Liposuction

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<strong>Liposuction</strong>: A Gynecologist’s Perspective evaluation of very subjective surgical results (Figures 1-3, page 00). Anesthesia Tumescent anesthesia revolutionized liposuction as compared to the earlier techniques performed under general anesthesia. The local approach to anesthesia has brought liposuction out of the operating room and into the office in carefully selected cases. To achieve FOCUSPOINT‣ Safety with tumescent anesthesia is well established but requires careful attention to dose. tumescent anesthesia, a dilute solution of lidocaine, epinephrine, and sodium bicarbonate is introduced by needle or cannula into the tissue to be treated. This infiltration anesthetizes the tissue, constricts blood vessels for improved hemostasis, expands the adipose treatment area for improved safety, and provides postoperative analgesia. In vitro evidence demonstrates that lidocaine is actually bactericidal for organisms isolated from skin lesions. 5-7 Lidocaine appears to have antibacterial effects for both gram-negative and grampositive bacteria, and in gram-negative bacteria, such as Escherichia coli and Pseudomonas aeruginosa, lidocaine appears to act synergistically with antibiotics by depolarizing the bacterial cell membrane and increasing cell membrane permeability. 6 Though in vivo studies have been mixed, supportive findings in vitro may explain the very low rate of infection associated with procedures utilizing this technique. Safety with tumescent anesthesia is well established but requires careful attention to dose. The lipophilic properties of lidocaine and the vasoconstriction of epinephrine facilitate the recovery of much of the administered dose with the aspirated adipose tissue. An infiltration of up to 45 to 50 mg/kg of lidocaine is generally considered a safe threshold for dosing tumescent anesthesia. The mixture used is typically 1000 mg of lidocaine (2 x 50-cc bottles), 1 mg of epinephrine (1 ampule of 1:1000), and 10 mEq sodium bicarbonate per liter. 8,9 Lidocaine toxicity is rare, but includes cardiac arrhythmias and central nervous system effects including seizures. Surgical complications associated with liposuction include hematoma, seroma, infection, embolic events, tissue necrosis, and contour irregularities. Any office or facility providing liposuction must be fully prepared for such complications. Despite the potential risk, a 2002 review of 66,000 cases using tumescent anesthesia identified a complication rate of 0.68 per thousand and no deaths. 10 Another review including 15,336 patients undergoing tumescent liposuction did not identify any serious complications. 11 The Procedure Preparation for a liposuction procedure begins with the patient selection process and thorough counseling about risks and expectations. Laboratory testing varies but often includes a complete blood count, prothrombin time, partial thromboplastin time, hepatitis panel, and HIV screening. Vitamin K is sometimes administered preoperatively to limit ecchymosis. Perioperative antibiotic prophylaxis is typical and may be continued for several days postoperatively. In addition to tumescent anesthesia, the surgeon’s choice of narcotic and anxiolytic may be administered. We use oral dosing and do not establish intravenous access. Patients are marked prior to infiltration of tumescent fluid to highlight focal areas of adipose tissue to guide aspiration efforts. Skin preparation and draping are performed as per standard surgical aseptic technique. Small 1- to 42 The Female Patient | VOL 37 MARCH 2012
<strong>Liposuction</strong>: A Gynecologist’s Perspective FIGURE 4. Typical incision placement for abdominal and fl ank liposuction. Photo courtesy of Dr Eric Swisher. 3-mm incisions using a scalpel or skin punch are used for infiltration access and cannula insertion. These incisions are strategically placed to allow optimal cosmesis and access to the targeted adipose tissue (Figure 4). Once tumescent anesthesia is established and the target area is again surgically prepped, 2- to 4-mm cannulas are introduced into the adipose layer through the small skin incisions to aspirate the unwanted fat. Cannulas are inserted and withdrawn using a gentle to-and-fro motion in a fan-like pattern to create tunnels in the adipose layer and collapse the protuberant tissue. FOCUSPOINT‣ Shallow subcutaneous aspiration is also ill-advised to avoid the creation of visible superficial tracts or focal devascularization. Various techniques assist in the safe aspiration of fat with a smooth contour in the final result. The angle and depth of entry is important to avoid perforation of the underlying fascia or peritoneum. Cannula insertion is generally parallel to the underlying fascial plane. With the tumescent technique and a conscious patient, the intact sensitivity of the deeper tissue planes adds to the safety of the procedure. Shallow subcutaneous aspiration is also ill-advised to avoid the creation of visible superficial tracts or focal devascularization. The art that defines a successful liposuction procedure is the balance between maximal removal of unwanted adipose tissue and avoidance of overly aggressive or misdirected aspiration evidenced by contour irregularities or subcutaneous grooves. Postoperative Care Postoperative care includes oral analgesics (hydrocodone or oxycodone) and a compression garment. Compression promotes drainage, limits bruising and swelling, and facilitates tissue retraction. For 24 hours following tumescent anesthesia and liposuction, patients should expect a significant volume of serosanguinous drainage. This drainage may in fact contribute to the low post-procedural infection rates in tandem with the use of prophylactic antibiotics and the bacteriostatic properties of lidocaine. Over the next 1 to 2 weeks, tissue edema creates induration, which obscures the surgical results but does contribute to the beneficial retraction attributed to the healing process. The final result is best-appreciated 2 to 3 months postoperatively. Subtle improvements may continue for several months thereafter. Financial Considerations Incorporating liposuction into our gynecologic practice has had no impact on malpractice insurance premiums, and this appears typical of the industry. From a risk-analysis standpoint, liposuction imparts less malpractice exposure than most gynecologic and 44 The Female Patient | VOL 37 MARCH 2012
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Liposuction

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