Patient Consultation
Liposuction is one of the most commonly performed procedures, but the limitations and advantages of the procedure must be explained to the patient. Alternative procedures should be discussed, which usually include abdominoplasty. This will help to guide the patient in making an informed decision when choosing liposuc- tion of the abdomen versus abdominoplasty. There are many different ways and techniques of performing li- posuction. The vibrotumescent liposuction technique has many advantages.
It is explained to the patient that liposuction has a rapid recovery time and the patient can usually return back to a normal daily routine after only a few days and there is much less morbidity and mortality associated with liposuction in contrast to abdominoplasty. A much more sculpted appearance can be obtained with lipo- suction than with a conventional abdominoplasty since when an abdominoplasty is performed, many surgeons prefer not to liposuction the flanks and the sides of the abdomen. Liposuction of the lower abdomen and the upper abdomen allows sculpturing of the lateral areas to a degree that has a properly esthetic appearance in com- bination with the patient’s hips and lateral thighs.
a b
Fig. 20.1. a Preoperative 43-year-old female with excess fat of the abdomen and loose lower abdominal skin. b One week postoper- atively following vibroliposuction of abdomen with excellent skin retraction and no bruising
nique, good skin retraction can be achieved depending on the type skin and the age of the patient (Fig. 20.1).
Even stretch marks of the skin can be improved (Fig. 20.2). The vibrotumescent liposuction also has minimum bruising and minimal blood loss during and after surgery (Figs. 20.1, 20.2). Minimal blood loss dur- ing surgery and minimal bruising after surgery is also partly dependent upon preoperative care instructions.
The vibrotumescent technique can achieve better re- sults than with conventional tumescent liposuction even with the addition of internal ultrasound and/or external ultrasonic assisted liposuction. There are few- er complications, skin necrosis, and skin burn. One other advantage is improvement of cellulite. Although there may be claims that liposuction can treat the cellu- lite problem, most patients having vibroliposuction have noticed improvement in their cellulite, decreasing by over 50 %. The vibrotumescent technique appears to break up the trabecular attachments of the skin to the underlying structures, which is the primary cause of the cellulite formation. Another advantage of the vibro- tumescent technique is the even distribution of the tu- mescent fluid, which is infiltrated into the subcutane- ous fat of the areas undergoing liposuction. This will al-
a b
Fig. 20.2. a Preoperative 28-year-old male with excess fat of abdomen and hips associated with marked striae of lower abdomen.
b One week postoperatively following vibroliposuction. Note marked improvement of striae of lower abdomen and no bruising
Fig. 20.3. Vibration (percussion massaging) of the abdominal wall after infiltration of tumescent fluid results in emulsifica- tion of the fat
low the surgeon to do proportionate liposculpting of the body.
Vibration of the area after infiltration of the tumes- cent fluid causes emulsification of the fat cells (Fig. 20.3).
It is obvious that the fat cells are more disrupted and in- jured. There is also more oil present in the aspirate. The pathology report from liposuction with vibration shows 80 % more disrupted and disfigured fat cells.
20.2
Surgical Technique
To do liposuction surgery, the procedure starts from the preoperative room taking the appropriate photos, and carefully marking the areas of liposuction to be done.
The most elevated areas are marked at the center as well as the depressed areas, but using a different color mark- ing pen. This is to avoid liposuctioning the wrong areas.
At surgery the patient is thoroughly prepped with betadine solution. There are some surgeons who be-
Fig. 20.4. Massaging the abdominal areas with the vibration machine over a sterile towel
lieve that prepping the patient for liposuction or even using sterile gloves to perform liposuction is not neces- sary due to the bactericidal effect of the lidocaine pre- sent in the tumescent fluid. It is not true that tumescent fluid will prevent infection. Make sure to prep the pa- tient with betadine rather than take the chance of hav- ing a complication or infection. It is far better to take a few extra minutes to prep the patient for a sterile sur- gery. Tumescent fluid is injected slowly and dispersed evenly into the subcutaneous fatty layer. The tumescent fluid consists of 1,000 cc lactated Ringer’s with 2 mg epinephrine and 500 mg of lidocaine. The usual tumes- cent fluid injected to aspiration is 1 : 1. The percussion massaging machine (Model: PA-1, HoMedic Inc., Com- merce Township, MI) is used to massage each area for 5 min (Fig. 20.4) following tumescent infiltration.
178 20 Vibrotumescent Liposuction of the Abdominal Wall
ing sure not to penetrate too deeply and injure vital or- gans. In the case of liposuction of the upper abdomen it is critical to use the non-dominant hand to push down on the ribs as the cannula passes in the fatty layer above
Fig. 20.5. Even pressure applied to abdominal wall with non-dominant hand to palpate the cannula tip
Fig. 20.6. Pressure on the lower chest wall with the non-dominant hand allows the cannula to pass easily over the ribs
domen checking for asymmetry and any fatty lumps that need to be corrected (Fig. 20.8).
Foam padding is applied with an abdominal binder, making sure there is even compression to the abdomen.
Fig. 20.7. Do not compress the tissue with the hand while performing liposuction. This allows uneven suctioning of the fat
Fig. 20.8. Pinching small areas of the skin and fat following liposuction allows recognition of asym- metry and fatty lumps
The liposuction incision sites are left open with 4 × 4 s applied. This will allow for free drainage of the fluid that is infiltrated into the area. The patient should be forewarned about the drainage so that bed sheets and furniture can be protected. Free drainage decreases the chance of seroma formation and infection and allows a faster recovery. It is important to make sure there is no kink or folding in the foam and the abdominal binder.
20.3
Postoperative
Postoperatively the patient is told to either lie down flat, sit up straight, or stand up to avoid folding the gar- ment. If the garment is folded, this will result in a fold in the skin that can result in a seroma or induration of the area, which can be difficult to treat (Fig. 20.9). This de-
fect with subcutaneous fibrosis requires the use of ul- trasound treatments (3 mHz for 15 min) to the area twice weekly for 16 sessions. Medrol DosPak should be used at the start of therapy and medication with a non- steroidal anti-inflammatory drug (NSAID) continued until the fibrosis has subsided.
The patient is seen on the first postoperative day to correct any kinking in the garment and padding and to guide the patient to use the correct posture. All the dressings and the foam are changed. The patient is ad- vised to walk as often as possible and told to make sure there is no folding in the binder.
On the third postoperative day the patient is again seen and the foam removed. The patient is allowed to take a shower but following the showers must immedi- ately reapply the abdominal binder. Baths are not al- lowed because all the liposuction incision sites are still not properly healed.
180 20 Vibrotumescent Liposuction of the Abdominal Wall
a b
Fig. 20.9. a Preoperative patient with lipodystrophy of abdominal wall. b Postoperatively the patient developed an indentation and subcutaneous fibrosis in the lower abdomen from a fold in the garment
On the 10th postoperative day abdominal exercise and sit-ups are begun. The number of exercises is slowly and gradually increased every week. The abdominal binder is used continuously for the next 4 – 6 weeks depending on the patient age, the skin texture, and the degree of loose skin. The patient is seen again at 4 – 6 weeks.
20.4 Discussion
The vibrotumescent technique emulsifies the fat, allow- ing the fat to be removed more easily. There is less bleeding and postoperative bruising when combined with low vacuum and proper foam padding with a gar- ment postoperatively.
