Abstract

“Second Thoughts” focuses on ways in which aesthetic surgeons have modified or even dramatically changed their techniques over time to achieve optimal results. Contributors are Aesthetic Society members and other recognized experts.

Gerald H. Pitman, MD, New York, NY, is a board-certified plastic surgeon and an ASAPS member.

Gerald H. Pitman, MD, New York, NY, is a board-certified plastic surgeon and an ASAPS member.

Over the last few years I have made several changes in my liposuction technique to improve cosmetic results and enhance patient safety.

Refining Cosmetic Results

Circumferential liposuction

For many patients, circumferential liposuction creates a more complete and satisfying contour reduction than liposuction of isolated local fat deposits. On the torso, simultaneous liposuction of the back, flanks, and anterior abdomen frequently provides a superior result to isolated liposuction of the anterior abdomen (Figure 1). In the lower extremity, the lateral thighs and lower buttocks are most likely to have large localized fat deposits; but fat may also be diffusely distributed in the anterior, medial, and posterior thighs. Circumferential treatment of these areas as well as the more distal calves and ankles produces dramatic girth reduction and a more optimal result (Figure 2).

Figure 1

A, C, and E, Preoperative views of a 44-year-old woman. B, D, and F, Postoperative views at 6 months after UAL of the back and flanks, suction-assisted lipoplasty (SAL) of the anterior abdomen, hips, and circumferential thighs, and excision of a segment of lax lower abdominal skin surrounding a low transverse scar from a previous gynecologic procedure. (Preoperative scar lies within hairline and does not show in photograph.) Overall, total volume of aspirate was 4500 mL. Patient's preoperative weight was 150 lb; postoperative weight was 140 lb. Note overall girth reduction in both torso and thighs. Abdominal skin resection has improved appearance of pubic area, as well as abdomen.

Figure 1

A, C, and E, Preoperative views of a 44-year-old woman. B, D, and F, Postoperative views at 6 months after UAL of the back and flanks, suction-assisted lipoplasty (SAL) of the anterior abdomen, hips, and circumferential thighs, and excision of a segment of lax lower abdominal skin surrounding a low transverse scar from a previous gynecologic procedure. (Preoperative scar lies within hairline and does not show in photograph.) Overall, total volume of aspirate was 4500 mL. Patient's preoperative weight was 150 lb; postoperative weight was 140 lb. Note overall girth reduction in both torso and thighs. Abdominal skin resection has improved appearance of pubic area, as well as abdomen.

Figure 2

A, C, and E, Preoperative views of a 49-year-old woman. B, D, and F, Postoperative views at 6 months after SAL of the abdomen and UAL of the hips, knees, and circumferential thighs. A total volume of 5050 mL was removed. Patient's preoperative weight was 142 lb; postoperative weight was 133 lb. The overall contour reduction of the anterior abdomen is limited by musculoaponeurotic laxity and the patient's poor posture. (Lower abdominal scar is from a previous gynecologic procedure.) In the lateral view, however, there is a striking diminution in anterior-posterior dimension, resulting from extraction of fat from the anterior and posterior thighs.

Figure 2

A, C, and E, Preoperative views of a 49-year-old woman. B, D, and F, Postoperative views at 6 months after SAL of the abdomen and UAL of the hips, knees, and circumferential thighs. A total volume of 5050 mL was removed. Patient's preoperative weight was 142 lb; postoperative weight was 133 lb. The overall contour reduction of the anterior abdomen is limited by musculoaponeurotic laxity and the patient's poor posture. (Lower abdominal scar is from a previous gynecologic procedure.) In the lateral view, however, there is a striking diminution in anterior-posterior dimension, resulting from extraction of fat from the anterior and posterior thighs.

I have altered patient positioning for patients undergoing circumferential liposuction because I find that these patients are more easily treated when they are in the prone and supine position rather than in the lateral decubitus position.

Use of ultrasound-assisted lipoplasty

My current indications for ultrasound-assisted lipoplasty (UAL) are based on reducing the surgeon's work and facilitating a smoother, more complete extraction of fat.

  • Treatment of posterior torso or thighs. In most patients the subcutaneous fat on the posterior trunk and thighs is tightly bound in a thickened fibrous stroma. Conventional liposuction in these areas requires increased mechanical effort on the part of the surgeon to extract fat from the supporting fibrous framework. UAL fragments the enveloping fibrous tissue, as well as the fat, so that fat is removed with less effort by the surgeon.

  • Treatment of gynecomastia. Fat in the breasts in men (and some women) is encased in a fibroglandular stroma that is relatively resistant to fat extraction by conventional liposuction. As in the posterior torso and thighs, UAL reduces the surgeon's work.

  • Secondary liposuction in scarred areas. Scarring of the subcutaneous fascial system can make fat extraction more difficult and tedious. By mechanically disrupting the scar and interstitial fat, UAL reduces work in scarred areas.

  • Large-volume liposuction (≥4000 mL). Large-volume fat removal involves vigorous, sustained physical effort. Use of UAL enables the surgeon to concentrate more on sculpting and shaping the tissues and less on the sometimes fatiguing mechanical effort of fat extraction.

Although UAL adds about 25% to operative time, in many cases it permits a smoother, more regular fat extraction, with less likelihood of postoperative contour irregularities. I have abandoned UAL on the anterior abdomen because I found the 10% seroma rate unacceptable.

UAL requires larger access incisions than conventional liposuction to accommodate the larger probe and skin protection sleeve. Incisions for UAL are therefore limited to the inferior gluteal crease, the groin crease, the posterior knee crease, and the midline of the back.

Lower abdominal skin segment resection

In the past 5 years, I have increasingly used this very simple, low-morbidity procedure as an adjunct to abdominal liposuction for the patient who has loose, lower abdominal skin without upper abdominal skin laxity or significant muscle flaccidity. The technique consists of excision of a transverse ellipse of skin and subcutaneous tissue of the lower abdomen, sometimes encompassing a previous scar but, in all cases, leaving the patient with a low transverse scar. The procedure rarely adds more than 20 minutes to overall operative time and does not increase the patient's recovery time (Figure 1).

Enhanced Patient Safety

Tumescent technique

The tumescent method provides hemostasis, local analgesia, and safe, gradual fluid replacement. It remains the gold standard for patient safety and comfort. 13 I have recently reduced lidocaine dosage and volume of subcutaneous fluid injection to increase clinical margin of safety.

Reducing lidocaine dosage by reducing lidocaine concentration

Starting in 1990, I performed all cases by preinjecting a solution of lidocaine, 0.05% (500 mg/L) with epinephrine, 1:1,000,000 (1 mg/L). More recently, I have found that reducing lidocaine concentration to 0.04% (400 mg/L) still provides supplemental intraoperative analgesia plus a sufficient level of postoperative analgesia so that narcotics are rarely required in the recovery room. The solution of lidocaine 0.04% with epinephrine 1:1,000,000 (1021 mL) is conveniently made with the following recipe:

Lidocaine 2% 20 mL 
Epinephrine 1:1000 1 mL 
Lactated Ringer's solution 1000 mL 
Lidocaine 2% 20 mL 
Epinephrine 1:1000 1 mL 
Lactated Ringer's solution 1000 mL 

The reduced lidocaine concentration permits use of larger volumes of infiltration with less risk of lidocaine toxicity. When using the 0.04% solution, I limit the total lidocaine dose to 50 mg/kg.

For patients having only one or two small areas treated while under pure local anesthesia, I increase the lidocaine concentration to 0.08% (800 mg/L) with epinephrine 1:1,000,000 to produce complete local anesthesia at the operative site. When using the 0.08% solution, I limit total dosage of lidocaine to 25 mg/kg.

Reduction of relative injected volume in larger cases

For small- to moderate-size aspirations (<3000 mL), infiltration volume (with the 0.04% solution) averages twice the volume of aspirate.3 Most of these cases are treated on an ambulatory basis, and I want to provide maximum postoperative local analgesia. Therefore the operative site is injected with sufficient volume to cause turgidity of the tissues. The complete three-dimensional saturation of the target tissues produces a very effective analgesia. Total injected volume is usually ≤6000 mL and well tolerated by the patient.

For patients having moderate- to large-volume aspirates (≥3000 mL), I limit subcutaneous injection to a volume equal to 1 to 1.5 times aspirate to avoid subjecting these patients to increased risk of fluid overload (GH Pitman, 1998, written communication). Although the resultant reduced saturation of the target tissues results in diminished hemostasis and analgesia, I prefer to accept slightly increased blood loss and a less perfect analgesia as the price of preventing a possible episode of fluid overload. The reduced subcutaneous fluid injection also minimizes the likelihood of persistent postoperative tissue edema from fluid retention at multiple operative sites.

Combined procedures

When I combine liposuction with other body contouring procedures (breast reduction, abdominoplasty, thigh lift, etc), I inject tumescent solution into all operative sites. Blood loss is dramatically diminished for the open procedures, and surgery is more efficient because time spent obtaining hemostasis is decreased. For added safety, I limit overall operating time to less than 5 hours for combined procedures.

Eliminating lidocaine from face and neck injections in combined procedures

If facial cosmetic surgery is performed simultaneously with body liposuction, I eliminate lidocaine from the facial infiltration to obviate the possibility of rapid lidocaine absorption from the richly vascularized face and neck tissues. Rapid lidocaine absorption from the face and neck can result in dangerously elevated levels of serum lidocaine.

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