Vibrotumescent Liposuction of the Abdominal Wall

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Gavin Reed
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1 Chpter 20 Virotumescent Liposuction of the Adominl Wll 20 Sid Mirrfti 20.1 Ptient Consulttion Liposuction is one of the most commonly performed procedures, ut the limittions nd dvntges of the proceduremusteexplinedtotheptient.alterntive procedures should e discussed, which usully include dominoplsty. This will help to guide the ptient in mking n informed decision when choosing liposuction of the domen versus dominoplsty. There re mny different wys nd techniques of performing liposuction. The virotumescent liposuction technique hs mny dvntges. It is explined to the ptient tht liposuction hs rpidrecoverytimendtheptientcnusullyreturn ck to norml dily routine fter only few dys nd thereismuchlessmoridityndmortlityssocited with liposuction in contrst to dominoplsty. A much more sculpted ppernce cn e otined with liposuction thn with conventionl dominoplsty since when n dominoplsty is performed, mny surgeons prefer not to liposuction the flnks nd the sides of the domen. Liposuction of the lower domen nd the upper domen llows sculpturing of the lterl res to degreeththsproperlyestheticppernceincomintion with the ptient s hips nd lterl thighs. When performing liposuction, there is lwys the question of skin retrction. With the virotumescent technique, good skin retrction cn e chieved depending on the type skin nd the ge of the ptient (Fig. 20.1). Even stretch mrks of the skin cn e improved (Fig. 20.2). The virotumescent liposuction lso hs minimum ruising nd miniml lood loss during nd fter surgery (Figs. 20.1, 20.2). Miniml lood loss during surgery nd miniml ruising fter surgery is lso prtly dependent upon preopertive cre instructions. The virotumescent technique cn chieve etter results thn with conventionl tumescent liposuction even with the ddition of internl ultrsound nd/or externl ultrsonic ssisted liposuction. There re fewer complictions, skin necrosis, nd skin urn. One other dvntge is improvement of cellulite. Although there my e clims tht liposuction cn tret the cellulite prolem, most ptients hving viroliposuction hve noticed improvement in their cellulite, decresing y over 50%. The virotumescent technique ppers to rek up the treculr ttchments of the skin to the underlying structures, which is the primry cuse of the cellulite formtion. Another dvntge of the virotumescent technique is the even distriution of the tumescent fluid, which is infiltrted into the sucutneous ft of the res undergoing liposuction. This will l- Fig Preopertive 43-yer-old femle with excess ft of the domen nd loose lower dominl skin. One week postopertively following viroliposuction of domen with excellent skin retrction nd no ruising

alterntive procedures should e discussed, which usully include dominoplsty. This will help to guide the ptient in mking n informed decision when choosing liposuction of the domen versus dominoplsty.

2 Virotumescent Liposuction of the Adominl Wll Fig Preopertive 28-yer-old mle with excess ft of domen nd hips ssocited with mrked strie of lower domen. One week postopertively following viroliposuction. Note mrked improvement of strie of lower domen nd no ruising Fig Virtion (percussion mssging) of the dominl wll fter infiltrtion of tumescent fluid results in emulsifiction of the ft low the surgeon to do proportionte liposculpting of the ody. Virtion of the re fter infiltrtion of the tumescent fluid cuses emulsifiction of the ft cells (Fig. 20.3). It is ovious tht the ft cells re more disrupted nd injured. There is lso more oil present in the spirte. The pthology report from liposuction with virtion shows 80% more disrupted nd disfigured ft cells Surgicl Technique To do liposuction surgery, the procedure strts from the preopertive room tking the pproprite photos, nd crefully mrking the res of liposuction to e done. The most elevted res re mrked t the center s well s the depressed res, ut using different color mrking pen. This is to void liposuctioning the wrong res. At surgery the ptient is thoroughly prepped with etdine solution. There re some surgeons who e- Fig Mssging the dominl res with the virtion mchineoversteriletowel lieve tht prepping the ptient for liposuction or even using sterile gloves to perform liposuction is not necessry due to the ctericidl effect of the lidocine present in the tumescent fluid. It is not true tht tumescent fluid will prevent infection. Mke sure to prep the ptient with etdine rther thn tke the chnce of hving compliction or infection. It is fr etter to tke few extr minutes to prep the ptient for sterile surgery.tumescentfluidisinjectedslowlynddispersed evenly into the sucutneous ftty lyer. The tumescent fluid consists of 1,000 cc lctted Ringer s with 2 mg epinephrine nd 500 mg of lidocine. The usul tumescentfluidinjectedtospirtionis1:1.thepercussion mssging mchine (Model: PA-1, HoMedic Inc., Commerce Township, MI) is used to mssge ech re for 5 min (Fig. 20.4) following tumescent infiltrtion.

Virtion (percussion mssging) of the dominl wll fter infiltrtion of tumescent fluid results in emulsifiction of the ft low the surgeon to do proportionte liposculpting of the ody.

3 20.2 Surgicl Technique 179 When the mssge is completed the res re ck to their originl shpe s it ws efore tumescent infiltrtion. Liposuction is performed using mm cnnuls under low vcuum ( mm). Lrger sized cnnuls cuse more trum nd increse the chnce of indenttions nd depressions tht cn result in wviness nd cnnul trct mrks. Full strokes should e performed evenly in the sme lyer working from the deep plne to the superficil plne. Even pressure is pplied to the skin using the plm of the non-dominnt hnd (Fig. 20.5). The nondominnt hnd should e used s guide directing the liposuction cnnul to sty in the sme plne nd mking sure not to penetrte too deeply nd injure vitl orgns.inthecseofliposuctionoftheupperdomenit is criticl to use the non-dominnt hnd to push down ontherissthecnnulpssesinthefttylyerove the ris (Fig. 20.6). Ech tunnel is liposuctioned three times efore strting new tunnel. Never squeeze the tissue with the hnd while performing liposuction (Fig. 20.7) unless you re n experienced surgeon nd hve done over 1,000 liposuction res. Squeezing the tissue in your hnd while doing liposuction cn esily chnge your plne nd cuse depressions nd wviness. If liposuction of the domen is done on hevy ptient, 4.0-mm cnnul is used in the deep plne nd lunt 3.0-mm cnnul for the superficil plne. Aout 1 cm of sucutneous ft is left. With the virotumescent technique the liposuctioned ft ppers emulsified nd oily. At the completion of the liposuction, the dominnt hnd is used to pinch smll res ll over the domen checking for symmetry nd ny ftty lumps tht need to e corrected (Fig. 20.8). Fom pdding is pplied with n dominl inder, mking sure there is even compression to the domen. Fig Even pressure pplied to dominl wll with non-dominnt hnd to plpte the cnnul tip Fig Pressure on the lower chest wll with the non-dominnt hnd llows the cnnul to pss esily over the ris

Full strokes should e performed evenly in the sme lyer working from the deep plne to the superficil plne. Even pressure is pplied to the skin using the plm of the non-dominnt hnd (Fig. 20.5).

4 Virotumescent Liposuction of the Adominl Wll Fig Do not compress the tissue with the hnd while performing liposuction. This llows uneven suctioning of the ft Fig Pinching smll res of the skin nd ft following liposuction llows recognition of symmetryndfttylumps The liposuction incision sites re left open with 4 4 s pplied. This will llow for free dringe of the fluid tht is infiltrted into the re. The ptient should e forewrned out the dringe so tht ed sheets nd furniture cn e protected. Free dringe decreses the chnce of serom formtion nd infection nd llows fsterrecovery.itisimportnttomkesurethereisno kink or folding in the fom nd the dominl inder Postopertive Postopertively the ptient is told to either lie down flt,situpstright,orstnduptovoidfoldingthegrment. If the grment is folded, this will result in fold in the skin tht cn result in serom or indurtion of the re, which cn e difficult to tret (Fig. 20.9). This defect with sucutneous firosis requires the use of ultrsound tretments (3 mhz for 15 min) to the re twice weekly for 16 sessions. Medrol DosPk should e used t the strt of therpy nd mediction with nonsteroidl nti-inflmmtory drug (NSAID) continued until the firosis hs susided. The ptient is seen on the first postopertive dy to correct ny kinking in the grment nd pdding nd to guide the ptient to use the correct posture. All the dressings nd the fom re chnged. The ptient is dvised to wlk s often s possile nd told to mke sure there is no folding in the inder. On the third postopertive dy the ptient is gin seen nd the fom removed. The ptient is llowed to tke shower ut following the showers must immeditely repply the dominl inder. Bths re not llowed ecuse ll the liposuction incision sites re still not properly heled.

Free dringe decreses the chnce of serom formtion nd infection nd llows fsterrecovery.itisimportnttomkesurethereisno kink or folding in the fom nd the dominl inder. 20.

5 20.4 Discussion 181 Fig Preopertive ptient with lipodystrophy of dominl wll. Postopertively the ptient developed n indenttion nd sucutneous firosis in the lower domen from fold in the grment On the 10th postopertive dy dominl exercise nd sit-ups re egun. The numer of exercises is slowly ndgrdullyincresedeveryweek.thedominl inder is used continuously for the next 4 6 weeks depending on the ptient ge, the skin texture, nd the degree of loose skin. The ptient is seen gin t 4 6weeks Discussion The virotumescent technique emulsifies the ft, llowing the ft to e removed more esily. There is less leeding nd postopertive ruising when comined with low vcuum nd proper fom pdding with grment postopertively.

The numer of exercises is slowly ndgrdullyincresedeveryweek.

Appendix D: Completing the Square and the Quadratic Formula. In Appendix A, two special cases of expanding brackets were considered:

Appendix D: Completing the Square and the Quadratic Formula. In Appendix A, two special cases of expanding brackets were considered: Appendi D: Completing the Squre nd the Qudrtic Formul Fctoring qudrtic epressions such s: + 6 + 8 ws one of the topics introduced in Appendi C. Fctoring qudrtic epressions is useful skill tht cn help you