Unsatisfactory Results of Liposuction

Unsatisfactory Results of Liposuction Editor s note: My thanks to the moderator, Joseph P. Hunstad, MD (board-certified plastic surgeon and SPS member, Charlotte, NC), and to panelists Richard. D mico, MD (board-certified plastic surgeon and SPS member, Englewood, NJ); Luiz S. Toledo, MD (boardcertified plastic surgeon and SPS member, São Paulo, razil); and Peter. Vogt, MD (board-certified plastic surgeon and SPS member, Minneapolis, MN), for sharing their opinions and clinical experiences. Dr. Hunstad: The first patient, a young woman concerned with the fullness of her neck, was treated with liposuction. Photographs show platysma bands and an unnatural, overcorrected appearance of the neck (Figure 1). Dr. D mico, would you discuss isolated liposuction of the face and neck? Joseph P. Hunstad, MD Dr. D mico: Facial fat is a precious resource, and rarely would I remove it. The neck, however, presents a different situation. I believe that judicious and conservative fat removal in the neck can be appropriate. Unfortunately, the postoperative Luiz S. Toledo, MD defect seen in this patient is all too common. When performing liposuction, we need to be careful to leave some subcutaneous fat in the neck. If this patient is dissatisfied with the results, I would consider performing a platysma band plication. t a later time, if needed, I would consider a filler procedure structural-type fat grafting would probably be my first choice. Dr. Hunstad: Dr. Toledo, does liposuction have a place when treating a young patient who is primarily concerned with her neck? Dr. Toledo: If the patient also has a fat face and you remove only the fat in the neck, the patient will end up with a very slim neck that is disproportionate to her face, which seems to be the case here. Therefore, when performing a corrective sling procedure, I use an endoscope, which enables me to pass a Gore-Tex strand from mastoid to mastoid, passing through the cervicomental angle. If there is excess skin, it should be managed with either superficial liposuction or skin removal. Richard. D mico, MD Peter. Vogt, MD Dr. Hunstad: Dr. Vogt, how would you treat a young person concerned about a full or fatty neck? Dr. Vogt: I agree with Dr. D mico. s we age, we lose fatty tissue in the face and neck regions. Therefore, I am conservative when removing fatty tissue. It is also important to maintain symmetry between the neck and face region. To correct this patient s problem, I would perform a neck lift, because I don t believe I would be able to correct it with only a platysma band repair. Dr. Hunstad: Would you consider removing buccal fat in this patient? Dr. Vogt: In this case, I would perform judicious facial liposuction. In my opinion, the removal of buccal fat pads is a tertiary procedure, which I reserve for patients with extremely round, disproportionate faces. The more experienced I become, the more conservative I am in regard to removing buccal fat pads. Dr. Hunstad: Dr. Toledo, do you have any comments with respect to aspirating facial fat? Dr. Toledo: I rarely aspirate fat above the jaw line. However, in some cases, I aspirate superficially from the jowls or above the nasolabial fold, or on rare occasions, from a cherubic face. Dr. Ulrich Kesselring from ESTHETIC S URGERY J OURNL ~ JULY/UGUST 1999 315

Figure 1. and, 38-year-old woman concerned with the fullness of her neck underwent liposuction in the submental region. Postoperative photographs reveal platysma bands and an irregular contour in the submental area. Switzerland performs an operation that involves the direct removal of fat and a Z-plasty to eliminate excess skin at the midline. I don t perform the procedure, but many surgeons seem to be satisfied with the results. Dr. Hunstad: The second patient is a 43-year-old woman who underwent circumferential liposuction of the thighs and inferior buttocks (Figure 2). fter the operation she expressed concern about the residual fullness in the lower gluteal crease area. Dr. Vogt, what does this deformity represent, how is it caused, and how would you correct it? Dr. Vogt: The subgluteal fold, or banana roll, that we see in this patient can occur for 2 reasons. First, in patients with unrecognized ptosis of the buttock, the banana roll tends to develop after surgery. You can recognize ptosis of the buttock before surgery by having the patient contract the buttock skin. If the skin does not elevate, the patient has buttock ptosis. Second, under-resection of fat in the immediate subgluteal fold can Facial fat is a precious resource, and rarely would I remove it. Richard. D mico, MD cause the deformity. ecause the incision is generally made in the gluteal fold, as was the case with this patient, access is difficult, and you may end up suctioning distal to or around it rather than in the immediate area, which can result in undertreatment. To avoid this problem, I use a small end-cutting cannula, 2 to 3 mm in diameter, so I can carefully sculpt the subcutaneous fat. To aid skin retraction, I tape the area for approximately 1 week after surgery. Dr. Hunstad: Dr. Toledo, would you comment on this patient? Dr. Toledo: I don t believe that this is a banana fold deformity. The banana fold is formed below the subgluteal fold. This patient appears to have a dropped buttock. It is important to carefully evaluate the preoperative photographs because some patients are initially seen with normal double folds. I believe that in this case too much deep fat was removed from the buttock itself, because when fat is removed superficially, the result is retraction of the lower third of the buttock. The fibrous support that keeps the buttock round and in place was eliminated with the deep suctioning of the lower third of the buttock. That is why the buttock dropped. This is a very difficult situation to correct. I usually remove the wedge of skin. Dr. Hunstad: Dr. D mico, what is your assessment of this patient? Dr. D mico: I agree that too much fat was suctioned too deeply. Some patients will accept this outcome the volume of their buttock has been reduced, and they feel better in their clothes. On the other hand, other patients are disappointed with the results and are willing to undergo 316 ESTHETIC S URGERY J OURNL ~ JULY/UGUST 1999 Volume 19, Number 4

removal of the skin even if that means being left with a scar. Dr. Hunstad: Dr. Vogt, how do you approach patients with skin laxity? Dr. Vogt: I examine the patient in a recumbent position. If I determine that the problem was over-resection rather than under-resection, I consider performing a belt lift. Patients are generally happy with the results. However, you have now performed a major operative procedure to correct a problem that could initially have been treated with a minor one. Dr. Hunstad: I have had good success in treating the banana fold by performing thorough, superficial suctioning. I have not had to resort to excision. Let s move on to the third patient, who was concerned about bilateral depressions in the trochanter region, where the entry site was located (Figure 3). The patient also has deformities of the buttocks, which were suctioned. Dr. Toledo, what is your assessment of this patient? Dr. Toledo: Over- or under-resection of fat are common problems of secondary liposuction. This patient has both. You can see that her flanks were underaspirated, so she has a good storage of fat for reinjection. I assume these irregularities in her buttocks are primary, and not the result of liposuction. The excess skin above the subgluteal fold may be due to excessive Figure 2. and, 43-year-old woman underwent circumferential liposuction of the thighs and inferior buttocks. fter the procedure, she was concerned with a residual fullness in the lower gluteal crease area. Postoperative photographs reveal a double roll in the gluteal crease. The more experienced I become, the more conservative I am in regard to removing buccal fat pads. Peter. Vogt, MD fat resection. The dimples in the trochanteric region appear to be secondary and are due to the use of an aspirator, which can potentially remove too much fat around the incision. y using a syringe, you avoid this problem, because suctioning stops when the syringe is full. I have had success treating irregularities in the buttock and trochanteric regions by using a V-tip dissector cannula, which creates tunnels into which I inject 3-mm threads of fat. I increase the number of threads until I have sufficiently filled the irregularities. Patients should understand that they may need to undergo a second and even third procedure to correct this problem. Dr. Hunstad: Please describe your technique in more detail. Dr. Toledo: Using a syringe, I harvest fat from wherever I can find it; no one site is better than another. If the fat comes out with blood, I gently wash it with Ringer s lactate not saline solution. I pass the fat from one syringe to the other, decant it, and centrifuge it at 1500 rpm for 1 minute. I then decant the excess fluid and slowly reinject the fat, using a cannula that is 3 mm wide. To avoid breaking the fat cells, it is best to inject on withdrawal. Dr. Hunstad: Do you inject into the underlying muscle to help fill the depression and to possibly get a better take of your fat grafting? Dr. Toledo: I inject approximately 50 to 60 ml of fat to fill a trochanteric depression such as the one seen in this patient, and I would probably need to inject deep. ecause the gluteus muscle begins at this site, not much fat can be injected there. I would inject fat mostly into the subcutaneous tissue but also into the gluteus muscle. Unsatisfactory Results of Liposuction ESTHETIC S URGERY J OURNL ~ JULY/UGUST 1999 317

Dr. Hunstad: Dr. Vogt, would you share your technique? muscle. Dr. D mico, would you discuss the severe problems seen in this patient? Dr. Vogt: First let me say that oversuctioning is a common problem. Most surgeons don t realize that the cannula continues to suction until it is removed, even if one takes his or her foot off the pedal. lipo-filling technique is the only way to treat this problem. I believe that fat needs to be extracted with a syringe. I don t believe that an aspirator, no matter where the pressure is set, will permit your fat graft to survive. Gentle handling of the lipo-filling material is critical. The smaller the needles that you use and the more tunnels you create, the better. Dr. Hunstad: Dr. D mico, would you share with us your experience in treating patients like this one? Dr. D mico: First of all, to avoid creating false hopes, I tell patients up front that it s unlikely that I am going to be able to completely restore their contour. When the skin is adherent to the deep tissues without the presence of subcutaneous fat, as is the case with this patient, correction is extremely difficult because there is no plane in which to layer the structural fat grafts. Therefore, you may need to inject into the muscle. This is one area in which ultrasound-assisted lipoplasty (UL) may be helpful, because if you cannot completely fill in the valley, you can at least improve the surrounding hills. Figure 3. and, 38-year-old woman complained of depressions in the hip area after undergoing liposuction. Evaluation revealed over-resection at the entry site and hip region and dimpling in the gluteus, where suctioning had been performed. Dr. Hunstad: Does anyone have experience treating similar depressions with undermining and manual manipulation of the surrounding fullness to fill the central depression? Dr. Toledo: When I suction close to the skin and create a depression, I can free the surrounding fat with a V-tip cannula. ut this is only effective in mild cases. Fat grafting should probably be the first option for more severe cases. Dr. Hunstad: The fourth patient is a 39-year-old woman who underwent large-volume liposuction that included internal UL (Figure 4). She had postoperative complications including hematoma, infection, and seromas, which left significant depressions, particularly over her left inner thigh, where the skin is now adherent to the underlying Dr. D mico: This case highlights some of the critical issues surrounding large-volume liposuction. We must reassess the advantages of the true tumescent approach with a ratio of 2:1 and 3:1 of infusate to aspirate, because of the potential for severe fluid overload and lidocaine toxicity. We should be promoting the super-wet approach with a 1:1 ratio. It is incumbent on surgeons who are using large lidocaine concentrations to monitor their patients for 12 to 14 hours, because of the potential of lidocaine toxicity during that time. It is of concern that in some states, patients are not allowed to stay overnight in officebased facilities and are therefore at home during that critical period. Dr. Vogt: First let me say that my definition of large-volume liposuction is removal of more than 4000 ml of total aspirate not 5000 ml. I prefer to use a general anesthetic to reduce the amount of lidocaine because I only use the super-wet technique and rarely exceed the 1:1 ratio. I use a formula that delivers a very low concentration of Xylocaine, preferably far below 35 mg/kg. To increase the safety and avoid fluid overload, surgeons need to be in concert with the anesthesiologists. Often, we believe we are doing well when we are using a 1:1 infusion to aspirate ratio, but if the amount of fluid being given exceeds a safe volume, we can create over- 318 ESTHETIC S URGERY J OURNL ~ JULY/UGUST 1999 Volume 19, Number 4

load because more fluid is absorbed than we may realize. Dr. D mico: It is important to review drug interactions with the anesthesiologist. For example, midazolam can mask early signs of lidocaine toxicity. ecause lidocaine and related drugs had been used in epidural anesthesia, I stopped using them. However, now that epidural anesthesia is performed with narcotics, many people are reconsidering its use. Dr. Toledo: I am against epidural anesthesia, because when you reposition the patient, the anesthesia level changes, causing breathing problems. I use low-tumescent or super-wet anesthesia at a 1:1 ratio, and on rare occasions at a 1:1.5 ratio. I only use oral midazolam for sedation. For large-volume aspirations, we give midazolam along with fentanyl, and sometimes propofol. lthough we do not intubate the patient, the anesthesiologist is ready should general anesthesia be needed. Rather than using absolute aspirate volume limits, my limit, for example, may be removal of 5000 ml of pure fat in a very heavy patient. I treat one side, turn the patient, and then infuse the other side. Dr. Hunstad: My definition of largevolume liposuction is when more than 3 to 5 L of pure fat is aspirated. We use general anesthesia and limit the lidocaine dosage to 35 mg/kg. I agree with Dr. D mico that lidocaine toxicity occurs 12 to 14 hours after surgery when the patient is at home rather than in the immediate postoperative period. Patients therefore need to be carefully monitored during that period. In states that have curtailed overnight stays in an office setting, patients may be cared for at home by an informed family member Figure 4. and, 39-year-old woman who underwent liposuction of the circumferential thighs experienced hematomas and other complications after the procedure, which caused severe depressions, irregularities, and deformity. On the left anterior thigh, the skin is literally adherent to the underlying fasciae with absolutely no fat present. Significant fullness remains in the right anterior and posterior thigh, the proximal inner thighs, the knees, and the infragluteal crease. or trained personnel and must have easy access to the hospital in the event that complications arise. They must be made aware of the signs and symptoms of lidocaine toxicity. Dr. Toledo: It is important to remember that you can always repeat the procedure. In some instances, it is much safer to perform the procedure in 2 or 3 stages, instead of trying to accomplish a big result all at once. Dr. Hunstad: Could some of this patient s complications have been caused by the use of UL? Dr. D mico: Experience has shown that by reducing the energy application time, the exposure of tissue to ultrasound energy is reduced, It is important to remember that you can always repeat the procedure. In some instances, it is much safer to perform the procedure in 2 or 3 stages, instead of trying to accomplish a big result all at once. Luiz S. Toledo, MD Unsatisfactory Results of Liposuction ESTHETIC S URGERY J OURNL ~ JULY/UGUST 1999 319

decreasing the incidence of seroma and other UL-related complications, such as burns and tissue damage. The risk of seroma and over-resection is reduced by adhering to defined end points. These end points are loss of resistance to cannula movement and change in the color of the aspirate from pale yellow to pink or tan. Treatment beyond these end points results in seroma and over-resections, as seen in this patient. ecause ultrasound cannulas cannot be bent, they remain straight when treating a curved or cylindrical surface (eg, the leg or thigh) and therefore can hit the skin on the opposite side of the cylinder, causing skin burns. One can prevent this with appropriately placed incisions, which must be carefully planned when using UL. One can also manipulate the tissues over a curved surface, bringing them to the cannula, to facilitate removal. In addition, I believe feathering is very important and should be done with UL and not be left for the evacuation phase. Feathering might have helped this patient. Dr. Hunstad: Dr. Vogt, you have begun to use the reciprocating cannula in deference to UL. Would you share your experience? Dr. Vogt: bout a year ago, because of the problems that Dr. D mico just alluded to, I began using a reciprocating suction device that uses a cold cannula and reciprocates at 4000/min. This allows access to difficult areas, such as the flank and hip. I still use UL in the upper extremity because I believe I get a bit more retraction of the skin, but my generator time is no more than 3 to 4 minutes per upper extremity. Dr. Hunstad: I share your experiences, as well as those of Dr. D mico. I have significantly reduced our UL on-times and have seen a proportionate decrease in dysesthesias and seromas. Dr. Toledo, you performed UL in razil long before it was available in the United States and have had a lot of experience with it. However, you no longer use UL. Please share with us your experience and tell us why you now prefer the syringe technique. Dr. Toledo: For the past 11 years, I have been using only the syringe. I have compared the results achieved by the use of UL with those obtained through the use of syringe liposuction, which I presented at the 1996 SPS meeting. There was no significant aesthetic difference, and there was more delayed healing, itching, and pain, and no less bruising, on the side treated with UL. So, I no longer use internal UL. However, I still use external UL. If it is difficult to aspirate with a syringe and a regular cannula, I use one of those new titanium-coated cannulas that slide easily and are very penetrating. Reprint orders: Mosby, Inc, 11830 Westline Industrial Drive, St Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/100694 320 ESTHETIC S URGERY J OURNL ~ JULY/UGUST 1999 Volume 19, Number 4