious and limited excision is warranted to preserve lingual function. Although BSL recurrence following incomplete excision may occur, the functional and cosmetic deficits that the patient has presented with are often reversed with limited resection. Mediastinal and thoracic disease requires a combined surgical approach with involvement of both an aesthetic surgeon and a thoracic surgeon. Wide excision is warranted if compressive symptoms lead to any compromise of cardiac function. Arrythmia and compressive pathology are life threatening and require prompt surgical attention. Deep infiltration of these areas also precludes liposuction as a surgical approach [9, 18].

50.5 Conclusions BSL is an unusual disease in which fat diffusely infiltrates local structures. Excessive accumulation in specific areas can cause functional as well as aesthetic concerns. If identified early, small deposits can be treated with liposuction. Unfortunately, most patients present with advanced deformities, and the choice to operate must balance the cosmetic goals, the functional deficits present, and the approach required. In these advanced cases, the surgery follows a more reconstructive paradigm, as incisions and scars may be extensive and the final result improved but still suboptimal.

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References   1. Brodie BC. Clinical lectures on surgery. Delivered at St. Georges hospital. Philadelphia: Lea & Blanchard; 1846. p. 275–80.   2. Madelung OW. Uner den Fetthals (diffuses Lipom des Halses). Diffuse lipomatosis of the neck. Arch Klein Chir Berlin. 1888;37:106–30.   3. Launois PE, Bensaude R. De l’adeno-lipomatose symmettrique. (The symmetrical adenolipomatosis). Bull Soc Med Hop Paris. 1898;1:298–318.   4. Fernandez-Vozmediano J, Armario-Hita J. Benign symmetric lipomatosis (Launois-Bensaude syndrome). Int J Dermatol. 2005;44:236–7.   5. Zhang X, Li N, Wen-lin X. Madelung disease: manifestations of CT and MR imaging. Oral Surg Oral Med Oral Pathol Oral Radio Endod. 2008;105:e57–64.   6. Busetto L, Strater D, Enzi G, Coin A, Sergi G, Inelman EM, Pigozzo S. Differential clinical expression of multiple symmetric lipomatosis in men and women. Int J Obes Relat Metab Disord. 2003;27(11):1419–22.   7. Enzi G, Busetto L, Ceschin E, Coin A, Digito M, Pigozzo S. Multiple symmetric lipomatosis: clinical aspects and outcome in a long-term longitudinal study. Int J Obes Relat Metab Disord. 2002;26:253–61.   8. Meningaud JP, Pitak-Arnnop P, Bertrand JC. Multiple symmetric lipomatosis: case report and review of the literature. J Oral Maxillofac Surg. 2007:65:1365–9.   9. Constantinidis J, Steinhart H, Zenk J, Gassner H, Iro H. Combined surgical lipectomy and liposuction in the treatment of benign symmetrical lipomatosis of the head and neck. Scand J Plast Reconstr Surg Hand Surg. 2003;37:90–6. 10. Ahuja AT, King AD, Chan ES, Kew J, Lam WW, Sun PM, et al. Madelung disease: distribution of cervical fat and preoperative findings at sonography, MR, and CT. AJNR Am J Neuroradiol. 1998;19:707–10. 11. Nielsen S, Levine J, Clay R, Jensen MD. Adipose tissue metabolism in benign symmetric lipomatosis. J Clin Endocrinol Metab. 2001;86:2717–20. 12. Nisoli E, Regianini L, Briscini L, Bulbarelli A, Busetto L, Coin A, Enzi G, Carruba MO. Multiple symmetric lipomatosis may be the consequence of defective noradrenergic modulation of proliferation and differentiation of brown fat cells. J pathol. 2002;198(3):378–87. 13. Haap M, Siewicke C, Schick F, et  al. Multiple symmetric lipomatosis: a paradigm of metabolically innocent obesity. Diabetes Care. 2004;27:794–5. 14. Leung NW, Gaer J, Beggs D, Kark AE, Holloway B, Peters TJ. Multiple symmetric lipomatosis: effect of salbutamol. Clin Endocrinol (Oxf). 1987;27:601–6. 15. Smith PD, Stadelman WK, Wasserman RJ, Kearney RE. Benign symmetric lipomatosis (Madelung’s disease). Ann Plast Surg. 1998;41:671–3. 16. Josephson GD, Sclafani AP, Stern J. Benign symmetric lipomatosis (Madelung’s disease). Otolaryngol Head Neck Surg. 1996;115(1):170–1. 17. Chan ES, Ahuja AT, King AD, Lau WY. Head and neck cancers associated with Madelung’s disease. Ann Surg Oncol. 1999;6(4):395–7.

50  Treatment Options in Benign Symmetric Lipomatosis 18. Wong DSY, Lam LK, Chung JHP, Ng RWM, et al. Aesthetic considerations in the cervicofacial management of Madelung syndrome. Scand J Plast Reconstr Surg Hand Surg. 2003;37:34–40. 19. Conroy JP. Airway management: a patient with Madelung disease. AANA J. 2006;74(4):281–4. 20. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg. 1987;4:236–67.

511 21. Guilemany JM, Romero E, Blanch JL. An aesthetic deformity: Madelung’s disease. Acta Otolaryngol. 2005;125(3):328–30. 22. Klein JA. Cytochrome P450 3A4 and lidocaine metabolism. In: Klein JA, editor. Tumescent technique: tumescent anesthesia and microannular liposuction. St Louis: Mosby; 2000. p. 131–40. 23. Grassegger A, Haussler R, Schmalzl F. Tumescent liposuction in a patient with Launois-bensaude syndrome and severe hepatopathy. Dermatol Surg. 2007;33:982–5.

Liposuction for Madelung’s Neck

51

Robert Yoho

51.1 Introduction Madelung’s neck is a variant of multiple symmetric lipomatosis (symmetric adenolipomatosis, Madelung’s syndrome, Buschke’s syndrome, Launois-Bensaude syndrome) [1–3]. The syndrome involves unencapsulated symmetrical lipomas, usually involving the neck, shoulders, and trunk. Microscopic examination shows normal fat tissue [4]. Madelung’s neck consists of multiple symmetrical lipomas of the neck and shoulders.

lipids have been reported [9]. Defects in lipolysis [10] and mitochondrial genetic errors [11] have been demonstrated. Treatment of the disorder has been mainly aggressive surgical resection [12, 13], but liposuction has been attempted as well [14]. Oral salbutamol (12 mg daily in divided doses) has been reported to be beneficial [15].

51.3 Clinical Case 51.2 Clinical Syndrome Clinically, the onset of multiple symmetrical lipomatosis is between the age of 35 and 45 years and is most prevalent in the male [5]. A familial pattern has been suggested [6]. At first, the patient notices difficulty in buttoning the collar of his shirt and symmetrical masses appear in the posterior part of the neck. Then masses occur in the submandibular region, the chest, and the rest of the body except for the extremities. Asthenia and apathy are usually present, compression of peripheral nerves can result in pain but not paresis, and dyspnea and cough may develop from airway compromise and mediastinal compression [7, 8]. Alcohol overuse has been frequently noted. Liver function tests may be slightly abnormal. Hyperuricemia, glucose intolerance, and high blood

R. Yoho 797 South Arroyo Parkway, Pasadena, CA 91105, USA e-mail: [email protected]

The 40-year-old male with a history of untreated hypertension gave a history of increasing size of asymptomatic lipomas of the neck and shoulder girdle over a 10-year-period of time. The patient was not obese, but examination disclosed large lipomatous masses in the neck and shoulders (Fig. 51.1). He was given salbutamol (3 mg 3 times daily) for a year. This appeared to limit the rate of growth of the lipomas. There had been three previous attempts at surgical removal of the masses. Aggressive tumescent liposuction of the neck was performed in May 1997. The tumescent solution consisted of 1,800  mL of saline solution containing 0.1  mg% lidocaine and 1:1,000,000 epinephrine. A total of 3,400 mL of fat and fluid was removed from the shoulder girdle. Following an uneventful recovery, the neck and back lipomas were removed by liposuction using 1,200 mL tumescent solution and removing 1,500 mL of fat and fluid. The patient was continued on salbutamol. The results were excellent at 7 weeks postoperatively (Fig. 51.2). Some of the areas of fatty deposit recurred over the following 2 years.

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_51, © Springer-Verlag Berlin Heidelberg 2010

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514 Fig. 51.1  Preoperative patient with Madelung’s neck

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Fig. 51.2  Seven weeks postoperative following liposuction and oral salbutamol

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51  Liposuction for Madelung’s Neck

51.4 Discussion Although there is no capsule around the fatty deposits in this syndrome, the liposuctioned areas respond like lipomas with the capsule left in situ in that there is a high likelihood of recurrence. In the areas where aggressive surgery had been performed, the long-term cosmetic results were better, although aggressive liposuction was more difficult because of the fibrosis. Salbutamol had a definite effect because the patient noted a significant worsening of the fat deposits when he was off the drug.

References   1. Agrez M, Hellew A, Barrie P. Benign symmetric lipomatosis. Aust NZ J Surg. 1995;65(8):616–8.   2. Enzi G. Multiple symmetric lipomatosis, an updated clinical report. Medicine (Baltimore). 1984;63(1):65–4.   3. Martin DS, Sharafuddin M, Boozan J, Sundaram M, Archer C. Multiple symmetric lipomatosis (Madelung’s disease). Skeletal Radiol. 1995;24(1):72–3.   4. Ruzicka T, Vieluf D, Landthaler M, Braun-Falco O. Benign symmetric lipomatosis Launois-Bensaude: report of ten cases and review of the literature. J Am Acad Dermatol. 1987;17(4):663–74.

515   5. Stavropoulos P, Zouboulis CC, Trautmann C, Orfanos CE. Symmetric lipomatosis in female patients. Dermatology 1997;194(1):26–31.   6. McKusick VA. Mendelian inheritance in man. Baltimore: Johns Hopkins University; 1978. p. 242.   7. Luscher NJ, Prein J, Spiessi B. Lipomatosis of the neck IMadelung’s neck. Ann Plast Surg. 1986;16(6):502–8.   8. Katou F, Shirai N, Motegi K, Satoh R, Satoh S. Symmetric lipomatosis of the tongue presenting as macroglossia: report of two caases. J Craniomaxillofac Surg. 1993;21(7):298–301.   9. Greene ML, Glueck CJ, Fujimoto WY, Seegmiller JE. Multiple symmetric lipomatosis with gout and hyperlipoproteinemia. Am J Med. 1970;48(2):239–46. 10. Enzi G, Inelman EM, Baritussio A, Dorigo P, Prosdocimi M, Mazzoleni F. Multiple symmetric lipomatosis: a defect in adrenergically stimulated lipolysis. J Clin Invest. 1977; 60(6):1221–9. 11. Klopstock T, Naumann M, Schalke B, Bischof F, Seibel P, Kottlors M, Eckert P, Reiners K, Toyka KV, Reichmann H. Multiple symmetric lipomatosis: abnormalities in complex IV and multiple deletions in mitochondrial DNA. Neurology 1994;44(5):862–6. 12. Selvaag E, Schneider M, Wereide K, Kviem M. Benign symmetric lipomatosis Launois-Bensaude successfully treated with extensive plastic surgery. Dermatol Surg. 1998;24(3):379–80. 13. Springer HA, Whitehouse JS. Launois-Bensaude adenolipomatosis. Plast Reconstr Surg. 1972;50(3):291–4. 14. Carlin MC, Ratz JL. Multiple symmetric lipomatosis: treatment with liposuction. J Am Acad Dermatol. 1988;18(2 Pt 1): 359–62. 15. Leung NW, Gaer J, Beggs D, Kark AE, Holloway B, Peters TJ. Multiple symmetric lipomatosis (Launois-Bensaude syndrome): effect of oral salbutamol. Clin Endocrinol (Oxf). 1987;27(5):601–6.

Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci

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Alberto Di Giuseppe

52.1 Introduction In order to achieve competence in aesthetic surgery of the body and face, it is expressively required for a board certified plastic surgeon to acquire ability in the techniques taught and learnt, together with an ability to sculpture the body through an evaluation of the body proportions. The talent to prefigure how to correct body asymmetries and imperfection is an art which needs to be studied, fully understood, and done on sculpture and drawing before performing it directly on a patient. When operating on a flat surface as the abdominal wall in a standard tummy tuck correction, no particular talent is required to figure and sculpture this area because of the safe general vision of the fat thickness of different zones of the abdomen. But when the area to be corrected is the thigh, the surgical plan should take into consideration the body proportions from a frontal and posterior view as a minimum. The analysis of the areas and zones to be corrected has always been taken from these two views, and the surgical techniques have been addressed to correct flanks, trochanter deformities, banana fold, inner side of the thigh, inner side of the knees, etc. (Figs. 52.1 and 52.2). This criterion has been followed by plastic surgeons in the last decades, following the indications that our teachers suggested to us. In the past I have been impressed as other surgeons by the classic drawing by Illouz (Fig. 52.3) [1] published in 1989 indicating the areas of adherence of the low body contouring to avoid threat or to threat with A. Di Giuseppe Department of Plastic and Reconstructive Surgery, School of Medicine, University of Ancona, 1, Piazza Cappelli, 60121 Ancona, Italy e-mail: [email protected] e-mail: [email protected]

care in order to prevent potential ­complications. As a matter of fact, the analysis of Illouz was also ­concen­trated on the evaluation of the frontal and posterior view of the patient.

52.2 History The author reviewed the studies on the body proportions by Leonardo da Vinci, starting from his paintings of a nude man, (1503, 1509) where he started studying the body figure and proportions from two standards views, frontal and dorsal, or anterior and posterior, as we have been instructed through all these years by our masters. The history of classic authors interested in the analysis of body proportions starts with Policleto who founded the so-called Mount Athos scheme that divided the total length of body figure into nine units. Alberti (1404–1472) introduced in his “The Statua: (1434–1435)” the new concept of depth of the body. Independently from the studies of Alberti and the others, da Vinci started to develop his own theories on body proportions: defining single parts of the body and then putting them in comparison with the total body of other single units. Instead of evaluating single absolute measure of the body parts, he evaluated the measurements in comparison with the body length, defining different criteria of proportions; not in absolute terms, but in relation to other body parts with studies on proportions of the head, trunk, arm, head, leg, and arm (Figs. 52.4 and 52.5). For a few years, da Vinci was influenced by the studies and theories of Durer (1471–1528), but mostly followed the scheme of the Uomo Vitruviano described by Marcus Vitruvius Pollio (first century bc)

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Fig. 52.1  Left: preoperative. Middle: surgical plan with lines showing concavities and convexities. Right: postoperative

in De Architectura, Libri Decem, where he introduced a Greek measurement system. Following this da Vinci introduced his anthropometric studies of body proportions and parts, simplifying the absolute criteria of Vitruvius based on a Greek measurement scheme (Fig. 52.6). Finally, he introduced the third dimension, as indicated in his drawings of the analysis of leg proportions (Fig. 52.7). The leg is measured with Greek letters at different distances, and compared between

upper, middle, and lower third of the leg that are done in absolute and relative terms. The lateral view of the thigh appears finally, after frontal and dorsal views which have been the only consideration in the previous period. In his drawing on study of proportions of the body standing, sitting, and on the knees (1490) (Fig. 52.8), he clearly indicated the correct way to approach and evaluate the body symmetry and evaluate body contouring.

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Fig. 52.2  Left: preoperative. Middle: surgical plan with lines showing concavities and convexities. Right: postoperative

The lost third dimension (Fig. 52.9) told the author of a different criteria to evaluate, and thus, correct body deformity mainly in the thigh area that has been considered for long time as a “forbidden area.” This relative hostility was due to the difficulty of sculpturing and mastering the anterior and anteromedial part of the thigh, and for the fear of damage with secondary irregularities and depressions. Since 2006, the author has used digital photos with bilateral side view, and bilateral 3/4 view, together

with the classical frontal and dorsal (anterior and posterior) views as standard evaluation for body contouring of the buttocks, thighs, and lower leg. This increases the global view of the asymmetries and body disproportions of the patient, and allows a better careful analysis of the areas of surgical intervention. Surgical planning (Fig. 52.10) comes after evaluation of fat body lipodystrophies, skin laxity, and flaccidity body lines. The target is to recreate a natural body line, with convexity and concavity lines, in order to really shape

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Fig. 52.3  Zones of adherence as described by Illouz

Fig. 52.4  Leonardo da Vinci studies on head, trunk, thighs proportions. Circa 1490, Royal Library, Windsor Castle

the body. Particularly in the thigh, the third dimension is reached with the possibility of thinning and modeling the frontal medial part of the thigh with Vaserassisted liposuction [2–5].

This technique is derived from the classic ultrasound-assisted lipoplasty [6], but utilizes fine titanium probes of 2.9–3.7 mm diameter. The 2.2-mm probe can be used to tailor the thin, soft areas of the knees

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Fig. 52.5  Leonardo da Vinci studies on face, arms, legs proportions. Circa 1490, Royal Library, Windsor Castle

with excess fat that need contouring. In the anterior thigh a plan is made and drawn in the area that needs thinning of fat, mostly from the superior patella to the inguinal crease. This is still considered by most authors an extremely difficult area to work on, with potential side effects and depressions, dimples, irregularities, etc. This might happen if a good device is not used. But with the help of a great technology as Vaser, the surgeon can master and approach this area without fear, in the attempt to sculpture the body fat as he likes. Thinning the anterior part of the thigh is the way to treat the area circumferentially and defining this third dimension that really increases the quality of the results (Fig. 52.11). From the photos it is possible to understand how the surgical plan is evaluated in the side view, ¾ view, and rear view in order to draw a new ideal line and shape. Surgically, apart from the classic approach to flanks, buttocks, banana fold, etc., the new approach concerns the anterior part of the thighs, the inner part of the thighs, and the suprapatella area. Incisions to approach these areas are made at the inguinal crease and over the knee. VASER requires superwet infiltration and superficial careful undermining of the soft tissue of the anterior thigh in order to allow secondary tissue retraction. The fat component of the anterior part of the thigh is normally limited to one layer. So surgical thinning

must be careful, but Vaser’s delicate action contributes to find the right surgical plane to work on. After completing the undermining of the superficial layer with the finest probe, the surgeon can approach the deeper layers with a thicker probe (3.7 mm). Normally, the two ring probe is utilized, power tunneled at 70% of power and timing of the ultrasound action with continuous wave varying from 5 to 20 min depending on the size of the body, thickness of the area, and amount to be removed. Even the shape of the buttock area can be refined with this technique, thinning carefully the target areas. In this case, the surgical plan includes thinning of the buttocks, banana fold correction, dorsum reshaping, and anterior thigh thinning. Of capital importance is planning the surgeries correctly (Fig. 52.9). The author normally uses yellow to mark the areas that should be thinned and defatted mainly, with care to imagine how to recreate a natural shape and a proportioned body area. The areas in red are not to be touched because there is no tissue to remove. There is no area forbidden with Vaser contouring, but of course there are areas that do not need to be touched because they are already well-shaped or just not improvable. Areas to be treated should be preplanned and marked. Digital photographs in similar conditions should also be the rule. A plastic surgeon

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Fig. 52.6  Leonardo da Vinci drawing of proportions following Vitruvio. Circa 1490, Venice, Gallerie Dell’Accademia

learns from his mistakes only by watching carefully his own results and is the best judge of his results. The different results in body shape of the thigh are approached with Vaser, even in the anteromedial part of the thigh together with the treatment of the trochanter. Only this fully circumferential approach to the thigh allows the treatment of the third dimension, giving a natural and really proportioned shape to the area, no matter for the size of the case (Fig. 52.12).

In limited case of localized lower body disproportions (Fig. 52.13), it is impressive how circumferential contouring can improve the general proportion of the area. From the various views it is possible to appreciate the natural shape acquired with the good proportions between elements reestablished. What da Vinci defined as the “Third Dimension” was not lost, but just forgotten by us as surgeons because we were worried about surgical approaches to

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Fig. 52.7  Leonardo da Vinci analysis of the proportions of the leg. Circa 1490, Royal Library, Windsor Castle

what was considered difficult or forbidden areas of the thigh. The author’s surgical experience with Vaser shows how this area can be successfully approached and treated and the superior aesthetic results obtained. Of course, Vaser can help a good plastic surgeon to perform body contouring of the thighs, but the talent to sculpture the body by the feeling with fat, noting body imaging and realizing how to reach your final goal is always a personal quality that cannot be taught.

The da Vinci’s drawing 1507 (Fig. 52.14) in his study of the musculature of the abdominal wall, where he already figured the surgical anatomy of the rectus abdominis and oblique muscles and the so-called six packs or eight packs, clearly indicates that what we supposed to have invented or discovered today was in reality invented or discovered 500 years ago. It is just a question of reading and studying da Vinci’s drawings.

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Fig. 52.8  Leonardo da Vinci’s studies on the proportion of a sitting, kneeling, or standing body. Circa 1490, Royal Library, Windsor Castle

Fig. 52.9  Surgical plan in red area untouched, yellow is volume to be reduced, and green area to be filled

52.3 Technique of Circumferential Thigh Vaser Contouring The process of the anteromedial approach to the thigh is to thin the subcutaneous fat of the thigh in areas

considered to be risky for the approach with classic liposuction. At the same time, the undermined tissues raise and represent a substantial benefit for the final contouring of the leg. Of course, the approach to the anterolateral part is the final step of a circumferential sculpturing of the thigh. A tridimensional vision of the

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axis in order to allow careful undermining of the tissue from underlying fat. This maneuver is essential for the final contouring of the area of the thigh, as it will allow the reduced tissues to adhere to the new, reduced body. The undermining ends when all the area has no more resistance with the ­underlying structures, respecting the vascular connection with the underlying layers that are not disturbed by the action of the ultrasound probe that carefully undermines without injuring the vascular network of the skin. This selectivity distinguishes Vaser ultrasound from other techniques in terms of protection of the subcutaneous vascular plexus (Fig. 52.16) [6].

Fig. 52.10  Anteromedial thigh planning interior thigh. Blue lines show increasing thickness to be reduced

full area is mandatory to model the different sides in harmony in between them. Infiltration of tumescence is vital in ultrasoundassisted lipoplasty. 1. The tumescent infiltration initially distends the tissue allowing vasoconstriction that diminishes bleeding and compacting the tissues that become uniform. The fluids are distributed superficially first and deeper to follow (Fig. 52.15) [7]. 2. Fat tissue is not dense, and tissue infiltration in the deep as well as in the superficial layer allows a firm surgical plane to be obtained. There are no anatomical layers of distinction in fat tissue so the two planes anatomical work with Vaser needs a precise layer of action of the probe (Fig. 52.16). The superficial superwet technique of infiltration really distends the tissue and allows a precise undermining by the 2.9 or 3.7 mm with one or two ring probes. With the power tunneled at 70% of power, the probe is directed parallel to the skin

The undermining, which may require 5–6 min of delicate Vaser action, always respects the skin superficial layers, the probe being directed into the deeper layers of the thigh. The volume of fat in the thigh has a peculiar distribution. The lateral part is normally the thinnest, corresponding to the fascia lata where the fat is normally minimally represented. This is the only forbidden area in body contouring, as the risk of depression is high and there is no need for fat removal. The anteromedial thigh, which is the proper target of this new technique, presents a thicker fat deposit, different from case to case, which can be emulsified with the same 2.9 or 3.7-mm probes. The power is raised to 80, or even 90%, with a total timing that is normally around 20 min of Vaser action. Once this phase is completed, the surgeon starts the most delicate part of the contouring, the removal of emulsified fat from the deeper layer (Fig. 52.17), the superficial spreading of the skin, and the careful aspiration in respect of the shape of the body (Fig. 52.18). Aspiration in the superficial layer has to be very conservative This part of the sculpting of the body allows the plastic surgeon to express his own talent and artistry, and is the unique part of the technique which cannot be taught, but just shown. Sculpturing the body by recreating lines of natural convexity or concavity is the fascinating and creative part of surgery. A 2.8-mm fine cannula is utilized to shape the superficial planes, with virtually no aspiration, and a 3.7-mm cannula to aspirate in the deeper planes (Fig. 52.18). Surgeon must go step by step, checking the new shape of the thigh, as the aspiration is progressing. Mistake may occur from excess aspiration and may

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Fig. 52.11  Left: preoperative. Middle: surgical plan with lines showing concavities and convexities. Right: postoperative

create depressions and irregularities. A tridimensional view of the surgical plan and a constant control of the preoperative photos allow a general evaluation of how surgery is progressing in terms of aesthetic result. The surgical approach to the thigh is through inguinal crease and suprapatellar skin incisions. Thanks to

these skin incisions, all of the anteromedial thigh is approached with the standard 25-cm long probes. Fat thickness in the thigh is different from anterior, medial, and lateral sides. The surgeon must take into account these anatomical limits when molding the area. Respecting proportions is a constant matter for the plastic surgeon in aesthetic surgery. Careful

52  Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci

Fig. 52.11  (continued)

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52  Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci Fig. 52.12  Tridimensional approach. (a) Front, (b) side, (c) back. Preoperative. Right: postoperative

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removal of fat in the anteromedial area of the thigh is essential to avoid unpleasant depressions or an overall not aesthetic result (Fig. 52.19). Gentle massage at the end of surgery helps the clearance of the remaining emulsified fluids from the skin incisions. In the abdomen suction drainage is routinely applied, but in other areas just leave the solution to spread out gently. Garment and elastic stockings area placed at the end of sur­gery and maintained for 2 months postoperatively. Lym­ phatic or leg Endermologie starts 10 days postoperatively and is continued for 8 weeks at a rate of 2 times per week.

52.4 Discussion The outcome from 250 cases is impressive (Figs. 52.20 and 52.21) and the improvement of the overall view of the thigh is a major issue, giving reason to the concept introduced by da Vinci in his drawings. The lost or forgotten third dimension of the thigh is that portion of the leg that has been ignored for many years because of the difficulties in treating this zone. But Vaser can give a hand to approach the area, thanks to the possibility of working on the superficial layers allowed by the fine probes and the ultrasonic energy.

52  Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci Fig. 52.13  (a) Front, (b) side, (c) 3/4, (d) back. Left: preoperative 23-year-old female. Right: postoperative following three dimensional contouring of the thighs. Balance and proportions, other than volume reduction, are essential to acquire and ideal profile with contouring, convexities, and concavities

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52  Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci Fig. 52.14  Leonardo da Vinci’s studies on abdominal wall muscles. Circa 1490, Royal Library, Windsor Castle

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Fig. 52.15  Skin incisions: inguinal and knee

c Fig. 52.17  (a, b) Level of undermining and emulsification. (c) Tissue adhesion after emulsified fat cleaning

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52  Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci Fig. 52.18  (a) Side, (b) front. Sin incision superficial with undermining using 2.9 or 3.7 probes with one or two rings

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Fig. 52.19  (a) The position of the probe (b) The visual effect: the skin raised by the probe. Careful aspiration of emulsified fat from superficial layers

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References   1. Illouz YG. Refinements in the lipoplasty technique. Clin Plast Surg. 1989;16(2):217–33.   2. Di Giuseppe A. Ultrasonic assisted liposculpture. Presented at the World Congress on Liposuction. San Francisco: 3–5 May 1996.   3. Scheflan M, Tazi H. Ultrasonically assisted body contouring. Aesthetic Plast Surg. 1996;19:117.   4. Tazi H, Scheflan M. Endoscopic evaluation of ultrasonic assisted liposculpture comparison to traditional liposuction

A. Di Giuseppe (video). Presented at American Congress of Aesthetic Plastic Surgery. San Francisco: 14–8 April 1995.   5. Zocchi M. Ultrasonic assisted lipectomy. Adv Plast Reconstr Surg. 1995;2:27–65.   6. Di Giuseppe A. Ultasound-assisted liposuction: physical and technical principles. In: Shiffman MA, Di Giuseppe A, editors. Liposuction: principles and practice. Berlin: Springer; 2006. p. 229–38.   7. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg. 1987;4:263–7.

Liposuction of the Calves and Ankles Associated with Calf Implant

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Adrien E. Aiache

53.1 Introduction Removal of fat from fatty ankles was first described by Schrude. This procedure consisted of making an incision in the posterior area of the ankles and using a curette for removal of the fat below the gastrocnemius. Complications were relatively numerous for the procedure to gain wide acceptance. Before Schrude, a French surgeon in the early 1900s had done this type of treatment; however, a ballerina treated by curettage ended up with generalized infection and lost her leg. With the new technique of liposuction, the improvement has been quite significant as it was developed by Fischer and later by Illouz.

53.2 Anatomy In view of the fact that the fascia superficialis is adherent to the muscular fascia, there are no deep fat deposits and the superficial fat layer represents a dense connective tissue associated with a florid lymphatic system. One needs to use an even fat liposuction to prevent irregularities. The anterior leg suction is performed on the prone patient with the legs flexed in order to proceed comfortably. It is often necessary to thin out around the ankles to a maximum and allow more fat in the upper leg at the junction with the gastrocnemius muscle belly. The anatomy consists of, posteriorly, the soleus muscle which comes from the

A. E. Aiache 9884 Little Santa Monica Blvd, Beverly Hills, CA 90212, USA e-mail: [email protected]

femoral condyle and goes down into the Achilles ­tendon into the calcaneus bone, and this muscle is covered by the gastrocnemius muscle which has usually two bellies, the medial belly being larger and lower than the lateral belly. The sural nerve travels between the two heads of the gastrocnemius and gives sensation to the posterior ankle area. Deeper than the gastrocnemius, the posterior popliteal nerve comes from the bifurcation of the posterior femoral nerve and goes around the fibular tubercle to enervate the muscles of the anterolateral aspect of the foot, and it gives a sensory nerve going to the lateral and posterior area of the leg and the foot. Medially, the posterior tibial nerve bifurcates and enervates the muscles of the leg, and gives, in addition, a sensory branch to the outer aspect of the leg. These nerves are to be avoided carefully during the liposuction and during the calf implantation (Fig. 53.1).

53.3 Indications Indications consist of either thin legs with an association of large knees needing liposuction or sometimes fat legs which have no special shape and are to be suctioned at the knee level and at the ankle level, and sometimes need to be associated with calf implants in order to give them a better shape. The appearance of the leg is deleterious to the aesthetic aspect of the leg in females. The problem consists of fat deposits interspersed with some fibrous tissue. It is found mainly in some ethnic groups. The condition worsens with age and it should be distinguished from dependent edema secondary to venous stasis. Palpation and the pinch test must reveal an excess of fat since some of the ankle bulk may be due to edema.

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and the element to be augmented by the implant. The patient is in the standing position and the exact amount of fat can be assessed. The area is marked up to the belly of the gastrocnemius muscle down to the ankle itself and around the Achilles tendon. This zone is extremely difficult since the circulation is poor in the midline above the Achilles tendon and often is the cause of superficial skin loss and even sometimes full thickness skin losses. The incision is usually made lateral and medial to the Achilles tendon. More anteriorly, some fatty deposits may be encountered and they are liposuctioned through an anterior horizontal foot incision.

53.5.2 Anesthesia Depending on the extent of the suction, anesthesia can be local, but more often general anesthesia is given. In cases of multiple suctioned areas, general anesthesia is preferable and the legs are then infiltrated, in addition, with the usual tumescent infiltration of the diluted solution of Xylocaine with epinephrine 1:1,000,000. In local anesthesia cases, the same anesthetic is used with some sedation instead of general anesthesia.

Fig. 53.1  Anatomical demonstration of the location of the gastrocnemius muscle and the different nerves such as the sural nerve, the lateral peroneal nerve, and the inferior tibial nerve

53.4 Contraindications Older patients with poor circulation, poor vascular supply, and extreme venous stasis are contraindications since the secondary problems can become serious after liposuction. The skin tone should show adequate elasticity since in some patients with poor circulation and brawny edema, there is a very thick layer of fibrous fatty tissue with lymphatic engorgement.

53.5 Technique 53.5.1 Markings Markings are done in the standing patient and the markings are used in marking the element to be suctioned-out

53.5.3 Instruments Four and three millimeter cannulas are useful. Finer cannulas are used in order to prevent the untoward direction of the cannula immediately below the skin creating dents and longitudinal depressions.

53.5.4 Incisions An incision lateral to the Achilles tendon in the ankle is used. This should be avoided if the surgeon is concerned about injuring the lateral peroneal nerve. Incision medial to the Achilles tendon is the most commonly used and allows the proper suction to the whole medial posterior area of the leg. A less common incision in the posterior popliteal fold can be useful if there are extremely heavy deposits of fat and the suction is done going downward. In addition, this incision will allow insertion of the posterior calf implants. Anteriorly, the incision can be situated in the upper portion of the

53  Liposuction of the Calves and Ankles Associated with Calf Implant

foot and below the patella either medially or laterally, allowing proper suction in front of the tibial bone and more medially over the tibia where more accumulation can be seen. In addition, an incision can be made in the lateral or medial port of the popliteal folds and this allows suction of the lateral legs and the ankles.

53.5.5 Procedure The procedure is performed most often on the patient prone and the local anesthesia product is infiltrated. Then the usual sawing wood motion of the cannula is used in parallel tunnels methodically in each tunnel, trying to be even in the suction process. Proper projection of the suction is checked continually by palpation and observation using the pinch test and the flat palm of the hand to assess the remaining thickness of the skin below, on top of the cannula, and below the hand. Although this defatting is adequate in most of the cases, it has been found that vigorous defatting suction is necessary to achieve a remarkable difference in the shape of the ankle. Aside from circulatory problems immediately on top of the Achilles tendon, no other untoward effect has been seen from strenuous suction. In other words, superficial suction is indicated in these cases and is the only possibility in the leg. While 0.5 cm is sufficient around the ankle, 1 cm will be necessary in the upper leg which is supposed to be larger in volume than the lower leg. To improve on the exact shape of the result, a computer suction machine can be used. It helps in comparing the fat removal on both sides (1.5–1,000 Aspirator by MD Engineering, 2536 Barrington Court, Hayward, CA 94545).

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procedure. This technique has been suggested by some, and under proper circumstances, it can be useful.

53.5.7 Calf Implantation After this has been done, the incision is performed in the posterior popliteal fold measuring approximately 1½–2 in. The incision goes down to skin, subcutaneous tissues, down to the deep fascia which consists of a ­multiple-layer type of fascia, and when all the layers have been entered with a knife, the surface of the gastrocnemius muscle can be seen. At this point, the dissection is carried out using the finger over the gastrocnemius muscle and under the deep fascia. Continuation of the dissection is performed using the ball dissector and the hammer dissector that are useful in severing the remaining septa and vessels that are touching the fascia and the muscle to the deep leg fascia (Fig. 53.2). Once the pocket is judged adequate for the implants medially, a pocket is dissected laterally leaving a large segment of untouched

53.5.6 Refinements Feathering at the junction of the defatted and nondefatted areas is performed with finer cannulas and either minimal suction or no suction at all. In addition, proper defatting in a less aggressive manner is done anteriorly and at the lower edge of the gastrocnemius muscle. The refinements are made using a Robles 2.4 or 3-mm cannula with either one or three openings. A proximal tourniquet can be sometimes used if large amounts of fat have to be removed; however, this has a negative effect of extreme bleeding in each leg when it is released at the end of the

Fig. 53.2  Dissection of the implants using a ball dissector and around the pocket in the superficial level. The fat could be either liposuctioned or reinjected, as well as in the ankles themselves

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layers of tissue under the deep fascia in order to prevent movement of the implants from one side of the pocket to the other. The second pocket is then created laterally over the lateral belly of the gastrocnemius muscle and under the deep fascia of the leg. Again, the finger is used first followed by the round ball dissector and the hammer dissector, which are useful to sever the remaining fascia or vessel present in the area. Once the two pockets have been properly created and checked, the implants are then introduced in the medial and lateral segments of the leg respecting the central segment of tissue containing the posterior sural nerve. Once the implants have been correctly placed, their proper position and location are checked on both sides in order to have correct symmetry with the other leg that is done in the same fashion. Once correct symmetry has been obtained, adjustment of the suction be performed, especially in the medial aspect of the knee and the lateral aspect of the calf laterally using a lateral part of the incision that has been used for the calf implantation. Once satisfaction is obtained, the deep fascia is closed using 3–0 or 4–0 Vicryl sutures followed by a subcuticular suture with 4–0 Vicryl sutures. Unless an inordinate amount of bleeding has been obtained, no drains are left in situ and the wounds are perfectly closed followed by the dressing, and the postoperative care is then given.

53.5.8 Postoperative Care Compression and massaging of the area are useful to reduce the edema postoperatively. Once complete defatting has been obtained, the incisions are closed with absorbable sutures reinforced by Steri-Strips. A garment can be applied, in addition to Ace bandages, to prevent deep vein thrombosis. The patients are asked to ambulate ad lib and are allowed to have moderate activities. The compressive garments are the most useful. Support hose is often reinforced by Reston foam (Allmed, 297 High Street, Dedham, Massachusetts 02026) and kept in place with a 6-in. Ace bandage (Fig. 12).

53.5.9 Circumferential Ankle Liposuction Using the posterior and anterior approaches, ­cir­cumferential suction is used in fatty legs when a definite increase in the superior fatty layer is palpated.

A. E. Aiache

It is performed with a 4 or 3-mm cannula. It is safe, depending on the specific vascular condition of the patient. Caution is advised is older patients with poor vascular status for fear of local skin slough and venous stasis and thrombosis. Through four incisions, the suction is then performed and the proper incision can reach the ankle and should crisscross the anterior midline. A combination of a long 4-mm cannula and a 3-mm cannula is sufficient to obtain good suction. Continuous feeling and the pinch test will direct such a process and, combined with repeated inspection and palpation, it will allow proper results and long-term postoperative results.

53.6 Complications The complications that are sometimes seen are mentioned such as infection, irregularities, and nerve injuries. Complications which are more common are swelling, excessive pain for an extended period of time, some areas of irregularities, extreme bleeding, and longterm pigmentation, in addition to complications seen with calf implantation consisting of bleeding, seroma formation, poor location of the implants, and eventual infection of the implanted area (Table 53.1). Table 53.1  Ankle liposuction complications Complication

Remedies

Insufficient removal

Fat grafting

Excess removal and dents

Allows only token ­improvement. The skin should be 0.5–1 cm thin all around

Hyperpigmentation

 

Edema

 

Pain

 

Hypesthesia

 

Uneven or unequal

 

Seroma and/or hematoma

Aspiration 

Infection

Implant removal

Contraindications: Circulatory problems, varicose veins, ankle edema, Raynaud’s syndrome, lymphedema, hypertrophic gastrocnemius muscle Comments: Ankle with pitting edema should be a contraindication. Lymphatic or venous incompetence can be the cause. The skin tone should be showing adequate elasticity, otherwise liposuction is not advised

53  Liposuction of the Calves and Ankles Associated with Calf Implant

53.7 Discussion Liposuction has been found to be extremely useful in cases of lipodystrophy of the lower leg. This technique can bring dramatic improvement to these cases. Contraindications are well known and they include old  age with circulatory problems, varicose veins, ankle edema, Raynaud’s syndrome, lymphedema, etc. Association of liposuction with calf implantation has been shown to be beneficial in improving the shape of the leg and improving the shape of the knee and the ankle (Fig. 53.3). Determination of the exact desire of the patient will help in deciding the amount of fat to be removed and aggressive suctioning may lead to irregularities in the ankle, but the overall result will be better than cases that are done too conservatively. The possibilities afforded by implants have shown that some patients can be improved in their contour by a combination of augmentation and reduction by liposuction allowing real sculpture of the body. Such cases are pectoral implants calf implants, buttock implants, as well as malar and chin implants. All of these cases can be associated with liposuction to improve their contour, in addition to augmentation by fat injection.

a

b

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In cases of deformities of the leg consisting of an underdevelopment of the muscular elements in the calf associated with excess fatty deposits around the lower thigh, the knees, and the upper leg, a combination of calf implants with liposuction of the knees, the lower thighs, and the upper calves has been shown necessary. Some patients will necessitate an inferior leg liposuction sculpturing the ankles and the areas below the gastrocnemius followed by subfascial implantation of the calf implants. This combination of techniques is used in conjunction during the same operation. The technique of calf liposuction is only secondary to the technique of implantation since the implantation itself is a procedure necessitating more vigorous asepsis, and the author favors the preliminary implantation of the calf implants and a closure of the layers of the fascia and the subcutaneous tissues followed then by liposuction of the knees and the calves. This combination approach has given more security in the attempt at reducing the potential problems of infection. The calves are marked in the usual manner for implantation, and the incision for the calf is used as in regular calf implantation shown in the following ­chapter. Following this implantation, the incisions for liposuction are performed in the lateral and medial aspect of the posterior popliteal incision for implantation, and in

c

Fig. 53.3  (a) Preoperative patient. (b) Preoperative markings of the liposuction areas. (c) Postoperative

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the medial and lateral aspect of the Achilles tendon if ankle suction is necessary. Once the suction has been performed in these cases, the patient is turned in the supine position, and using a small incision in the medial aspect of the knee above the patella, the completion of the liposuction of the knees is performed.

A. E. Aiache

53.8 Conclusions A combination of liposuction of the ankles, knees, and lower thighs in association with calf implants gives a better result than either one of these procedures alone.

Management of HIV-Associated Lipodystrophy: Medical and Surgical Options for Lipoatrophy and Lipohypertrophy1

54

C. Scott Hultman and Anne Keen

54.1 Introduction Over 25 years after the first published cases of the acquired immunodeficiency syndrome in 1981, human immunodeficiency virus (HIV) has infected an estimated 65 million people and resulted in at least 25 million deaths [1]. During the latter part of the 1990s, potent HIV therapies became available and produced a dramatic improvement in the prognosis of this fatal viral illness. Suppression of viral replication by highly active antiretroviral therapies (HAART) and subsequent increases in CD4+ cell count have yielded increases in disease-free survival. The benefits of HAART, however, have been tempered by the development of metabolic complications and morphologic changes in patients receiving these therapies, which may occur in 10–60% of this population [2]. Insulin resistance, dyslipidemia, lactic acidosis, and alterations of fat distribution in varying combinations have been observed during HAART [2]. Given the association of these conditions with heightened risk of cardiovascular disease, there is increasing concern about the long-term consequences of HIV treatment. Further, metabolic complications can threaten the success of HAART. The need for lipid-lowering or hypoglycemic medications can increase pill burden and jeopardize medication adherence. In addition, adverse metabolic effects, particularly those that

Funding: Supported in part by the Ethel and James Valone Plastic Surgery Endowment.

1

C. S. Hultman (*) Division of Plastic and Reconstructive Surgery, University of North Carolina, Suite 7040, Burnett-Womack Building, CB#7195, Chapel Hill, NC 27599-7195, USA e-mail: [email protected]

impact appearance, can reduce patient acceptance of HIV therapy. Disfiguring body shape changes from HAART, in addition to potentially compromising the success of medical control of HIV infection, can threaten confidentiality and lead to increased stigmatization of those living with HIV. Originally described by Carr in 1998, HIV-associated lipodystrophy results in abnormal fat redistribution, with lipoatrophy of the nasolabial folds, malar region, temples, buttocks, and distal extremities, and lipohypertrophy of the neck, trunk, and breasts [3–12]. Furthermore, adverse body shape changes can have psychological consequences and contribute to feelings of unattractiveness, low self-esteem, poor selfimage, and depression [13–17]. Accumulation of fat in the cervicodorsal region and anterior neck can also interfere with function, causing significant pain, altered posture, limited range of motion, and sleep apnea [18].

54.2 Pathophysiology Developing effective treatment for fat distribution abnormalities accompanying HIV therapy has been limited by a continuing lack of understanding of the etiology of fat accumulation in the setting of HIV. While early studies implicated antiretroviral agents of the protease inhibitor (PI) class in fat accumulation, recent data suggest that other antiretroviral classes and host factors are also responsible [2]. Many of the PIs and nucleoside reverse transcriptase inhibitors (NRTIs) bind to homologous regions on endogenous proteins that control normal lipid metabolism, leading to paradoxical, concurrent adipocyte apoptosis and/or hypertrophy. Specific targets of inhibition that have been implicated include cystoplasmic retinoic-acid binding protein type 1, which may

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_54, © Springer-Verlag Berlin Heidelberg 2010

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control adipocyte differentiation and maturation, and low-density lipoprotein-receptor-related protein, which may negatively impact clearance of serum triglycerides and transport of hepatic chylomicrons [19–23].

54.3 Patient Assessment A complete assessment of the patient is critical to help identify and guide patient expectations, optimize procedural outcomes, minimize perioperative morbidity, and decrease risk to the providers. As with all patients, a thorough history and physical examination must be performed. Preoperative history should include determination of disease status and overall health, confirmation that the patient has a medical home and is followed by an infectious disease expert, and review of previous and current antiretroviral regimen. Furthermore, the provider should investigate history of opportunistic infections, sexually transmitted diseases, viral hepatitis, tuberculosis, cardiovascular status, substance abuse, and insulin resistance and hyperlipidemia [24]. Regarding the physical examination, the surgeon should evaluate the status of the airway and focus on morphologic changes in body habitus, differentiating subcutaneous from visceral fat and assessing the severity of lipoatrophy and lipohypertrophy. Suitable candidates for surgery included those individuals who (1) have specific anatomic areas amenable to lipectomy (anterior neck, posterior neck, trunk, extremities), (2) have stable HIV disease with an optimized HAART regimen, (3) display a history of compliance with medical therapy, (4) have attempted to improve their lipodystrophy through exercise and nutrition, and (5) demonstrate realistic expectations regarding the possible benefit of surgery. In addition to checking a full viral panel (CD4+/CD8+ cell counts and viral RNA titers), we also obtain such laboratory data as lipid panels (triglycerides, LDL/HDL, cholesterol), routine serum chemistries, hemoglobin/hematocrit, and platelets. Higher complication and mortality rates have been associated with absolute CD4+ counts less than 200 cells/mL and viral load greater than 10,000 copies/mL [24]. Radiographic imaging may be helpful in selected cases: lateral cervical spine roentgenograms screen for cervical disc disease, while computerized tomography may evaluate the extent of subplatysmal fat and parotid hypertrophy or cystic degeneration.

C. S. Hultman and A. Keen

Perioperative considerations include deep venous thrombosis prophylaxis and patient education regarding postoperative pulmonary toilet and early mobilization. Prophylactic antibiotics are administered within 30 min prior to the incision and are continued postoperatively only if a drain is placed or unexpected contamination occurs. Antibiotics are not used for injection of permanent or semipermanent subdermal fillers, but are utilized for structural fat grafting.

54.4 Medical Therapy The efficacy of medical therapy for HIV-associated lipodystrophy is largely unknown, and treatment options, therefore, remain limited. Diet and exercise have been found to lead to some reduction in abdominal fat, but these changes have been modest and many patients have difficulty adhering to such lifestyle interventions. Recombinant growth hormone has been shown to reduce visceral and cervicodorsal fat in HIVinfected patients; however, this agent, which is prohibitively expensive, is associated with a number of toxicities, including worsening glucose intolerance, myalgias, and carpal tunnel syndrome. Further, reaccumulation of fat is often seen following discontinuation of growth hormone. Small studies of the PPAR-gamma agonist rosiglitazone, as well the insulin sensitizer metformin in HIV-infected patients with insulin resistance, have found beneficial effects on visceral fat accumulation, but larger studies have yielded contrary results [2].

54.5 Surgical Treatment Surgical approaches to HIV-associated lipodystrophy show considerable potential in correcting the stigmata of fat redistribution [25–52]. For lipoatrophy, soft tissue replacement can be achieved by structural fat grafting via autotransplantation, dermal-fat grafts, subperiosteal malar implants, semipermanent soft tissue fillers, off-label silicone injection, and even intramuscular gluteal implants [24–39, 52]. Polylactic-l-acid (Sculptra) was approved by the FDA in 2004 for large volume restoration and/ or correction of facial lipoatrophy in patients with

54  Management of HIV-Associated Lipodystrophy

HIV-associated lipodystophy, with augmentation lasting at least for 2 years [38, 39]. Another semipermanent filling agent, calcium hydroxylapatite (Radiesse), has been used off-label to treat HIV-associated facial lipoatrophy and demonstrates an excellent safety profile with favorable 1-year durability [37]. Recently, polyacrylamide hydrogel (Aquamid) has been used as a semipermanent filler to provide contour correction of the nasolabial folds and midface, with significantly improved quality of life, as measured by objective inventories [52]. Specific anatomic areas of lipoatrophy that benefit from soft tissue augmentation include temples, glabella and brow, zygomatic arch, lower eyelid, nasojugal groove, malar triangle, nasolabial fold, oral commissures, chin, and peri-jowl area. For lipohypertophy, the patient must understand that surgery can function as a primary or adjunctive modality, and that techniques for fat resection are still in evolution [40–51]. Surgery should be offered only to patients with stable HIV infection, who have realistic expectations regarding outcomes, and who have focal areas of fat accumulation that are amenable to UAL, SAL, and/or direct, open lipectomy. Informed consent must include the understanding that suboptimal correction or recurrence of the lipohypertrophy may occur and that staged or late reoperation may be necessary. Surgical planning may benefit from preoperative imaging, which helps to define the extent and distribution of abnormal fat accumulation. Despite the potential for recurrence, a combination of UAL and SAL appears to be very effective and safe in reducing the volume of the cervicodorsal fat pad, improving range of motion and neck posture, and reducing discomfort. Because of the fibrous nature of the fat observed in HIV lipodystrophy, UAL is required for surgical resection, as this modality allows for cavitation of adipocytes and extraction of lipoaspirate, with considerably less tissue trauma than SAL alone. Direct excision of extremely dense fat, such as in the mastoid region, should also be considered and can be accomplished through a pretrichal, posterior scalp incision. The anterior neck, however, represents a significant challenge, in terms of safety, efficacy, and longterm improvement. The two goals of fat removal and improved contour may be difficult to achieve with liposuction alone, due to the extensive amount of subplatysmal fat and potential for parotid hypertrophy or cystic degeneration. Subplatysmal fat is not

547

safely accessible by liposuction and may require open, direct excision, through a submental approach or transverse cervical approach. Furthermore, UAL may cause neuropraxia or nerve injury, secondary to collateral ultrasonic damage, thereby placing the facial nerve at risk. This potential for nerve injury, combined with the inaccessibility of subplatysmal fat, redundant neck skin, and anterior platysmal diastasis, argues toward an open approach that incorporates SAL with a face-lift and neck lift. The best results may be obtained by superficial liposuction, direct submental and subplatysmal lipectomy, anterior platysmal plication, SMAS elevation, and skin resection via traditional face-lift and neck lift methods. Recently, the authors have utilized a transverse anterior neck excision to remove both supra- and subplatysmal fat, tighten the platysma, and redrape the excess anterior neck skin. Regarding the torso, body contouring can be performed via a combination of UAL/SAL of the abdominal wall, back, and flanks. Standard principles of patient safety (fluid resuscitation, low-volume liposuction of 1 year), which was observed in 25% of our patients, surgical management of HIV-associated lipohypertrophy was efficacious and safe, with minimal morbidity. Nerve injury, infection, hematoma, fat necrosis, or thermal injury were not observed. Reoperation was performed in 2/12 patients to correct contour irregularities or residual areas of lipohypertrophy. Based upon the results of this small case series, the authors believe that UAL/SAL is particularly beneficial in reducing the cervicodorsal fat pad, while face-lift and neck lift may be necessary to adequately address anterior neck lipohypertrophy. Truncal procedures may need to be staged or repeated during follow-up. The authors, in 2007, [51] combined the data from 11 studies on the surgical management of HIVassociated liposdystrophy and identified 88 patients who underwent surgical removal of fat in the anterior neck, posterior neck, torso, and breasts. The overall rate of reported complications was 26.1%, and the recurrence rate in 72 patients available for follow-up was 23.6%. Length of follow-up, however, was only reported in four studies, with a range of 12–30 months. No major systemic complications or deaths were observed. This pooled analysis supports our conclusion that surgical management of the HIV-related lipohypertrophy is efficacious and effective in the majority of patients. Most recently, Davison et al. [24, 49, 50] provided comprehensive perioperative guidelines and a surgical algorithm for the management of HIV-associated lipodystrophy. In their cohort of 27 patients, 3 underwent treatment for isolated buffalo hump, 10 underwent treatment for isolated facial wasting, and 14 were treated for both conditions. Mild facial wasting was treated with synthetic, semipermanent fillers, moderate wasting was treated with structural fat grafting, and severe wasting was treated with fat, parotidectomy, and mastectomy graft material. Cervicodorsal lipohypertrophy was addressed by UAL and SAL. The

C. S. Hultman and A. Keen

authors raise the possibility of superficial parotidectomy to address cystic degeneration and hypertrophy, which is often observed in HIV-associated lipodystrophy and can contribute to abnormal facial morphology. To reduce the incidence of Frye’s syndrome to less than 10%, this group utilizes a layer of acellular dermal matrix between the deep lobe of the parotid and the skin flaps.

54.7 Patient Studies Lipoatrophy: This 31-year-old HIV+ male patient, with body mass index of 24.1, had severe facial lipoatrophy, manifested by wasting of the malar and buccal fat pads, temporal hollowing, and prominence of the nasolabial fold (Fig. 54.1). He had been on a HAART regimen for 9 years, with a CD4 count of 800 and no detectable viral load. The posterior oblique view helps to illustrate this pathognomonic form of HIV lipoatrophy. Treatment involved four sessions of poly-l-lactic acid injections, spaced 3–4 weeks apart, using 6 mL of reconstituted filler per side. The malar and submalar regions were treated with a radial fanning technique, injecting 3–4 mL of material from a medial to lateral direction, as the 25 gauge needle is withdrawn, at the junction between the dermis and subcutaneous fat. The nasolabial folds were augmented using a cross-hatching pattern, placing product in the subcutaneous fat, deep to the dermal surface. The nasojugal folds and lower eyelids, which have thinner skin than the cheek, were injected in a submuscular plane, with less than 0.5 mL per session. Temporal depot shots, with ~1 mL of product, were placed between the temporalis muscle and temporal bone. Finally, the zygomatic arch was augmented with 0.5 mL in a supraperiosteal plane to facilitate lateral tapering of the malar region. The patient experienced no adverse sequellae such as subcutaneous nodules or inflammatory papules and has a stable appearance, 1 year following his reconstruction (Fig. 54.1). Lipohypertrophy: This 52-year-old HIV+ male patient, with a body mass index of 32.1, had been on a HAART regimen for 13 years with stable disease and no opportunistic infections. He complained of neck ache, shoulder strain, and decreased range of motion in his neck, plus self-reported sleep apnea. In addition to

54  Management of HIV-Associated Lipodystrophy

549

a1

a2

a3

a4

b1

b2

b3

b4

Fig. 54.1  (a1–4) Preprocedural views of a 31-year-old man, body mass index of 24.1, with lipoatrophy of nasolabial folds and malar region. (b1–4) Postprocedural after four rounds of

subcutaneous and submuscular augmentation with semipermanent filler (poly-l-lactic acid)

having mild lipoatrophy of the malar region and moderate to severe anterior neck lipohypertrophy, he had severe cervicodorsal fat accumulation (Fig.  54.2), affecting cervical posture and causing abnormal neck flexion and head extension. Ultrasonic-assisted liposuction was utilized to emulsify the fat in the posterior neck, through three port sites (Fig. 54.2). After infiltrating the cervicodorsal fat pad with 600 mL of wetting solution (from a solution of 1,000  mL of Ringer’s lactate, 1  amp of epinephrine 1:1,000 and 50  mL of 1% lidocaine), 300  mL of fat was cavitated over 4.5  min with the blunt-tipped ultrasound probe, on a setting of 6 out of 10. Using this technique, the surgeon can emulsify this fat, which is extremely fibrous, at a rate of

50–75  mL/min. The liquefied fat was then removed with conventional suction-assisted lipectomy, utilizing progressing smaller cannulas, to help taper the resection onto the lateral neck and posterior chest. Extreme care should be taken near the posterior triangle of the neck to avoid injury to the spinal accessory nerve, which passes subcutaneously from the sternocleidomastoid to the trapezius muscle, for a short distance. Traditional endpoints for UAL are used – loss of resistance, presence of blood-tinged lipoaspirate, and reaching the preoperatively calculated duration of cavitation – to minimize potential for thermal injury. Drains are now only placed for largevolume UAL, and compression garments are critical to assist with final shaping.

550

a1

b

C. S. Hultman and A. Keen

a2

a3

c1

c2

Fig. 54.2  (a1–3) Preoperative 52-year-old man, body mass index of 32.1, with lipohypertrophy of anterior and posterior neck. (b) Intraoperative. (c1,2) Postoperative

54.8 Future Directions While the definitive management of HIV-associated lipodystrophy has yet to be determined, future approaches will most likely include manipulation of the HAART regimen to reduce drug toxicities, addition of pharmacologic agents to improve adipocyte metabolism and lipid processing, dieting and exercise, and surgical intervention. Reconstructive techniques to correct fat redistribution show considerable promise and may be effective as primary or adjunctive therapy in well-selected candidates. The combination of soft tissue augmentation for lipoatrophy, via semipermanent fillers, and fat removal for lipohypertrophy,

through UAL/SAL, offers the potential to correct the stigmata and functional sequellae seen in patients with HIV-associated lipodystrophy.

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54  Management of HIV-Associated Lipodystrophy   3. Carr A, Samaras K, Chisolm DJ, Cooper DA. Abnormal fat distribution and use of protease inhibitors. Lancet. 1998;351(9117):1736.   4. Schambelan M, Benson CA, Carr A, Currier JS, Dube MP, Gerber JG, Grinspoon SK, Grunfeld C, et al. Management of metabolic complications associated with antiretroviral therapy for HIV-1 infection: recommendations of an international AIDS Society-USA panel. J Acquir Immune Defic Syndr. 2002;31(3):257–75.   5. Tien PC, Grunfeld C. What is HIV-associated lipodystrophy? Defining fat distribution changes in HIV infection. Curr Opin Infect Dis. 2004;17(1):27–32.   6. Sutinen J. Interventions for managing antiretroviral therapyassociated lipoatrophy. Curr Opin Infect Dis. 2005; 18(1):25–33.   7. Jones D. HIV facial lipoatrophy: causes and treatment options. Dermatol Surg. 2005;31(11 Pt 2):1519–29.   8. James J, Carruthers A, Carruthers J. HIV-associated facial lipoatrophy. Dermatol Surg. 2002;28(11):979–86.   9. Bacchetti P, Gripshover B, Grunfeld C, Heymsfield S, McCreath H, Osmond D, Saag M, Scherzer R, Shlipak M, Tien P. Study of fat redistribution and metabolic change in HIV infection (FRAM). Fat distribution in men with HIV infection. J Acquir Immune Defic Syndr. 2005;40(2): 121–31. 10. Tien PC, Cole SR, Williams CM, Li R, Justman JE, Cohen MH, Young M, Rubin N, Augenbraun M, Grunfeld C. Incidence of lipoatrophy and lipohypertrophy in the women’s interagency HIV study. J Acquir Immune Defic Syndr. 2003;34(5):461–6. 11. Krause JC, Toye MP, Stechenberg BW, Reiter EO, Allen HF. HIV – associated lipodystrophy in children. Pediatr Endo­ crinol Rev. 2005;3(1):45–51. 12. Garg A. Lipodystrophies. Am J Med. 2000;108(2):143–52. 13. Guaraldi G, Orlando G, Murri R, Vandelli M, De Paola M, Beghetto B, Nardini G, Ciaffi S, Vichi F, Esposito WuAW. Quality of life and body image in the assessment of psychological impact of lipodystrophy: validation of the Italian version of assessment of body change and distress questionnaire. Qual Life Res. 2006;15(1):173–8. 14. Power R, Tate HL, McGill SM, Taylor C. A qualitative study of the psychosocial implications of lipodystrophy syndrome on HIV positive individuals. Sex Transm Infect. 2003; 79(2):137–41. 15. Wohl DA. Editorial comment: correcting facial lipoatrophy has little to do with vanity. AIDS Read. 2005;15(7):372. 16. Echavez M, Horstman W. Relationship between lipoatrophy and quality of life. AIDS Read. 2005;15(7):369–75. 17. Lichtenstein KA. Redefining lipodystrophy syndrome: risks and impact on clinical decision making. J Acquir Immune Defic Syndr. 2005;39(4):395–400. 18. Gold DR, Annino DJ Jr. HIV-associated cervicodorsal lipodystrophy: etiology and management. Laryngoscope 2005;115(5):791–5. 19. Nagy GS, Tsiodras S, Martin LD, Avihingsanon A, Gavrila A, Hsu WC, Karchmer AW, Mantzoros CS. Human immunodeficiency virus type 1-related lipoatrophy and lipohypertrophy are associated with serum concentrations of leptin. Clin Infect Dis. 2003;36(6):795–802. 20. Vigouroux C, Maachi M, Nguyen TH, Coussieu C, Gharakhanian S, Funahashi T, Matsuzawa Y, Shimomura I, Rozenbaum W, Capeau J, Bastard JP. Serum adipocytokines

551 are related to lipodystrophy and metabolic disorders in HIVinfected men under antiretroviral therapy. AIDS 2003; 17(10):1503–11. 21. Buffet M, Schwarzinger M, Amellal B, Gourlain K, Bui P, Prevot M, Deleuze J, Morini JP, Gorin I, Calvez V, Dupin N. Mitochondrial DNA depletion in adipose tissue of HIVinfected patients with peripheral lipoatrophy. J Clin Virol. 2005;33(1):60–4. 22. Cherry CL, Lal L, Thompson KA, McLean CA, Ross LL, Hernandez J, Wesselingh SL, McComsey G. Increased adipocyte apoptosis in lipoatrophy improves within 48 weeks of switching patient therapy from Stavudine to abacavir or zidovudine. J Acquir Immune Defic Syndr. 2005;38(3): 263–7. 23. Roge BT, Calbet JA, Moller K, Ullum H, Hendel HW, Gerstoft J, Pedersen BK. Skeletal muscle mitochondrial function and exercise capacity in HIV-infected patients with lipodystrophy and elevated p-lactate levels. AIDS 2002;16(7):973–82. 24. Davison SP, Reisman NR, Pelligrino ED, Larson EE, Dermody M, Hutchison PJ. Perioperative guidelines for elective surgery in the human immunodeficiency virus-positive patient. Plast Reconstr Surg. 2008;121(5):1831–40. 25. Moyle GJ. Plastic surgical approaches for HIV-associated lipoatrophy. Curr HIV/AIDS Rep. 2005;2(3):127–31. 26. Abood A, Ong J, Withey S, Johnson M, Butler P. Facial atrophy in HIV-related fat redistribution syndrome: a plastic surgical perspective on treatment options and a look to the future. Int J STD AIDS. 2006;17(4):217–20. 27. Serra-Renom JM, Fontdevila J. Treatment of facial fat atrophy related to treatment with protease inhibitors by autologous fat injection in patients with human immunodeficiency virus infection. Plast Reconstr Surg. 2004;114(2):551–5; discussion 556–7. 28. Burnouf M, Buffet M, Schwarzinger M, Roman P, Bui P, Prevot M, Deleuze J, Morini JP, Franck N, Gorin I, Dupin N. Evaluation of Coleman lipostructure for treatment of facial lipoatrophy in patients with human immunodeficiency virus and parameters associated with the efficiency of this technique. Arch Dermatol. 2005;141(10):1220–4. 29. Guaraldi G, De Fazio D, Orlando G, Murri R, Wu A, Guaraldi P, Esposito R. Facial lipohypertrophy in HIVinfected subjects who underwent autologous fat tissue transplantation. Clin Infect Dis. 2005; 40(2):e13–5. 30. Strauch B, Baum T, Robbins N. Treatment of human immunodeficiency virus-associated lipodystrophy with dermafat graft transfer to the malar area. Plast Reconstr Surg. 2004;113(1):363–70; discussion 371–2. 31. Wechselberger G, Sarcletti M, Meirer R, Bauer T, Schoeller T. Dermis-fat graft for facial lipodystrophy in HIV-positive patients: is it worthwhile? Ann Plast Surg. 2001;47(1):99–100. 32. Benito-Ruiz J, Fontdevila J, Manzano M, Serra-Renom JM. Hip and buttock implants to enhance the feminine contour for patients with HIV. Aesthetic Plast Surg. 2006; 30(1): 98–103. 33. Funk E, Bressler FJ, Brissett AE. Contemporary surgical management of HIV-associated facial lipoatrophy. Otolaryngol Head Neck Surg. 2006;134(6):1015–22. 34. Hodgkinson DJ. Facial atrophy in HIV-related fat redistribution syndrome: anatomic evaluation and surgical reconstruction. Ann Plast Surg. 2003;50(3):328.

552 35. Talmor M, Hoffman LA, LaTrenta GS. Facial atrophy in HIV-related fat redistribution syndrome: anatomic evaluation and surgical reconstruction. Ann Plast Surg. 2002;49(1):11–7; discussion 117–8. 36. Binder WJ, Bloom DC. The use of custom-designed midfacial and submalar implants in the treatment of facial wasting syndrome. Arch Facial Plast Surg. 2004;6(6):394–7. 37. Silvers SL, Eviatar JA, Echavez MI, Pappas AL. Prospective, open-label 18-month trial of calcium hydroxyapatite (Radiesse) for facial soft-tissue augmentation in patients with human immunodeficiency virus-associated lipoatrophy: one-year durability. Plast Reconstr Surg. 2006;118(3 Suppl):34S–45S. 38. Lam SM, Aizzadeh B, Graivier M. Injectable poly-l-lactic acid (Sculptra): technical considerations in soft-tissue contouring. Plast Reconstr Surg. 2006;118(3 Suppl): 55S–63S. 39. Valantin M, Aubron-Olivier C, Ghosn J, Laglenne E, Pauchard M, Schoen H, Bousquet R, Katz P, Costagliola D, Katlama C. Polylactic acid implants (New-Fill) to correct facial lipoatrophy in HIV-infected patients: results of the open-label study VEGA. AIDS 2003;17(17):2471–7. 40. Ponce-de-Leon S, Iglesias M, Ceballos J, Ostrosky-Zeichner L. Liposuction for protease-inhibitor-associated lipodystrophy. Lancet 1999;353(9160):1244. 41. Wolfort FG, Cetrulo CL, Nevarre DR. Suction-assisted lipectomy for lipodystrophy syndromes attributed to HIVprotease inhibitor use. Plast Reconstr Surg. 1999;104(6): 1814–20. 42. Rohrich RJ, Kenkel JM. Invited discussion: suction-assisted lipectomy for lipodystrophy syndromes attributed to HIVprotease inhibitor use. Plast Reconstr Surg. 1999;104: 1821–2. 43. Chastain MA, Chastain JB, Coleman WP. HIV lipodystrophy: review of the syndrome and report of a case treated with liposuction. Dermatol Surg. 2001;27(5):497–500. 44. Gervasoni C, Ridolfo AL, Rovati L, Vaccarezza M, Carsana L, Galli M. Maintenance of breast size reduction after mas-

C. S. Hultman and A. Keen toplasty and switch to a protease inhibitor-sparing regimen in an HIV-positive woman with highly active antiretroviral therapy-associated massive breast enlargement. AIDS Patient Care STDS. 2002;16(7):307–11. 45. DeWeese JE, Delaney AR, Klein D, Horberg M. UAL of HIV lipohypertrophy of the head and neck. Presented at the Poster Session of the Annual Scientific Meeting of the American Society of Plastic Surgeons, San Diego, CA, 25–29 Oct, 2003 and published in Plastic Surgical Forum 2003;XXVI:317–8. 46. Piliero PJ, Hubbard M, King J, Faragon JJ. Use of ultrasonography-assisted liposuction for the treatment of human immunodeficiency virus-associated enlargment of the dorsocervical fat pad. Clin Infect Dis. 2003;37(10):1374–7. 47. Gervasoni C, Ridolfo AL, Vaccarezza M, Fedeli P, Morelli P, Rovati L, Galli M. Long-term efficacy of the surgical treatment of buffalo hump in patients continuing antiretroviral therapy. AIDS 2004;18(3):574–6. 48. Connolly N, Manders E, Riddler S. Suction-assisted lipectomy for lipodystrophy. AIDS Res Hum Retroviruses. 2004;20(8):813–5. 49. Davison SP, Timpone J, Hannan CM. Surgical algorithm for management of HIV lipodystrophy. Plast Reconstr Surg. 2007;120(7):1843–58. 50. Reilly MJ, Burke KM, Davison SP. Wound infection rates in elective plastic surgery for HIV-positive patients. Plast Reconstr Surg. 2009;123(1):106–11. 51. Hultman CS, McPhail LE, Donaldson JH, Wohl DA. Surgical management of HIV-associated lipodystrophy: role of ultrasonic-assisted liposuction and suction-assisted lipectomy in the treatment of liphypertrophy. Ann Plast Surg. 2007;58(3):255–63. 52. De Santis G, Jacob V, Baccarani A, Pedone A, Pinelli M, Spaggiari A, Guaraldi G. Polyacrylamide hydrogel injection in the management of human immunodeficiency virusrelated facial lipoatrophy: a 2-year clinical experience. Plast Reconstr Surg. 2008;121(2):644–53.

Prevention and Treatment of Liposuction Complications

55

Melvin A. Shiffman

55.1 Introduction Liposuction may be associated with a variety of complications most of which can be avoided. The more aggressive the liposuction, especially in the superficial subcutaneous tissues and with large amounts of fat removal, the more likely a complication will occur. “It is not what is removed that is so much important, but what is left behind” [1]. The surgeon performing liposuction must be cognizant of the risks and complications of the procedure and the ways to prevent or treat them. Early recognition of a complication is essential and treatment should be started in a timely fashion. The surgeon must inform the patient of the complication, its probable or possible cause or causes, the proposed treatment, and the length of time for complete recovery. Consultation may be obtained and should be done in a timely manner.

55.2 Complications 55.2.1 Asymmetry If the patient has asymmetry of the abdominal wall preoperatively, this should be pointed out to the patient and recorded with adequate photos. More fat may have to be removed from one side or one area because of the asymmetric accumulation.

M. A. Shiffman 17501 Chatham Drive, Tustin, CA 92780-2302, USA e-mail: [email protected]

Asymmetry can be avoided by being aware of the amounts of fat and fluid removed from each side of the abdomen, so that there is no large discrepancy. Observing the results carefully at the end of liposuction may disclose further areas that need correction. Asymmetry can be corrected by removing more fat from the excess area, liposhifting fat into the depressed area, or reinjecting autologous fat. Asymmetry that is present postoperatively may need revision liposuction for the removal of excess fat from those areas affected. If there is a deficit in any area that needs correction, injection of autologous fat may be considered.

55.2.2 Bleeding, Hematoma Tumescent technique in liposuction has reduced the amount of bleeding to a minimal degree. To prevent or limit bruising, the patient must be forewarned to stop all aspirin containing products, nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, and herbals at least 2 weeks before and after surgery. Excessive liposuctioning in a single area may cause bloody fluid to appear in the tubing and this should forewarn the surgeon not to continue surgery in that area unless further tumescent solution is used. Compression over the areas of liposuctioning will help to limit bruising. This includes the use of garments, stretch tape, and foam dressings (polyurethane pads). Bleeding following liposuction may appear as bright red blood coming from the incision site or may be hidden and appear as orthostatic hypotension when the patient tries to sit up or stand. Postoperative dizziness and feeling faint should not be considered as a

M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_55, © Springer-Verlag Berlin Heidelberg 2010

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drug reaction or dehydration until after the Hgb or HCT is checked. Intravenous fluid resuscitation may be enough if the bleeding is not over 15% of the blood volume, but some patients with more blood loss may require Hespan, Dextran, albumin, or blood to restore the blood volume. A low Hgb or HCT does not necessarily require transfusion. The patient’s clinical status is more important and if vital signs are stable, conservative measures such as volume replacement may be taken. The patient who has had an acute episode of bleeding and stabilizes with low Hgb or HCT may be followed for at least a week at which time the Hgb and HCT should start to rise. It may take a few weeks for the blood count to come back to normal, but usually the patient can resume normal activity after the Hgb reaches 8 g. If the bleeding continues and conservative measures do not work, surgical exploration may be necessary. This is more likely with other concomitant procedures such as abdominoplasty, since compression in the areas of liposuctioning will usually stop any bleeding from small vessels. Hematoma in the tissues can be treated conservatively with aspiration. This should be distinguished from bruising that requires no treatment. A hematoma that becomes a persistent untreated mass will form a seroma and then a chronic pseudocyst. The pseudocyst can be treated with aspiration followed by injection of an equal amount of room air. This will usually cause the walls to adhere to each other and prevent further accumulation of fluid.

M. A. Shiffman

55.2.4 Depressions (Grooves, Waviness) Excessive or superficial liposuction too close to the skin may result in depressions. (Fig. 55.1) Superficial liposuction should not get closer than 1 cm below the skin in most areas except the face and neck, and smaller cannulas (102°) 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 CPK) (c) Mucous membrane (conjunctiva, oropharynx) (d)  Renal (BUN or creatinine > 2 times normal) (e) Hepatic (bilirubin, SGOT, SGPT > 2 times n­ ormal) (f)  Hematologic (platelets < 1,00,000) 6. Negative results on the following studies (if obtained) (a) Blood, throat or cerebral spinal fluid (CSF) cultures

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(b) Serologic tests for Rocky Mountain Spotted ­Fever, Leptospirosis, measles Treatment consists of surgical debridement for necrosis, antibiotics, circulatory and respiratory care, anticoagulant therapy for disseminated intravascular coagulation, and immunoglobulin [47]. Experimental approaches have included the use of antitumor necrosis factor, monoclonal antibodies, and plasmapheresis.

55.4 Conclusions Complications of liposuction are best avoided when possible. The surgeon should be aware of the preventive methods and the available treatments for the various complications. Aggressive liposuction by removing very large amounts of fat and doing very superficial liposuction in order to get more skin retraction can be associated with increased complications. It may be preferable to remove less than 5,000 of fluid and fat at each sitting and repeat the procedure at a later date than perform large volume or megaliposuction. The risk of complications may then be reduced.

References   1. Illouz Y-G. Principles of the technique. In: Illouz Y-G, editor. Body sculpturing by lipoplasty. Edinburgh: Churchill Livingstone; 1989. p. 67.   2. Fournier P. Autologous fat for liposuction defects during and after surgery. In: Shiffman MA, editor. Autologous fat transplantation. New York: Marcel Dekker; 2001. p. 233–42.   3. Saylan Z. Liposhifting: treatment of post liposuction irregularities. Int J Cosmet Surg. 1999;7(1):71–3.   4. Ross RM, Johnson GW. Fat embolism after liposuction. Chest 1988;93(6):1294–5.   5. Abbes M, Bourgeon Y. Fat embolism after dermolipectomy and liposuction. Plast Reconstr Surg. 1989;84(3):546–7.   6. Laub DR Jr, Laub DR. 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.   8. Scroggins C, Barson PK. Fat embolism syndrome in a case of abdominal lipectomy with liposuction. Md Med J. 1999; 48:116–8.   9. Bulger EM, Smith DG, Maier RV, Jurkovich GJ. Fat embolism syndrome: a 10-year review. Arch Surg. 1997;132(4): 435–9.

M. A. Shiffman 10. Estebe JP. From fat emboli to fat embolism syndrome. Ann Fr Anesth Reanim. 1997;16(2):138–51. 11. Paris DM, Koval K, Egol K. Fat embolism syndrome. Am J Orthop. 2002;31(9):507–12. 12. Arakawa H, Kurihara Y, Nakajima Y. Pulmonary fat embolism syndrome: CT findings in six patients. J Comput Assist Tomogr. 2000;24(1):24–9. 13. Heyneman LE, Muller NL. Pulmonary nodules in early fat embolism syndrome: a case report. J Thorac Imaging. 2000; 15(1):71–4. 14. Ravenol JG, Heyneman LE, McAdams HP. Computed tomography diagnosis of macroscopic pulmonary fat embolism. J Thorac Imaging. 2002;17(2):154–6. 15. Parizel PM, Demey HE, Veweckmans G, Verstreken F, Cras P, Jorens PG, Schepper AM. Early diagnosis of fat cerebral embolism syndrome by diffusion-weighted MRI (starfield pattern). Stroke 2001;32(12):2942–4. 16. Dominguez-Moran JA, Martinez-San Millan J, Plaza JF, Fernandez-Ruiz LC, Masjuan J. Fat embolism syndrome: new MRI findings. J Neurol. 2001;248(6):529–32. 17. Richards RR. Fat embolism syndrome. Can J Surg. 1997; 40(5):334–9. 18. Kubota T, Ebina T, Tonosaki M, Ishihara H, Matsuki A. Rapid improvement of respiratory symptoms associated with fat embolism by high-dose methylprednisolone: a case report. J Anesth. 2003;17(3):186–9. 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):173–8. 20. Medical Board of California v Greenberg. Case No. 04-9776124, OAH No. L-1999020165, 1998. 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):562–5. 23. Gibbons MD, Lim RB, Carter PL. Necrotizing fasciitis after tumescent liposuction. Am Surg. 1998;64(5):458–60. 24. Heitmann C, Czermak C, Germann G. Rapidly fatal necrotizing fasciitis after aesthetic liposuction. Aesthetic Plast Surg. 2000;24(5):344–7. 25. Rhee CA, Smith RJ, Jackson IT. Toxic shock syndrome associated with suction-assisted lipectomy. Aesthetic Plast Surg. 1994;18:161–3. 26. Umeda T, Ohara H, Hayashi O, Ueki M, Hata Y. Toxic shock syndrome after suction lipectomy. Plast Reconstr Surg. 2000;106(1):204–7. 27. Cawley MJ, Briggs M, Haith LR Jr, Reilly KJ, Guilday RE, Braxton GR, Patton ML. Intravenous immunoglobulin as adjunctive treatment for streptococcal toxic shock syndrome associated with necrotizing fasciitis: case report and review. Pharmacotherapy 1999;19(9):1094–8. 28. 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. 29. Bircher AJ, Surber C. Anaphylactic reaction to lidocaine. Aust Dent J. 1999;44(1):64. 30. Kennedy KS, Cave RH. Anaphylactic reaction to lidocaine. Arch Otolaryngol Head Neck Surg. 1986;112(6):671–3.

55  Prevention and Treatment of Liposuction Complications 31. Zimmerman J, Rachmilewitz D. Systemic anaphylactic reaction following lidocaine administration. Gastrointest Endosc. 1985;31(6):404–5. 32. Anibarro B, Seoane FJ. Adverse reaction to lidocaine. Allergy 1998;53(7):717–8. 33. de Jong R. Titanic tumescent anesthesia. Dermatol Surg. 1998;24:689–92. 34. Shiffman MA. Medications potentially causing lidocaine toxicity. Am J Cosmet Surg. 1998;15(3):227–8. 35. Fodor PB. Lidocaine toxicity issues in lipoplasty. Aesthet Surg J. 2000;20(1):56–8. 36. Lombardi AS, Quirke TE, Rauscher G. Acute median nerve compression associated with tumescent fluid administration. Plast Reconstr Surg. 1998;102(1):235–7. 37. Grazer FM, de Jong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg. 2000;105(1):436–46. 38. Teillary v Pottle, New Hanover County (NC), Superior Court. In: Medical malpractice verdict, settlements & experts 1996;12(8):47 and 1996;12(11):46. 39. Talmor M, Fahey TJ, Wise J, Hoffman LA, Barie PS. Largevolume liposuction complicated by retroperitoneal hemorrhage: management principles and implications for the

563 quality improvement process. Plast Reconstr Surg. 2000; 105(6):­2244–8. 40. Gilliland MD, Coates N. Tumescent liposuction complicated by pulmonary edema. Plast Reconstr Surg. 1997;99(1): 215–9. 41. Pitman GH. Tumescent liposuction complicated by pulmonary edema. Plast Reconstr Surg. 1997;100(5):1363–4. 42. Shiffman MA. 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 venous thromboembolism. Int Angiol. 1992;11:151. 44. Estate of Marinelli v Geffner, Ocean County (NJ), Superior Court. In: Medical Malpractice Verdicts, Settlements Experts. 1999;16(10):54–5. 45. Rhee CA, Smith RJ, Jackson IT. Toxic shock syndrome associated with suction-assisted liposuction. Aesthetic Plast Surg. 1994;18(2):161–3. 46. McCormick JK, Yarwood JM, Schlievert PM. Toxic shock syndrome and bacterial superantigens: an update. Annu Rev Microbiol. 2001;55:77–104. 47. Baracco GJ, Bisno AL. Therapeutic approaches to streptococcal toxic shock syndrome. Curr Infect Dis Rep. 1990; 1(3):230–7.

Comparison of Blood Loss in SuctionAssisted Lipoplasty and Third-Generation Ultrasound-Assisted Lipoplasty

56

Onelio Garcia Jr.

56.1 Historical Perspective One of the most important recent advances in body contouring has been the significant decrease in the blood loss associated with the current lipoplasty procedures [1]. The relatively small amount of blood currently present in ultrasound-assisted lipoplasty (UAL) aspirate has significantly increased the safety and efficacy of lipoplasty procedures. This is particularly important in the high volume aspirations or those involving the posterior trunk. When first introduced in the early eighties, “dry suction lipoplasty” was associated with 20–45% blood losses of the volume aspirated [2, 3]. The use of epinephrine-containing wetting solutions decreased the blood loss to 8–30% of the aspirated volume [3, 4]. The introduction of the superwet technique using a 1:1 ratio of the infiltrating solution to the expected volume of aspirate and the tumescent technique, which required up to a 3:1 ratio of the infiltrate to the expected aspirate, significantly lowered the blood loss associated with these procedures to a single digit percentage of the aspirate volume [1, 5, 6]. The use of UAL further decreased the blood in the aspirate [1, 7–10], and it has been documented that the third-generation internal solid probe UAL yields even a cleaner aspirate, with a higher percentage of supernatant fat [1, 11, 12]. Recently, Garcia and Nathan [1] documented minimal blood loss in the aspirate using the third-generation solid probe UAL in a series of thirty consecutive

O. Garcia Jr. Division of Plastic Surgery, University of Miami, Miller School of Medicine, 3850 Bird Road, Suite 102, Miami, FL 33146, USA e-mail: [email protected]

female patients undergoing VASER-assisted lipoplasty of the posterior trunk. Suction-assisted lipoplasty (SAL) remains the most common cosmetic surgical procedure performed in the United States with over 4,00,000 cases performed last year [13]. In spite of its well documented clinical advantages [7, 11, 14–18], UAL is currently performed in only 17.4% of the lipoplasty cases [13]. Several factors such as increased costs [19], increased surgical time [14, 15, 20], technical difficulty with a steep learning curve [21], greater potential for complication [14, 22–24], complex machinery, and instrumentation certainly play a role in the infrequent use of UAL in body contouring. The introduction of the third-generation internal ultrasound devices has addressed many of the drawbacks associated with the early UAL devices; however, in spite of the well-documented clinical efficiency and safety of the new devices [1, 11, 12, 16–24], the use of UAL has decreased almost 4% in the past 3 years [25].

56.2 Blood Loss in Lipoplasty Current lipoplasty aspirate contains fat, saline, blood, epinephrine, and local anesthetics when utilized. How much blood is there in the aspirate? What is the source of the blood loss? What is the cause of postoperative ecchymosis? These are all valid questions regarding blood loss in lipoplasty. Figure 56.1a shows two rectangular markings of the same dimensions that correspond to the mirror image areas overlying the mid abdominal perforators. SAL was performed on one of these areas and VAL on the other. The same volume and composition of the wetting solution was infiltrated into both areas. The same

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O. Garcia Jr.

a

b

c

d

e

f

Fig. 56.1  (a) Two rectangular markings of the same dimensions that correspond to the mirror image areas overlying the mid abdominal perforators. (b) The exposed superficial epigastric vessels. (c) Injection of the ISOVUE-300 (Iopamidol 61%)

contrast into the vessels. (d) The abdominal specimen subjected to mammography. (e) Vascular perforators intact following SAL. (f) Vascular perforators also intact following VAL

56  Comparison of Blood Loss in Suction-Assisted Lipoplasty and Third-Generation Ultrasound-Assisted Lipoplasty

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Fig. 56.2  Reverse contrast studies in areas of extensive lipoplasty reveal that most of the extravasation occurs in the microvasculature between the perforators and the subdermal plexus

number of passes were applied to each area with a 3 mm suction cannula over a timed 3 min interval. Figure 56.1b shows the exposed superficial epigastric vessels and Fig. 56.1c depicts the injection of the ISOVUE-300 (Iopamidol 61%) contrast into the vessels. The abdominal specimen was subjected to mammography as depicted in Fig. 56.1d. The radiological contrast study of the intact abdominal perforators in an area subjected to extensive SAL is depicted in Fig. 56.1e, while similarly intact abdominal perforators are seen in Fig. 56.1f that corresponds to the VAL area. Garcia [26], found that major perforators were not injured during extensive SAL or VAL. Reverse contrast studies in areas of extensive lipoplasty reveal that most of the extravasation occurs in the microvasculature between the perforators and the subdermal plexus (Fig. 56.2). Dermal biopsies of the skin overlying the areas subjected to extensive superficial SAL and VAL did not reveal significant injury to the subdermal plexus. This was true as long as there was adequate infiltrating solution present in the superficial tissues and the deep dermis had not been subjected to “end hits” [26]. Superficial SAL when performed with proper technique, does not appear to cause significant damage to the subdermal plexus. However, there appeared to be a greater amount of free blood in the dermal biopsies of skin overlying the SAL area, as opposed to the dermal biopsies of skin overlying the VAL area (Fig. 56.3). An adjacent area

Fig. 56.3  (a) A greater amount of free blood in the dermal biopsies of the skin overlying the SAL area. (b) Control dermal biopsy that is almost bloodless. (c) Dermal biopsies of the skin overlying the VAL area with no bleeding

568

Fig. 56.4  High power magnification of the deep dermis purposely subjected to an “end hit” in the area is highlighted by the arrow

was used for control and had the same wetting solution infiltrated into the tissues but was not subjected to lipoplasty. The control dermal biopsy is almost bloodless and closely resembles the VAL area dermal biopsy. Subdermal plexus injuries are frequently caused by “end hits” as a result of improper lipoplasty technique. These “end hits” are a direct result of thrusting the suction cannula or ultrasound probe perpendicularly into the deep dermis. High power magnification of the deep dermis purposely subjected to an “end hit” in the area is highlighted by the arrow in Fig. 56.4. Note the significant amount of free blood within the dermis in the area of the trauma. “End hits” result in significant postoperative ecchymosis in the area of the dermal injury. They can be avoided by keeping the axis of the suction cannula parallel to the deep dermis when performing superficial lipoplasty. Appropriate use of pulsed solid probe UAL in superficial lipoplasty also avoids injury to the subdermal vessels (Fig. 56.5) which depicts a high power magnification of an intact subdermal vessel in an area subjected to extensive superficial VAL. The microvascular extravasation (Fig. 56.2) depicts the source of free blood in the tissues following lipoplasty and the most likely cause of the postoperative ecchymosis seen in these patients. These vessels are highly responsive to epinephrine when given adequate time for the vasoconstrictive effects of the drug to take place. The author has found that 14 min following the infiltration of the tissues with the epinephrine solution is an adequate time interval for the vasoconstrictive effects to take place. It is surgical time well invested since proper vasoconstriction can significantly reduce the blood loss associated with lipoplasty procedures.

O. Garcia Jr.

Fig. 56.5  High power magnification of an intact subdermal vessel in an area subjected to extensive superficial VASER-assisted lipoplasty

Increased blood loss with sometimes severe postoperative ecchymosis can also occur in lipoplasty patients who take aspirin or certain anti-inflammatory drugs that interfere with platelet function. An adequate medication history is vital in prospective lipoplasty patients so that all the drugs that could interfere with the coagulation process can be stopped preoperatively.

56.3 Comparison of Blood Loss in Third-Generation UAL and SAL 56.3.1 Methods Twenty-seven consecutive female patients ranging in age from 18.75 to 54.5 years, with an average age of 33.3 years, underwent SAL that included contouring of their back and posterior flanks. The patients in this group had a body-mass index (BMI) range of 18.8 to 30.1, with an average BMI of 24.3. The volume of the wetting solution used was approximately a 1:1 ratio of the infiltrate to aspirate and consisted of 1 mg. of epinephrine 1:1,000/L of normal saline. There was approximately a 15-min interval between the infiltration of the wetting solution and the suction phase, to allow for the vasoconstriction effects of the epinephrine to take place. Mercedes-type lipoplasty cannulas (3.5 and 3 mm) were employed and general anesthesia was used in all the cases. The aspirate corresponding to the back and posterior flank lipoplasty was kept separate and sent for analysis. The total volume of the aspirate ranged from

56  Comparison of Blood Loss in Suction-Assisted Lipoplasty and Third-Generation Ultrasound-Assisted Lipoplasty

a

569

b

Fig. 56.6  (a) Typical bloody aspirate from the back and posterior flanks during lipoplasty. (b) Less bloody aspirate with VASER-assisted lipoplasty aspirate from the back and posterior

flanks. Copyright by The American Society for Aesthetic Plastic Surgery Inc. [1]. It is the author’s own work and is reproduced by permission of Elsevier Publishing

1,250 to 5,250 mL, with an average of 3,366 mL. The back and posterior flank portion of the aspirate volume ranged from 450 to 1,400 mL with an average of 768 mL. Thirty consecutive female patients ranging in age from 18.5 to 70.3 years, with an average age of 41.9 years, underwent third-generation internal UAL using the VASER device, (Sound Surgical Technologies, Louisville, CO). The BMI range in this group was 19.6–33.7, with an average BMI of 25.6. All of these cases included lipoplasty of the back and posterior flanks and the aspirate corresponding to those anatomical areas was kept separate and sent for analysis. The total volume of aspirate ranged from 1,600 to 9,200 mL with an average of 5,755 mL. The portion of the aspirate volume corresponding to the back and posterior flanks ranged from 800 to 4,200 mL with an average of 2,450 mL. For the purposes of this study, the wetting solution used also consisted of 1 mg. of epinephrine1:1,000/L of normal saline at a 1:1 ratio of the infiltrate to aspirate. (The author usually uses a ratio of 3:1 infiltrating solution to aspirate). There was also an approximately 15-min interval following the infiltration of the wetting solution to allow for the vasoconstriction effects to take place. For the purposes of this study, the amplitude setting on the device was 90% continuous VASER mode applied for approximately 1 min per 100 mL of the infiltrating solution used. (The author’s usual VASER times are approximately 50–60% longer). The VASER probes used were mainly 3.7-mm 2-ring and 2.9-mm 3-ring. VentX cannulas (Sound Surgical Technologies); 3.7 and 3.0-mm cannulas were used in all of the VAL cases. All of these cases were performed under general anesthesia. Informed consent was obtained from all the patients in both the SAL and VAL groups. The aspirate from the

back and posterior flanks was chosen for analysis because these are tight, fibrous, anatomic areas that are associated with greater blood loss during lipoplasty procedures. The aspirate from the back and posterior flanks was bloody during lipoplasty, whereas with VAL, it was less bloody. (Fig. 56.6). (whereas it was less bloody with VAL)Note that both the SAL and VAL aspirates are approximately of the same volume; however, the VAL aspirate is typically cleaner and contains a higher percentage of supernatant fat. The aspirate analysis consisted of complete blood counts after separation of the fat. This was performed by an independent laboratory on a Beckman Coulter LH 750 blood analyzer (Fullerton, CA). Normal values on this analyzer are 12–16 g/dL for hemoglobin and 37–47% for hematocrit. Since the main purpose of the study was to document and compare the blood loss in the lipoplasty aspirates, only the hemoglobin and hematocrit values of the complete blood counts were evaluated.

56.3.2 Results The hematocrit values for the SAL aspirate ranged from 2 to 7.2%, with a mean of 3.98%, compared to the VAL aspirate, which had a hematocrit range of 0.3–1.1%, with a mean value of 0.61%. The hemoglobin content of the SAL aspirate ranged from 1.2 to 3.4 g/dL, with a mean of 2.23 g/dL. By comparison, the hemoglobin content of the VAL aspirate ranged from 0.01 to 0.9 g/dL, with a mean of 0.3 g/dL. The complete raw data is depicted in Table 56.1. The mean hemoglobin content of the SAL aspirate was 7.5 times greater than that in

570

O. Garcia Jr.

Table 56.1  The complete raw data Patient Age (year) Total aspirate (mL) SAL VAL SAL VAL

Back/flank aspirate (mL) SAL VAL

Hematocrit (%) SAL VAL

Hemoglobin (g/dL) SAL VAL

 1

39.75

42.3

3,650

5,600

1,000

2,200

2

0.7

1.8

0.2

 2

37.5

48.5

3,000

5,450

800

2,000

2.4

0.6

2

0.6

 3

31

34.75

2,850

6,800

700

2,850

2.4

0.4

1.4

0.1

 4

42.3

18.5

2,600

3,600

650

1,200

3.2

0.7

1.2

0.2

 5

20.5

21

3,250

4,250

700

1,950

2

0.5

1.3

0.1

 6

28.75

29.8

4,100

6,600

950

2,800

2

0.5

2

0.2

 7

24.3

42.5

4,450

7,450

700

3,450

3.5

0.7

3.4

0.2

 8

19.5

47.6

1,800

4,900

500

2,300

7.2

0.5

2.7

0.1

 9

49.1

24.3

3,100

6,200

650

2,500

4

0.5

1.4

0.7

10

30.9

56.75

4,750

5,150

900

2,200

2.3

0.7

2.4

0.1

11

36.5

19.5

4,250

3,450

800

1,250

4.5

0.8

3

0.1

12

41.3

46

3,900

6,000

650

2,300

5.5

0.4

1.8

0.2

13

34.75

70.3

1,600

3,850

450

1,450

3

0.5

2.1

0.7

14

54.5

36.9

3,950

9,200

700

4,000

4.5

0.9

2.2

0.1

15

38.3

48.5

4,400

4,800

1,100

2,050

4.2

0.9

2.3

0.2

16

22.2

62.1

1,250

3,000

450

900

4.8

1.1

1.8

0.2

17

32.2

57

4,700

4,600

1,400

2,150

3

0.8

2.8

0.4

18

39

41.3

5,250

8,400

1,250

3,650

5.5

0.5

2.9

0.1

19

43.5

49.75

3,400

5,000

650

2,200

4.9

0.5

2.7

0.1

20

23.75

20.25

2,200

5,750

600

2,250

4.1

0.5

1.9

0.2

21

28

63.9

3,950

1,600

800

800

5.2

0.7

2.8

0.8

22

18.75

47.25

2,450

6,050

700

2,800

6.7

0.3

3.2

0.2

23

40.25

31.1

4,000

8,750

850

4,200

4.7

0.8

2.7

0.2

24

27.8

60.5

4,900

4,800

1,200

1,800

3

0.3

1.8

0.9

25

21.2

30.9

2,150

8,400

500

3,950

4

0.6

2.2

0.1

26

48.5

29.8

1,800

7,750

450

3,700

4.9

0.5

2.4

0.3

27

25.3

50.5

3,200

6,100

650

2,350

4.1

0.6

2

0.2

28

–

47.5

–

5,500

–

2,250

–

0.3

–

0.1

29

–

22.3

–

8,250

–

3,800

–

0.8

–

0.6

30

–

58

–

5,400

–

2,200

–

0.6

–

0.8

Total

–

–

90,900

1,72,650

20,750

73,500

107.6

18.2

60.2

9

Mean

33.3

41.97

5,755

768.5

2,450

3.98

0.61

2.23

0.3

Variance

1,949

0.0372

0.3483

0.0648

SD

1,3961

0.1929

0.5902

0.2546

Copyright by The American Society for Aesthetic Plastic Surgery Inc. [1]. It is the author’s own work and is reproduced by ­permission of Elsevier Publishing

56  Comparison of Blood Loss in Suction-Assisted Lipoplasty and Third-Generation Ultrasound-Assisted Lipoplasty

the VAL aspirate. The mean hematocrit value for SAL aspirate was 6.5 times higher than that in the aspirate from the VAL group. VAL yielded a more consistent aspirate with significantly less dispersion of both hemoglobin and hematocrit values (Fig. 56.7). The data were subjected to an independent t-test for statistical significance. The t-score for the hematocrit values was +13.13 and for hemoglobin +16.31 ,with p values 75% cell damage

There was a tendency to use the syringe to collect smaller amount of fat and the suction machine to retrieve larger amounts of fat with some surgeons using both methods. Needle

No. of surgeons (7)

13 gauge

2

14 gauge

5

Cannula size

No. of surgeons (12 surgeons)

2 mm

3

3 mm

7

4 mm

4

>4 mm

2

57.6 Insulin Some physicians have added insulin to the fat in preparation for transplantation [12, 40, 41]. The theory is that insulin inhibits lipolysis. Sidman [42] found that insulin decreases lipolysis. Hiragun et al. [43] stated that theoretically, insulin may induce fibroblasts to pick up the lipid lost and become adipocytes. Chajchir et al. [44] found that the use of insulin did not show any positive effect on adipocyte survival during transplantation, compared to fat not prepared with insulin.

57.7 Centrifugation

When a needle was utilized to obtain fat, the 14 gauge was most often the choice. When cannula was utilized to obtain fat, the 3 mm was most often the choice. Some surgeons used multiple sizes. 2. Treatment of the Harvested Fat Ten surgeons washed the fat, five strained it, while six decanted the excess blood and fluid. Some surgeons used more than one method. 3. Reinjection of Fat No surgeon used a cannula to reinject the fat. When using a needle to reinject, six surgeons used more than one gauge.

Needle (gauge)

The 16 and 18 gauge needles were most often used for the reinjection of fat. At the present time, small cannulas have been devised with relatively blunt tips which can be used for reinjection without the problem of bleeding in the recipient area.

Reinjection of fat No. of surgeons

14

5

15

2

16

7

18

7

Some physicians centrifuge the adipose tissue to remove blood products and free lipids to improve the quality of the fat to be injected [40, 45, 46]. Asken [9] stated that his “method of reducing the material to be injected to practically pure fat is to place the fat-filled syringe with a rubber cap (the plunger having been previously removed and kept in a sterile environment) into a centrifuge. The syringe is then spun for a few seconds at the desired rpm and the serum, blood, and liquefied fat collects in the dependent part of the syringe…” Toledo [39] reported that, “for facial injection, we spin the full syringes for 1 min….. in a manual centrifuge (about 2,000 rpm), eject the unwanted solution, and transfer the fat…” Uebel [47] centrifuged autologous fat at 10,000 rpm for 10 min in order to obtain a “fat-collagen graft.” The centrifuged material on histologic examination showed cell residues, collagen fibers, and 5% intact fat cells. The material is absorbed at a slow rate and maintains contour and volume for 18–24 months. A new graft procedure is always performed to achieve a more permanent result. Chajchir et al. [44] centrifuged 1 cc of bladder fat pad from mince (both at 1,000 rpm for 5 min and 5,000 rpm

15

13

14

Ersek [27]

Fournier [32]

Fragen (Personal communication, 1996)

50

520

12

96

43

Johnson [24]

Krulig [35]

Lewis [36]

Newman [37]

Pinski [38]

3

14

13

3

4

3

4

2–3

3

4

4

2–4

3–6

Shiffman

+

+

+

+

+

14

13

14

14

Wash with saline

Spin and decant or wash with Lactated ringers

Decant, wash with lactated ringers if necessary

Sterile trap decanted

Luken’s strap irrigated with lactated ringers

Cleansed with saline

Caught in Trap, Strained and washed with physiologic solution

Sifted and Washed

Remove blood

Wash with saline

Agitated with wire wisk, cleansed Eagles medium suspended in physiologic solution (Tsol)

Decanted

Liquid absorbed with a cottonoid

Strained in coarse gauze pad

No washing

Strained

Excess fluid drained

Irrigated with lactated ringers micro deposition

Drain through Cheesecloth for micro deposition

Treatment

Harvesting fat reinjection Cannula (mm)

3–6 +

+

20 mL

+ (low)

>50 mL

Machine

Needle (gauge)

Toledo [39]

Skouge [22]

37

Illouz [34]

Hin [33]

24

+

Carraway [30]

Chang [31]

+

Bircoll [29]

Billie [28]

+

70

Asadi [1]