Liposuction, formally known as suction-assisted lipectomy, represents one of the most commonly performed aesthetic surgical procedures worldwide. Primarily a body contouring procedure, liposuction utilizes vacuum suction to remove subcutaneous adipose tissue in certain anatomical areas. Of note, liposuction should not be portrayed as a weight loss procedure. Since the inception of liposuction in the early 1980s, liposuction has undergone a series of technological and procedural advancements (e.g., lasers, ultrasound), some of which will be discussed herein.
It is important to have an intimate understanding of the orientation and architecture of subcutaneous fat before one can become proficient in liposuction. Clinically, it is easy to appreciate that fat is divided into the superficial fat layer and the deep fat layer, which is usually separated by a superficial fascia system like the Scarpa fascia in the trunk or the superficial musculoaponeurotic system (SMAS) in the face. One must appreciate that while the superficial layer is often targeted, it is also the one most prone to liposuction-related complications, namely contour irregularities or vascular compromise to the overlying tissue. These complications can be avoided by limiting aggressive superficial liposuction and ensuring cannula ports are not directly engaged with the overlying skin.
The consistency of the fatty tissue can be divided into two groups:
The zones of adherence (ZOA), where the subcutaneous tissue adheres to the fascia of the underlying muscle, should be avoided during liposuction to decrease the risk of contour irregularities. ZOA include:
In discussing the indications for liposuction, one must take into account that liposuction most often is considered an aesthetic procedure and, as such, is completely elective. Therefore, the burden of proof for demonstrating that the patient is a viable candidate for the procedure lies with the surgeon.
A thorough medical history should be taken in all patients, as well as a social history screening for alcohol and tobacco use.
Since the inception of liposuction, the cannulas used have encountered several evolutions. Once sharp and single holed, today's preferred cannulas are blunt with multiple holes placed near the tip. Blunt tip cannulas help lower the risk of inadvertent puncturing into the pleura, peritoneum, or deep spaces of the neck and help lower intraoperative blood loss as well.
The cannula functions to avulse adipose cells from the fibrous stroma separating the fat, which allows the fat to enter the suction system. Accordingly, a cannula with a larger diameter (and surface area) causes more stromal disruption and fatty avulsion; however, the larger diameter cannulas also cause more indirect trauma and blood loss than smaller diameter cannulas. Again, the type and size of the cannula used vary based on surgeon preference and location of proposed liposuction. For a more detailed discussion of such preferences, the reader is referred to further reading for the various types of liposuction and their respective cannulas, including body liposuction, submental liposuction, face liposuction, and liposuction for fat grafting.
The choice of suction device for liposuction (manual syringe versus suction machine) depends on the amount of fat to be removed and its intended use. For instance, if the harvested fat is planned to be used for autologous fat grafting, one would generally avoid high-pressure suction devices to maximize the viability of the harvested fat. So too, consider using a manual syringe for liposuction if only a small portion of fat needs to be harvested (e.g., for facial fat grafting). The liposuction aspirate system is a delicate balance of physical forces, with the cannula demonstrating the highest point of resistance to flow in any negative pressure liposuction system.
One technique that owes its origins to liposuction is the use of a wetting solution (i.e., tumescent solution) that is composed of a diluted lidocaine and epinephrine mixture infiltrated subcutaneously prior to the actual liposuction being performed. The use of the tumescent solution, which is nearly ubiquitous in all liposuction procedures, should be administered using a 1 to 1 ratio of the wetting solution to projected lipoaspirate volume. For example, if 50 ccs of fat are planned to be harvested from the abdomen for autologous fat grafting, then 50 cc of the wetting solution should be administered before liposuction is performed.
Body liposuction requires an astute anesthesiologist to help mitigate any fluid losses and shifts that are incited by the procedure. It has been demonstrated in the literature that approximately 30% of the wetting solution that is infiltrated may be removed during liposuction; however, the remaining wetting solution can shift into the intravascular space postoperatively.
Thankfully, guidelines exist for intraoperative fluid management for our anesthesia colleagues assisting with liposuction.
There are a variety of techniques that are preferred for the actual liposuction procedure, though basic principles include:
The debate continues as to whether the addition of either UAL or LAL adds any benefit to traditional SAL procedures. A recent review of the literature, however, would suggest that, for the most part, LAL and UAL offer no demonstrable benefits over SAL to recommend a change in practice patterns. With that being said, the authors did report that LAL and/or UAL may offer the following benefits in select scenarios:
Patients must be counseled before the procedure that some complications are definitely expected, such as postoperative bruising. The following are some common complications that the patient and the team should be mindful about:
Liposuction is one of the most popular cosmetic surgical procedures. The significance of understanding the basic core principles of the procedure is valuable for the entire health care team involved. The greater one understands the processes at work, the better one is equipped to manage these surgical patients, improve aesthetic outcomes, and, even more importantly, address complications that may be encountered during the course of their treatment and recovery.
The entire interprofessional team is involved in managing the outcome of liposuction patients. In one instance of the literature over a span of 10 years, consisting of 1,645 liposuction patients, 1.6% of patients filed a complaint in regards to their care. [Level 4]
As stated previously, the surgeon, anesthesiologist, and nurses all have a role to play in the successful execution of a liposuction procedure and maintaining a satisfied patient. Many of the areas in which the healthcare team can work together to improve outcomes come in the postoperative period to assuage the common complaints of the poor aesthetic outcome, complications, and the quality of care which the patient receives.
Perhaps the most important role for the interprofessional team during the window of intervention is the application of sequential compression devices in the postoperative care area, and the encouragement of early ambulation as soon as the patient is ready. Furthermore, as with all surgical procedures, the healthcare team must instruct the patient on care once they are discharged.
For liposuction, many surgeons opt for tight compressive dressings in the postoperative recovery phase to minimize edema and ecchymosis. The nursing team in the postoperative area must be adamant in reiterating these instructions to the patient and understanding that the patient is well aware of these instructions and has the capacity to carry out these instructions.
The nursing staff is usually the last healthcare team facet to see the patient prior to discharge, and a sense of interprofessional communication must be maintained throughout the team. Reviewing home medications and those which should be abstained from during the recovery phase and those which should be immediately started must be reviewed. Incision and drain care must be reviewed with the patient as well.
High-risk surgical patients must be monitored closely overnight by a nursing member of the interprofessional team. High BMI, large volume liposuction of that over 5000 mL, a procedure in length greater than six hours, combined procedures, high-risk comorbidities such as coronary artery disease, or any inter-operative aberrant vital signs are all criteria for admission to an observation unit for overnight monitoring by a skilled nursing member with continuous care.
As is standard procedure before discharge, the healthcare team must certify that the patient is stable for discharge and has a well-entrusted environment and caretaker at home as well. Furthermore, for the management of complications and outcomes, it has been well documented in the literature that the details of the surgical procedure and any unforeseen intraoperative surgical events be well documented. Thorough counseling by the interprofessional team in the postoperative window can greatly enhance patient satisfaction and safety.
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