Liposuction

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Liposuction: A Gynecologist’s Perspective elective procedures. 1 Nevertheless, more women, as evidenced by the growing number of cosmetic procedures being performed in this country, are seeking information and access to these cosmetic interventions. Often, it is the woman’s gynecologist whom she first approaches to inquire about cosmetic therapy. Even with this rapidly growing consumer demand, there are a relatively small number of practitioners certified to provide these procedures. 2 Obstetricians and gynecologists are the women’s health physicians from whom many women still seek both specialty and primary care. Is there a justified role for cosmetic therapies in the scope of the practicing ObGyn? Market FOCUSPOINT‣ An ACOG task force on the role of the ObGyn in cosmetic procedures did not clearly define the responsibilities of the individual practitioner. demand certainly argues the increasing importance of this question. Should education and training be offered in residency programs? If so, will this expanded scope of clinical practice include additional skills to train providers in counseling patients about such relevant issues as self-esteem, body image, peer-pressure, and a greater understanding of sexuality? These questions lack easy answers. As pointed out in an editorial by Laube, 2 an ACOG task force on the role of the ObGyn in cosmetic procedures did not clearly define the responsibilities of the individual practitioner. Instead, a review of cosmetic practice among gynecologists only poses additional challenges, such as ethical issues and financial conflicts. Ethical dilemmas arise from both the marketing of these practices and the financial incentives of elective procedures, despite the patient-driven demand for such services. As posed by Laube, should these financial incentives warrant condemnation if performed within the appropriate ethical framework with informed decision-making? Ours is a market-driven economy with cosmetic procedures increasing by over 800% during the last 15 years. Over two-thirds of the general American public approves of cosmetic interventions, and one-third of women report considering or having had cosmetic surgery that included Botox injections, microderm abrasion, laser hair removal, and liposuction. 2 In recent years, liposuction has become one of the most common cosmetic surgery procedures in the United States. The American Society for Aesthetic Plastic Surgery reported liposuction was performed on 176,863 patients in 1997. This number increased to 283,735 in 2010. 3 Techniques Much of the popularity of liposuction lies in the evolution of techniques that have made lipectomy or lipoplasty more accessible and affordable. Fischer, an Italian gynecologist, introduced modern liposuction in 1974. The tumescent technique was brought to the procedure by dermatologists, Klein and Lillis, in 1985. 4 Innumerable alterations in the technology have followed, but many of the basic principles of tumescent anesthesia and negative pressure lipectomy introduced by Klein and Lillis remain. Liposuction generally involves the use of fenestrated blunt metal cannulas and suction to disrupt and remove subcutaneous adipose tissue. As the technique has evolved, cannulas have become smaller (1-4 mm) and various methods of disruption have become available. Earlier approaches to liposuction included manual disruption of the adipose tissue septations with a rasped cannula followed by aspiration of the disrupted fat. More recently, energy-assisted methods 40 The Female Patient | VOL 37 MARCH 2012 All articles are available online at www.femalepatient.com
Swisher and Weiss (eg, power-assisted liposuction) using rotation, reciprocation, ultrasound, pulsatile water infiltration, and laser have combined disruption and aspiration into a single step for improved results and efficiency. The use and advantages of the specific modalities is beyond the scope of this article. No particular method has demonstrated clinical superiority, so surgeon preference dictates the technique implemented. Patient Selection Patient selection is critical to a successful liposuction procedure or any cosmetic procedure for that matter. Though larger patients are seeking to meet contouring goals with liposuction and succeeding, results are generally less than ideal. Liposuction is not a means to weight loss but rather intended for contour improvement. Patients at or near an ideal body weight with localized areas of concerning adipose tissue are much better candidates than the obese. That said, a patient’s goals and expectations are paramount in preoperative planning. Even an ideal liposuction patient is a poor candidate for the procedure if his or her expectations are unrealistic. Likewise, an obese patient who simply wants a reduced pannus or better-fitting clothing may very well find suboptimal liposuction results satisfying. The surgeon must thoroughly explore and evaluate the cosmetic patient’s goals to ensure they correlate with a realistic outcome for the procedure. Common treatment sites include the abdomen, flanks, thigh, and the submental fat pad. To minimize complications, medical conditions that affect healing and surgical risk, such as diabetes, hypertension, lupus, coagulopathies, and tobacco use among others, are contraindications to liposuction procedures in most cases. Liver dysfunction, which could affect lidocaine metabolism, is also a concern when screening patients. Age, skin elasticity, and striae do not affect safety but will certainly influence potential results and should be reviewed with the patient preoperatively. Preoperative and postoperative photographs are critical to documentation, patient education, and a more objective FIGURE 1. Left: Preoperative abdominal view for abdomen and fl ank liposuction. Right: Postoperative result following power-assisted liposuction. Photos courtesy of Dr Eric Swisher. FIGURE 2. Left: Preoperative abdominal view with pannus which did not require abdominoplasty. Right: Postoperative following power-assisted liposuction productive of 3,500 cc of adipose supernatant. Photos courtesy of Dr Eric Swisher. FIGURE 3. Left: Preoperative oblique view prior to liposuction. Right: Postoperative following power-assisted liposuction of the upper abdomen, lower abdomen, and fl ank. Photos courtesy of Dr Eric Swisher. The Female Patient | VOL 37 MARCH 2012 41
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