Tumescent liposuction

Overview

Liposuction is a surgical operation that removes fat from particular parts of the body using a suction method, such as the belly, hips, thighs, buttocks, arms, or neck. These regions are also contoured through liposuction. Liposuction is also known as lipoplasty and body sculpting.

Tumescent liposuction is a procedure that uses local anaesthetic to numb substantial amounts of subcutaneous fat, allowing liposuction.

While the suctioned fat cells are gone for good, total body fat recovered to pre-treatment levels within a few months. This is despite sticking to the prior diet and exercise routine. While some of the fat returned to the treated area, the majority of the additional fat was found in the abdominal area.

Tumescent liposuction definition

In the United States, the most frequent cosmetic operation is liposuction. Liposculpture, lipoplasty, and suction-assisted lipectomy are other terms for it. The ideal candidate is physically active and consumes well-balanced meals, but is unable to remove a well-localized fatty deposit that frequently appears to entail a hereditary vulnerability.

Previously, the operation necessitated blood transfusions due to considerable blood loss in the aspirate. Dr. Jeffrey Klein, a dermatologic surgeon, is credited with developing the tumescent method, which allows liposuction to be performed under local anaesthetic while limiting blood loss and the hazards associated with general anesthesia. Liposuction using the tumescent approach has had a great safety record since its introduction.

Tumescent liposuction may remove fat from practically any region of the body safely, including the face, neck, chin, breast, stomach, hips, flanks, back, inner and outer thighs, buttocks, knees, calves, and ankles. It is used to treat excessive underarm perspiration and enlarged male and female breasts, as well as to remove lipomas, or benign fatty tumors.

Structure of fat

Subcutaneous fat is organized into lobules that are divided by septae. Blood veins, nerves, and lymphatics are all found within the fibrous septae. Each lobule is made up of fat cells, which are largely made up of triglycerides and take up practically the whole cell, pushing the nucleus to one side. It has been demonstrated that during the initial weight gain in any individual, the size of the fat cell increases.

With persistent weight gain, the number of fat cells increases as mesenchymal stem cells are transformed to fat cells. Diet and exercise have been demonstrated to reduce fat cell size but not fat cell quantity, a condition known as "resistant fat."

Advantages of tumescent liposuction

The several advantages of the tumescent approach include the following:

There is less blood loss.
It is not essential to refill intravenous fluids.
Bacteriostatic lidocaine has been shown to reduce the risk of infection.
Tumescence amplifies flaws, therefore the necessity for a further operation may be reduced.
Lipid-soluble lidocaine is suctioned out along with the aspirated fat.
Absorption is reduced by vasoconstriction.
Epinephrine may enhance cardiac output, which speeds up the hepatic metabolism of lidocaine.
The duration of the anesthetic action might extend up to 24 hours.
Lidocaine can be safely administered at doses of up to 45 mg/kg, and in certain cases, much more.

Indications

Liposuction is often used to reduce localized fatty deposits, which appear to be linked to a hereditary vulnerability.

There are other circumstances in which tumescent liposuction may be beneficial. Lipoma removal, Madelung disease, axillary hyperhidrosis, axillary bromhidrosis, hematoma evacuation, pseudogynecomastia, and the contentious phased liposuction for morbidly obese patients are among them.

Contraindications

Contraindications are as follows:

Patient expectations that are unrealistic
Patient's physical condition is deteriorating
Patient who went on a crash diet right before the consultation
Obesity with morbidity (megaliposuction controversial due to higher risk of mortality from fluid shifts)

Technique

Patient evaluation

The patient's expectations must be reasonable. The optimum individual is only 10 to 20 pounds overweight. Patients should be aware that, while the look of cellulite may improve, it is not expected to diminish. The patient must be in decent physical condition. A nutritious, well-balanced diet is essential for sustaining surgical outcomes and supporting optimum recovery during the convalescence period.

Crash diets taken just before a consultation to be considered a candidate for surgery may increase the risk of problems due to electrolyte imbalances or nutritional deficiencies. The doctor should be convinced that the patients' motivations are sound and that their dissatisfaction with their appearance is not a symptom of a more serious problem in their lives, such as marital or work problems.

Some patients have tried to diet several times throughout their lives but have always regained their weight. Patients who get liposuction frequently report a reduction in appetite for several months after the procedure. This diminished appetite may give incentive for the patient to safeguard his or her investment in the future by not overindulging.

Furthermore, some patients who are obsessed with losing that final few pounds may jeopardize their quality of life by overexerting themselves at the expense of time that could be spent with their family, friends, or at work. Because the bulge may be resistant to exercise-induced volume decrease, people may increase their efforts in vain, detracting from other aspects of their lives.

The highest quantity of fat that may be safely removed by tumescent liposuction is likely to be around 4–5 litres. In general, it is best to avoid so-called megaliposuctions because they are connected with difficulties. With the elimination of more fat, the danger of adverse effects increases. Generally, different locations, such as the belly and the thigh or buttock, are not combined in a single session. However, both buttocks and both thighs can be treated in a single session. If the patient wants to remove fat from more than one location or requires more than 4–5 litres of fat, the operation can be repeated at any time after two weeks.

A full medical history should always be collected, with special attention paid to a history of bleeding diathesis, emboli, thrombophlebitis, infectious illnesses, poor wound healing, and diabetes mellitus. Before undergoing liposuction, patients with a history of these disorders must be checked and cleared by a physician. Liposuction is not recommended in individuals who have significant cardiovascular illness, severe coagulation abnormalities such as thrombophilia, or who are pregnant.

Prior abdominal procedures, such as caesarean sections, that result in scarring, should also be noted in the patient's history. A thorough drug history is required. Because lignocaine is metabolized by the liver, medications that compete with it for cytochrome P450 enzyme system metabolism or displace lignocaine from plasma proteins can raise lignocaine blood levels and produce lignocaine toxicity.

Procedure

A solution comprising a local anesthetic and the medication epinephrine will be injected into the locations of excess fatty deposits that have been identified. The solution fills the fatty layer of the skin, causing it to enlarge and firm up, giving the surgeon more control when contouring the region. The solution also causes blood vessels to temporarily contract, minimizing blood loss during the treatment and bruising, swelling, and discomfort afterward.

After injecting the solution, the surgeon creates a tiny incision in the skin and inserts a cannula, which is a short, slender tube attached to a vacuum-like machine, into the fatty layer. The fat is sucked through the tube into a sterile collection system using back and forth motions. After that, an elastic compression garment is worn to assist the skin in contracting and healing.

Using a tiny, curved hemostat, the site is enlarged and pretunneled into the subcutaneous tissue. A blunt infusion catheter is then introduced through this tunnel into the prospective surgical location, and tumescent anesthesia is given radially to the deepest layer, then more superficially. An electric-powered peristaltic pump is used to infiltrate anesthesia. Some doctors prefer to infiltrate with a spinal needle without concern for specific insertion locations.

Although the addition of hyaluronidase may expedite anesthetic dispersion, it may also allow for higher absorption, varied peak levels, and a longer duration of anesthetic action. Corticosteroids are also avoided since they have not been shown to reduce postoperative discomfort and may increase the risk of infection.

Cross-tunneling, or inserting the cannulae from two distinct axes (typically perpendicularly), produces a smoother outcome and is frequently utilized during tumescent local infiltration. Periphery mesh-undermining is a technique in which cannulae are placed beyond the topographic map of the surgical region without suction aspiration in order to merge the afflicted area with the peripheral normal contour. This approach aids in avoiding a severe step-off shape at the surgical site's edge.

Liposuction cannulae are inserted into insertion sites while the nondominant hand constantly watches the positioning and trajectory of the cannula. This "brain hand" also allows the surgeon to feel the progress of the region and identify the surgical endpoint.

Once the desired outcome is achieved on the surgical table, the physician can have the conscious patient stand up to see whether any regions were missed, and then quickly return the patient to the table to complete the procedure. When patients were under general anesthesia or sedation, this approach reduced the frequency of subsequent operations compared to the first wet technique. There is an orthostatic table that allows surgeons to shift their patients who are under general anesthesia into a "standing" posture to assess their outcomes, however this table has yet to gain popularity among American surgeons.

Some surgeons suture the insertion sites immediately after surgery, whereas others leave them to heal with second goal to allow for greater drainage, less bruising, and less inflammation. For the first several days after surgery, compression garments and absorbent pads are used. Depending on the surgeon, this can range from a few days to many weeks.

Many patients report that the clothes improve their comfort. The early swelling is caused by the anesthesia, and when this subsides, surgical edema appears in the first two weeks. As the swelling subsides, the size of the garment is frequently reduced. Depending on the patient's comfort, the patient may be able to resume physical activity within a few days. Mild exercise is preferable to bed rest in the early postoperative phase because it allows for improved fluid drainage and resorption and reduces blood flow stasis in the extremities.

Postoperative dressing and follow-up

The postoperative dressing is a critical step in tumescent liposuction. An significant aspect of the tumescent process is that part of the fluid is still left behind at the conclusion of the treatment, ensuring anaesthesia in the immediate postoperative period and reducing the need for strong oral analgesics. This fluid drains away after 3–5 days, allowing the adits to mend by secondary intention rather than suture.

Tight pressure bandages are required to guarantee that the tumescent fluid drains properly. In the first two days, two layers of pressure dressing (called bimodal compression) are used to ensure tight compression. On the first postoperative day, the dressings are removed, and the adits are reopened if necessary to ensure appropriate drainage. Inadequate drainage raises the risk of panniculitis, secondary infection, and irregularity.

Antibiotics and analgesics are maintained postoperatively. After three days, the pressure in the dressing is reduced and maintained for at least two weeks. The patient is instructed to return for a three-day follow-up for daily dressing. While the patient can return to regular sedentary work in 1–2 days, exercise and excessive effort should be avoided for at least 10 days.

Risks

If all of the necessary protocols are followed, tumescent anaesthesia is a surprisingly safe technique. Side effects have been quite infrequent.

Because of the constant anaesthetic fluid in the tissue, postoperative pain is negligible in the first two days. All that is necessary are mild oral analgesics such as paracetamol. Mild soreness may be felt at the location of adits for 3–5 days. An antibiotic cream (such as fucidic acid or mupirocin) may be recommended for use at the adit sites.
Postoperative oedema over dependent regions (such as the legs and genitals) is possible because to the inflammation generated by aspiration motions. It is kept to a minimum by utilizing tiny cannulae and appropriate postoperative dressings.
Postoperative syncope is common and is caused by the rapid reduction of pressure while removing the tight bandages. It is readily prevented by removing the bandage in the supine posture and instructing the patient to slowly rise. Mild sensitivity over the adit sites is also to be expected.
Postoperative ecchymosis is possible, although it normally goes away on its own within a week. This is prevalent in hypertensive people, thus blood pressure management is critical.
If the drainage is not done properly, it might cause diffuse discomfort and induration.
Panniculitis and fat necrosis are uncommon, but can develop in diabetics. As a result, good diabetes management is critical.
If sufficient aseptic measures are taken, postoperative infection is rare.
Seromas are cystic swellings that develop as a result of severe superficial fat suction. They are more prevalent with ultrasound-assisted aspiration, but the author saw them in only two individuals.
Irregularity and asymmetry can emerge if the quantities of fat aspirated in various regions varies and pressure garments are not correctly applied. This is frequent in the upper chest and abdomen. It is also frequent in males treated for gynaecomastia and in individuals who have had big cannulas used to swiftly remove fat.
Pigmentation over adit scars is frequent in Indian patients, although none of our patients had keloids.

Nonsurgical Alternatives

Nonsurgical adipose reduction therapies, such as cryolipolysis (CoolSculpting, from Zeltiq Aesthetics, Inc.), ultrasonic reduction therapy (UltraShape, from Syneron Medical Ltd.), and electromagnetic stimulation of underlying muscle contractions, have emerged in recent years (Emsculpt, by BTL Industries, Inc.). Previous attempts at adipose reduction utilizing external laser sources failed to provide long-term fat reduction.

Cryolipolysis

Freezing has been demonstrated to destroy fat cells. However, because the temperature necessary for adipocyte necrosis is greater than that required for skin freezing, the skin is retained while the fat is damaged in this treatment. Several applicators have been designed to fit various body locations, with therapy consisting of putting one or more applicators to the desired fat reduction region.

Treatment takes at least one hour each applicator, and the treatment can be repeated every 1-2 months if necessary. Most patients experience mild to moderate discomfort during the first 5-10 minutes of treatment, after which they are numb for the remainder of the session.

Cryolipolysis is a noninvasive, low-risk technique. Ultrasonographic tests have indicated that one CoolSculpting treatment results in a 20% decrease in adipose tissue volume.

Ultrasound

The UltraShape ultrasound therapy is normally painless and is administered in a course of three biweekly sessions. The findings are not as substantial as those obtained with cryolipolysis.

ThermiTight radiofrequency

Injectable radiofrequency, or Thermitight, is a relatively novel procedure that has been used in place of or in addition to liposuction. Following the injection of local anesthetic, a tiny cannula is introduced into the skin through a needle puncture. Radiofrequency radiation is used to heat the fat, causing it to dissolve while simultaneously causing adipocyte necrosis (cell death)

For a few weeks, ThermiTight causes swelling and bruising; compression garments are needed, same like in liposuction.

Conclusion

Liposuction is the surgical removal of subcutaneous fat using aspiration cannulae inserted through tiny skin incisions and suction. Liposuction surgery, suction-assisted lipectomy, suction lipoplasty, fat suction, blunt suction lipectomy, and liposculpture are all synonyms used in the literature.

Liposuction is one of the most prevalent cosmetic procedures performed nowadays. Dermatologists currently execute around one-third of these operations in the United States and have been at the forefront of many innovations in liposuction, particularly in the domains of ambulatory surgery and local anaesthetic.