University of Toronto Plastic Surgery Seminar Series

EXCESS FAT, BODY SCULPTURING, AND POST BARIATRIC BODY CONTOURING

Update: Allan Eckhaus

Previous author: Cory Goldberg September 2006 Discussors: Dr. Levine

Excess fat, body sculpturing, liposuction TABLE OF CONTENTS 1 INTRODUCTION ...... 1 1.1 Definitions and Abbreviations...... 1 2 ANATOMY AND PHYSIOLOGY OF FAT...... 1 2.1 Fat Embryogenesis...... 1 2.2 Fat Maturation...... 1 2.3 Anatomy of Fat (Markham and Barton, PRS, 1987) (FIGURE 1: and FIGURE 2:)2 2.4 Physiology of Fat...... 2 3 AND “EXCESS FAT”...... 3 3.1 Classification...... 3 3.2 of Obesity...... 4 4 EVALUATION OF THE PATIENT WITH “EXCESS” FAT...... 4 4.1 History...... 4 4.2 Physical Exam and Investigations...... 4 5 TREATMENT OPTIONS FOR EXCESS FAT / BODY CONTOURING...... 5 5.1 Non-Operative...... 5 5.2 Operative...... 5 6 SUCTION-ASSISTED LIPECTOMY ...... 6 6.1 Introduction...... 6 6.2 Physics...... 6 6.3 Applications for SAL...... 7 6.4 Indications for SAL / Patient Selection...... 7 6.5 Contraindications to SAL...... 7 6.6 Technique...... 7 6.7 Safety Issues...... 8 6.8 Operative Management...... 9 6.9 Post-Operative Management...... 10 6.10 Advantages of Superwet / Tumescent Technique (Compared to “Dry” method)...10 6.11 Complications...... 11 7 ULTRASONIC-ASSISTED LIPOSUCTION...... 11 7.1 Physics...... 11 7.2 Indications for Ultrasonic Technique...... 11 7.3 Comparison of Ultrasonic Technique to Standard SAL...... 12 7.4 UAL Technique – 3 stages...... 12 8 DERMOLIPECTOMY OF THE TRUNK ...... 12 8.1 Pathophysiology:...... 13 8.2 Vascular Anatomy of the Abdomen...... 13 8.3 Classification Of Abdominal Deformities...... 14 8.4 Indications and Contraindications...... 14 8.5 Goals of Surgery...... 14 8.6 Mini-abdominoplasty...... 14 8.7 Abdominoplasty...... 15 8.8 Truncal Lipectomy...... 15 8.9 Umbilicoplasty...... 15 8.10 Complications...... 15 9 UPPER BODY PROCEDURES ...... 16 10 DERMOLIPECTOMY OF THE UPPER EXTREMITY...... 16

Excess fat, body sculpturing, liposuction 10.1 Classification...... 16 10.2 Indications and Contraindications...... 16 10.3 Preoperative Evaluation...... 16 10.4 Surgery...... 16 10.5 Complications...... 17 11 DERMOLIPECTOMY OF THE LOWER EXTREMITY ...... 17 11.1 Etiology...... 17 11.2 Classification (Grazer and Klingbeil, 1980)...... 17 11.3 Surgery...... 17 11.4 Complications...... 18 12 BIBLIOGRAPHY...... 19

Excess fat, body sculpturing, liposuction Page 1

1 INTRODUCTION

1.1 Definitions and Abbreviations Body contouring: Surgical reshaping of specific body areas into more aesthetically pleasing outlines (BMI): A formula to assess body composition by relating weight to height. weight(kg) BMI = height(m)2 Diastasis recti: Separation from the midline of the rectus abdominus muscles. Excess body fat: Localized or generalized subcutaneous greater than the culturally accepted normal amount. Lipodystrophy: Localized adiposity in disproportion to general body habitus. Massive : Loss of over 100lbs or 100% of ideal body weight. Deflation: appearance after massive weight loss (loss of fat, excessive skin) SAL: Suction-assisted lipectomy. Removal of fat under negative pressure applied by means of a cannula inserted subcutaneously through a small incision. UAL: Ultrasound-assisted lipectomy.

2 ANATOMY AND PHYSIOLOGY OF FAT

2.1 Fat Embryogenesis · 3rd month of gestation: - Mesenchymal stem cells → Adipoblasts → Preadipocyte → Adipocytes

2.2 Fat Maturation · First year: Individual adipocytes triple in size · 1 to 5 years: Adipocytes continue to both enlarge and multiply · Adolescence: Adipocytes grow without significant · Adulthood: - No new adipocytes formed, except in the morbidly obese - Ultimate number of cells remains stable in the face of changes in basal metabolic rate and other physiologic alterations

Excess fat, body sculpturing, liposuction Page 2 2.3 Anatomy of Fat (Markham and Barton, PRS, 1987) (FIGURE 1: and FIGURE 2:) · Subcutaneous fat in torso and proximal legs is composed of two layers I. Superficial layer - Located above the superficial fascia - Composed of compact lobules, vertically compartmentalized by well-organized fibrous septa (retinacula cutis) - Vertical septations are responsible for appearance of cellulite II. Deep layer - Between the superficial and deep fascia – traditional target of SAL - Consists of more areolar, loose fat bound by an irregular, haphazard arrangement of septa - Preferential sites of fat accumulation: prominent bilaterally in periumbilical, paralumbar and gluteal-thigh regions - Represents reserve fat that is difficult to lose and probably genetically determined - No deep layer below the knee 2.4 Physiology of Fat · Adipocytes - Possess two chemical receptors for sympathetic FIGURE 1: Diagram showing cross-section of nervous system (NE) superficial (SL) and deep (DL) fat layers at various locations in the body (SQF = subQ fascia) § β1 – induces lipolysis via lipase § α2 – promotes lipogenesis and blocks lipolysis (with fasting, , hypothyroidism) · Post-adipocytes: Become active and replicate to accommodate excess lipid storage requirements in morbidly obese · White adipose tissue (locular adipocytes) - Makes up majority of fat deposits in - Primary function is storage and mobilization of lipids, specifically triglycerides and free fatty acids - Alterations in the balance of storage and mobilization dictates changes in adipose tissue mass · Brown adipose tissue (multilocular adipocytes) - Known to play a role in thermogenesis of newborns - Function in adults in unclear - Location: retrosternal, pericardial, interscapular, floor of anterior neck triangle) FIGURE 2: Diagram showing cross-section of superficial (SL) and deep (DL) fat layers in abdomen and proximal thigh

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3 OBESITY AND “EXCESS FAT”

3.1 Classification BMI Classification A. Generalized Fat Excess (classify by Grade and Etiology) <18.5 Underweight Grade 18.5-25 Normal · Obesity – body weight greater than 20% over ideal 25-30 · Morbid obesity - body weight greater than 100% over ideal 31-35 Class I- · Most accurately classified by BMI Moderate obesity 35-40 Class II- Etiology Severe obesity · Genetic: Genetic “predisposition”, Prader-Willi syndrome (an 40-49 Class III- involuntary urge to eat constantly) Very severe obesity · Childhood à hyperplastic = • size + • # adipocytes (Morbidly obese) · Adulthood à hypertrophic = • size only >50 Super obese · Environmental: identical twin study has confirmed this as (severely obese) primary factor International Obesity Task Force (IOTF) classification as modified by World Health § Nutritional Organization (1997) § Physical inactivity · Endocrine: hypothyroid, Cushing’s syndrome / disease (•ACTH production), hypothalamic tumour / injury, polycystic ovary disease (< 1% of pts. with obesity) · Other: Depression, drugs (steroids, BCP, antidepressants) B. Localized Fat Excess (classify by Anatomical location and Specific Conditions) Anatomy · Infra-Trochanteric/Lateral thigh (riding breeches, saddle bags) · Flanks (love handles) · Abdomen (pot belly) · Medial thigh / knee, lower leg · Arm · Neck Specific Syndromes and Conditions · Progressive Lipodystrophy (loss of subcutaneous fat i.e. Barraquer-Simons disease) · Painful Lipodystrophy (Adiposis Dolorosa aka Dercum’s Disease) · Multiple Knotty Lipomatosis (Lanois-Bensaud disease) · Multiple Symmetric Lipomatosis (Madelung’s disease) · Acute Panniculitis (Nodular Fat Necrosis) · Diabetic Lipodystrophy · Drugs (i.e. HIV protease inhibitors) C. Cellulite · Caused by retinacula cutis (septations) of the superficial fat · Categorization: - Primary (Illouz’s) cellulite: d/t hypertrophy of adipocytes. - Secondary cellulite: d/t age related ptosis of overlying soft tissues, amenable to skin/fascial tightening procedures.

Excess fat, body sculpturing, liposuction Page 4 3.2 · U.S. 35% of women and 31% of men (age >19) overweight or obese (by BMI) · U.S. 20-25% of children overweight or obese · Black female > white female> white male> black male · Females have higher percent body fat

4 EVALUATION OF THE PATIENT WITH “EXCESS” FAT

4.1 History A. Body Habitus / Aesthetic · Age of onset of fat excess, eating habits, · Methods of weight loss: success, amount lost, amount kept off, use of drugs FIGURE 3: Diagram showing typical gynecoid areas of fat · Family history accumulation · Expectations – esp. for men B. Medical / Surgical · R/O endocrine disorders: hypothalamic, adrenal, pituitary, ovarian, thyroid · CAD, DM, OA, PVD, BP, coagulopathic / thromboembolic disorders · Respiratory disorders, · GI: gallstones, fatty liver · Skin: intertrigo, fungal + yeast infections · Smoking (should quit 6 weeks prior to body contouring surgery) 4.2 Physical Exam and Investigations A. General · General exam with emphasis on endocrine disorders · BP, neurological deficits, hirsutism, myxedema, FIGURE 4: Diagram showing typical android areas of fat accumulation hair / skin changes, etc. B. Aesthetic / Assessment of deformity · Height and weight, BMI · Deviation from male/female ideal contour FIGURE 5: Diagram - Gynecoid / Android fat distribution (FIGURE 3: showing fusion of the superficial fascia to fascia and FIGURE 4:) lata. Only superficial fat is · Adipose tissue characteristics found in the upper thigh anterior to this line. - Locations of relative excess fat (liposuction areas) Violation results in - Regions of adherence (non-liposuction areas) superficial extraction, with (FIGURE 5:) resultant dents / contour defects.

Excess fat, body sculpturing, liposuction Page 5 - Pinch test: assess thickness of fat folds - Dimpling or cellulite - Intraperitoneal versus extraperitoneal fat - Asymmetries · Skin - Skin tone, turgor, elasticity, strength, excess - Scars, striae (sign of poor elasticity), hernias · Areas of particular concern to patient C. Labs: TSH, lipid profile, glucose, cortisol, LFTs D. Imaging: Photography, +/- CT (to r/o hernias)

5 TREATMENT OPTIONS FOR EXCESS FAT / BODY CONTOURING

5.1 Non-Operative Goals: 1) Reduce morbidity and mortality 2) Weight loss (0.5 Kg / week): maximize fat loss, minimize loss of 3) Social acceptance Treatment: 1) Supportive Referrals to 2) - Achieve weight loss then maintain it family - Must be nutritionally complete physician, 3) Behavior modification nutritionist, - Diary of what, where, when and how much is eaten dietician, - New modes of eating are suggested after diary analyzed endocrinologist, 4) Exercise etc. as 5) Drug therapy appropriate - Only useful as a short-term adjunct to above treatments

5.2 Operative / SURGICAL

Indications: Morbid obesity with failure of non-operative management ± complications (sleep apnea, heart failure, phlebitis, and arthritis) Summary: Bariatric surgery- procedures classified as:

Ø Malabsorptive- ¯ SB size- Jejunoileal (historical mostly, shortened SB from 400 cm to 45 cm à ++complications Ø Restrictive- Gastric banding (vertical banded gastroplasty, lap bands, adjustable bands) gaining popularity, weight loss is slower Ø Both Gastric bypass (most common) Roux-en-Y gastric bypass BODY CONTOURING

Body Contouring Surgery After Massive Weight Loss Roundtable Panel. Dallas Dec. 2004 PRS. Body Contouring Surgery After Massive Weight Loss. Kenkel JM. 117(1) Supp 2006

Excess fat, body sculpturing, liposuction Page 6 Panel Discussed: Types of Bariatric Surgery, preoperative evaluation of patients, informed consent, staging of body contouring procedures, safety issues specific to massive weight loss, marking and surgical techniques, complications and their avoidance and treatment.

Staging: Suggest the following order of procedures:

1. Lower Body- Dermolipectomy à miniabdominoplasty, abdominoplasty, belt lipectomy, panniculectomy, lower body lift, +/- flank excision, buttock augmentation · This is done first because lower body procedures will often affect the thighs. Therefore may obviate the need for LE procedure, or change the degree of deformity 2. Upper Body- Breast Reduction, Mastopexy, Augmentation, lateral chest and back lipectomy 3. Upper Extremity- brachioplasty 4. Lower Extremity – thighs (vertical vs. horizontal resection) 5. Face- rhytidectomy

Liposuction- SAL, UAL, (dry, wet, superwet, tumescent), alone or as adjunct

Preoperative Evaluation Key Points in Post Bariatric Patients · Body habitus/fat deposition patterns · Morphology of skin redundancy · Degree of skin deflation · Body mass index at presentation · Quality of skin envelope, skin laxity · Scar placement · Role of Liposuction · Marking patient (allow time, look for asymmetries, use hatch marks, do not over commitàadjust intra-op)

6 SUCTION-ASSISTED LIPECTOMY

6.1 Introduction · First attempted by Dujarrier (1921): liposuction around the knees of a ballerina; perforated the femoral artery ultimately necessitating amputation · SAL is the most commonly performed surgical procedure in the world every year · Accounted for 5.4% of all surgical procedures in the U.S. (2002) · 34% increase in number of procedures from 1999 to 2000 (US figures) 6.2 Physics 1. Mechanical thrust plus suction avulses globules of fat 2. Near total vacuum: - Results in lower vapour pressure - Produces vapourization (boiling) of adipose tissue - Forces fragments / fluids up suction line 3. Septa between muscle fascia and skin are preserved, forming sponge-like networks

Excess fat, body sculpturing, liposuction Page 7 6.3 Applications for SAL 1. Aesthetic i. Primary body contouring ii. Adjunctive: BBR, abdominoplasty, rhytidectomy / neck lift, , “touch-ups” · Controversy: safety of large volume liposuction in combination with abdominoplasty (ASAPS survey, 2001). o Mortality of SAL alone: 1 in 47,415 (0.002%) o Mortality of SAL & abdominoplasty: 1 in 3281 (0.03%) 2. Reconstructive / Therapeutic: Contour deformities, flap contouring, lipoma removal 3. Preventative health: may increase HDL cholesterol and reduce risk of CAD 6.4 Indications for SAL / Patient Selection · “Young”, healthy patients within 50 lbs of ideal body weight · Minimal to moderate localized fat deposits unresponsive to diet and exercise · Good skin tone · Realistic expectations, committed to long-term lifestyle changes

6.5 Contraindications to SAL Absolute Relative · Medically unfit · Poor skin tone · Obesity / morbid obesity · Smokers · Skin excess · Poor wound healing · Unrealistic expectations properties · Psychological factors (skewed perception) · Location of fat · Multiple / poorly located surgical or traumatic scars deposition · Pregnancy 6.6 Technique 6.6.1 Classification of Liposuction Techniques I. Machine vs. syringe II. Standard SAL vs. ultrasonic III. Superficial vs. deep (traditional) IV. Dry / wet / superwet / tumescent V. Small volume vs. large volume (> 5000 cc, ASPRS criteria) 6.6.2 Cannulas A. Blunt Tip · Lumen sufficiently far back to avoid removal of subdermal fat · Various styles: - single vs multiple hole - Cobra - lumen at tip - Ilouz, Mercedes (3 hole), etc. · Various sizes: - major body work: 4- to 6-mm - specialized (facial and neck): 1.5-, 2.4-, and 3.8- mm - Wider and shorter give better flow (Pousseille’s law)

Excess fat, body sculpturing, liposuction Page 8 B. Focused-Energy · Ultrasonic (see below) · Laser: not FDA approved · Power assisted: oscillating cannula tip (2-4mm displacement) reduces fatigue · External ultrasound: efficacy not confirmed in a double-blinded study 6.6.3 Infiltration Technique · Four techniques: dry, wet, superwet, tumescent · Dry and wet are largely historical · Controversy: superwet vs. tumescent · Many wetting solutions have been proposed · No clear proof any one solution better than another; most important factor is the anesthetic dose and volume of fluid delivered to the patient · Typical formula (Hunstad): Ringers lactate 1000 ml Final concentrations: Lidocaine 50 ml of 1% Lidocaine 0.05 % Epinephrine 1 ml of 1:1,000 Epinephrine 1:1,000,000 ±Na bicarb 12.5 mg · Other adjuncts – hyaluronidase, gentamycin – questionable benefit

6.7 Safety Issues 6.7.1 Lidocaine +/- epinephrine Drugs: · In highly dilute lidocaine (<0.1%) Maximum total dose = 35 mg / - Oral contraceptives (increase free unbound kg lidocaine) · Reports indicating up to 50 mg/kg may be safe - B-blockers (decreased · Not really due to suction of tumescent fluid, but to substantial lidocaine clearance and tissue binding of injected dilute lidocaine autonomic effects) · Halve lidocaine concentration of infusate for infiltrations > 5000 cc - Tricyclic antidepressants · Peak levels (with tumescent technique): 6 – 12 h post injection - Diet pills · Patient may be discharged from surgical facility prior to peak - Cimetidine lidocaine levels Conditions: · Extra caution required in certain patients (FIGURE 6:) - Hypovolemia · Mortality 1/5,224 - Hypokalemia - Hypophosphatemia · Toxicity rarely results in convlusions, more commonly depression of cardiac conduction and contractility leading to asystole FIGURE 6: Drugs and conditions that can affect the tumescent · Controversy: utility of lidocaine, as it may not decrease pain liposuction technique · Marcaine not recommended- rapidly absorbed, slow elimination, not easily reversed · Epinephrine max dose: 0.07 mg/kg (avoid use in pts with hyperthyroidism, severe , cardiac disease, PVD, pheochromocytoma)

6.7.2 Fluid Resuscitation · Most deaths from SAL related to inappropriate fluid resuscitation (over / under) · Ideal ratio of subcutaneous fluid to total aspirate controversial (see Table 1) · Generally avoid infiltrations > 5000 cc

Excess fat, body sculpturing, liposuction Page 9 · Generally minimize IV fluid load when using superwet or tumescent techniques – patient only receives volume sufficient to maintain IV access and administer medications · For large volume aspirations (> 3000 – 5000 cc) admit patient overnight, monitor BP and urine output · Ensure patient able to void prior to discharge

Table 1 Guideline for Fluid Resuscitation in SAL

TECHNIQUE VOLUME OF ESTIMATED BLOOD LOSS FLUID RESUSCITATION INFILTRATE (as % of ASPIRATE) Volume of Aspirate Fluid replacement DRY No infiltrate 20 - 45% < 1500 ml 2:1 IV fluid : aspirate 1500 - 3000 ml 2:1 IV fluid : aspirate 1 unit Blood > 3000 ml 2:1 IV fluid : aspirate 2 units Blood WET 200 - 300 cc / area 4 - 30% < 2500 ml Intraoperative - 1:1 IV fluid : aspirate Postoperative - 1:1 IV fluid : aspirate > 2500 ml Add 1 to 2 units blood for Hct < 30 SUPERWET Volume infiltrate ~ 1% < 3000 ml Minimize IV, 1X anticipated encourage PO fluids aspirate > 3000 ml 1:1 IV fluid : aspirate Monitor urine output TUMESCENT Inflate to uniformly 1% Minimize IV fluid turgid operative site: administration Volume infiltrate ~ > 3000 ml Monitor urine output 2-3X anticipated aspirate 6.8 Operative Management Markings · Patient standing · Mark tissue topography: fat deposits, depressions, irregularities · Zones of adherence · Review markings with patient, agree on areas of treatment / non-treatment Anesthesia · Local (tumescent) ± IV sedation · General Deep Liposuction · Small stab incisions made along relaxed skin tension lines / creases · Blunt tip cannula introduced into deep subcutaneous layer to pre-tunnel prior to suctioning · Avoid violation of zones of adherence: - Lateral gluteal depression - Gluteal crease - Posterior inferior thigh - Distal lateral thigh - Mid-inner thigh

Excess fat, body sculpturing, liposuction Page 10 · Remove deep fat: 10 - 15 strokes per tunnel to break up fat + allow easier removal · Use pinch test to assess progress · For better contour, use two sites + tunnel at right angles to each other · Goal: create honeycomb, leaving fibrous septae intact containing vessels, nerves and lymphatics with 1 - 2 cm of fat under dermis to ensure smooth contour · Feather edges of treatment zone to blend into adjacent areas · Role of superficial liposuction controversial – should certainly be approached with caution · Record volumes of infusate and aspirate Superficial Liposuction · Controversy: indications may include flaccid skin, cellulite, secondary liposuction · Multiple closely spaced narrow tunnels using thin cannulas · May be combined with deep liposuction · Promotes skin retraction 6.9 Post-Operative Management Dressings: - Compression garment 3-6 weeks Medications: - Analgesics - Prophylactic antibiotics controversial (no proven benefit) - Peri-operative steroids controversial Activity: - Early ambulation - Normal activities in 3 - 5 days; exercise in 3 - 6 weeks Therapy: - Massage + ultrasound may soften areas of hardening 6.10 Advantages of Superwet / Tumescent Technique (Compared to “Dry” method) Advantages Disadvantages · Decreased blood loss · Lidocaine toxicity · Decreased bruising / swelling · Epinephrine toxicity · Improved analgesia · Fluid overload / pulmonary - ¯ Perioperative analgesic requirements edema - More rapid discharge from surgical facility · Fluid replacement – ¯ IV fluid requirements · Enhanced ability to perform small and large volume aspirations - Reduced work effort - More rapid evacuation - Greater potential fat removal

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6.11 Complications Early Late · Minor · Over / undercorrection - Temporary hypesthesia - Generalized - Faint hemosiderin deposits - Localized – asymmetry, - Transient asymmetry / irregularity / waviness grooving, dents, divots, contour - Seroma (more common with UAL), hematoma irregularity - Incision site infection, skin necrosis · Persistent dys- / hypesthesias - Thermal injury (UAL) · Persistent pain from muscle / fascia · Major damage - Fluid imbalance (over / under) · Ptosis, unsatisfactory skin contraction - DVT / Pulmonary embolus / MI · Vascular damage – pigmentation - Fat embolism syndrome (rare) · Pseudobursa formation - Massive infection - Perforation of major organ or vessel (caution in re-dos) - Xylocaine toxicity

· Could also classify aesthetic, wound related, medical · Fat embolism syndrome: 24-72 hours post op, secondary to FFA in blood •platelet adhesiveness, hypercoagulability, emboli to brain, heart, lungs o Dx- tachypnea, tachycardia, fever, neuro changes, hemoptysis, petechiae (anterior ax fold, sub conjunctivae), ARDS, ¯plts o Treatment- supportive, +/- steroids

7 ULTRASONIC-ASSISTED LIPOSUCTION

7.1 Physics · Electrical energy is converted into high frequency sound by piezoelectric crystals · Ultrasound is transduced through a hand piece into mechanical vibrations emitted at the tip of a titanium probe, with resultant tissue effects: - Micromechanical: direct tissue trauma by the ultrasound wave - Thermal: conversion of mechanical energy into heat - Cavitation: tissue fragmentation achieved by means of the formation and collapse of intracellular microbubbles · Adipocytes implode + liquefy, then the fatty emulsion is aspirated · Moving the titanium rod through dry dense tissue will cause thermal burns, therefore it is essential that fat is infiltrated with a wetting solution + the rod is kept in constant slow motion at all times

7.2 Indications for Ultrasonic Technique · Large volumes (> 5000 cc) · Localized fat deposits in fibrous areas: - Back, upper and lower abdomen, flank / hips, buttock, lateral thighs, arms, male breast · Secondary liposuction sites or revision contouring · Need minor amount of skin tightening

Excess fat, body sculpturing, liposuction Page 12 7.3 Comparison of Ultrasonic Technique to Standard SAL Advantages Disadvantages · Achieve “smoother” contour · Direct and immediate damage (vessels / nerves) due to · Decreased surgeon effort thermal effects / cavitation · Decreased surgeon fatigue · Indirect damage / long-term damage (?metaplasia) · Enhanced skin retraction (may · Inability to go around curves (“end hits”) causing full obviate or reduce skin thickness skin burns excision in some patients) · Slightly larger access incisions required · More effective for cellulite · Need for skin protection · More effective for fibrous areas · Equipment costs · Less blood loss · Cannulas have finite lifespan · Less disruption of vasculature · Increased OR time and perioperative record keeping · Learning curve · Still requires SAL for evacuation / contouring 7.4 UAL Technique – 3 stages I. Infusion of wetting solution · Ultrasound cavitation will only occur in a wet environment AND significant thermal injury will occur with dry technique · Use only superwet / tumescent technique for UAL II. UAL · Involves the actual application of ultrasound energy to the adipose tissue, creating an emulsion of liquefied fat and wetting solution - Optimal wet environment - Avoid “end hits” - Skin protector at incision site - Moist towel on skin near incision site – to protect external skin from contact with probe - Ultrasound probe must be kept in constant motion - Respect anatomic boundaries and lines of fascial fusion - Avoid use near important superficial nerves - Endpoints: loss of tissue resistance, blood in aspirate, target vol. reached - Final contour is not an endpoint as this will result in overtreatment III. Evacuation phase with standard SAL · All emulsified fat must be removed · Standard SAL is performed with small to medium liposuction cannulas to remove emulsified fat · Final contouring and smoothing is performed

8 DERMOLIPECTOMY OF THE TRUNK Abdominal dermolipectomy: Surgical procedure to improve contour of the abdominal wall by excision of skin + fat, with or without plication of underlying musculoaponeurotic system Abdominal lipectomy: Surgical procedure that excises adipose tissue where it lies with minimal undermining Abdominoplasty: An aesthetic procedure for excision of redundant abdominal tissue carried out in the absence of obesity and often with plication of the abdominal musculoaponeurotic system

Excess fat, body sculpturing, liposuction Page 13 Panniculectomy: Excision of hanging apron of skin + subcutaneous tissue, usually after massive weight loss Lower Body Procedure in Massive Weight Loss: Points to consider · Marking (with patient flexed at waist- many suggestions in article) · Scar placement · Role of infiltration · Liposuction of the back +/- thighs · Positioning (prone-supine vs. supine/lateral decubitus · Role of buttock augmentation (preferably autologous augmentation of essentially subcut fat flap) · Mons reduction · Umbilicoplasty (smaller is better, avoid concentric circle incision due to contraction · Closure

8.1 Pathophysiology: · Redundant, flaccid skin, particularly subsequent to pregnancy · Excessive adipose tissue · Muscular diastasis + musculoaponeurotic laxity · Scar deformities including striae

8.2 Vascular Anatomy of the Abdomen

III I III

ASIS II

Zone Boundaries Vascular Supply I Central Xiphoid to level of ASIS + between Superior + inferior epigastric arteries lateral borders of both recti II Lower From line joining ASISs to pubic and Superficial epigastric, superficial external pudendal, inguinal creases inferior epigastric, superficial + deep circumflex iliac arteries III Lateral Lateral abdominal wall and flanks Segmental: posterior and lateral perforating branches of lower 6 intercostal, 4 lumbar, Zone I + most of Zone II are sacrificed during abdominoplasty, and the resulting flap is perfused via Zone III + collateral flow from SCIA in Zone II

Excess fat, body sculpturing, liposuction Page 14 8.3 Classification Of Abdominal Deformities · Two basic classification schemes (Matarasso and Regnault) I. Matarasso – classification based on severity of the skin, fat + muscular flaccidity (Matarasso, 1989)

Category Skin Laxity Fat Musculofascial System Treatment Type I Minimal Variable Minimal flaccidity Suction-assisted lipectomy Type II Mild Variable Mild lower abdominal flaccidity Miniabdominoplasty Type III Moderate Variable Moderate lower and/or upper abdominal flaccidity Modified abdominoplasty Type IV Severe Variable Significant lower and/or upper abdominal Standard abdominoplasty flaccidity with suction lipectomy

II. Regnault – classification based on location of deformity and recommends different techniques depending on type A. Upper Medial Obesity > T excision (modified Weinhold) B. Torso Obesity > Belt (circumferential) excision C. Lower Medial Obesity > Fleur-de-lis excision (inverted T) 8.4 Indications and Contraindications Indications Contraindications · Postpartum deformities (laxity, diastasis recti, · Medically unfit striae, flabbiness) · Smoking · Adiposities · Future expected pregnancies · Surgical scars · Unrealistic expectations · Moderate obesity with overhanging pannus · Previous incisions that may · After massive weight loss jeopardize blood supply to the abdominal flap · Morbid obesity 8.5 Goals of Surgery · Resect excess skin · Close muscular diastasis · Hide scar in bikini area · Facilitate personal hygiene · Improve body image · Excise scar deformities (including striae) 8.6 Mini-abdominoplasty Indications: – Infraumbilical flaccidity + regional fat deposition, minimal skin excess – Based on the theory that musculofascial support below the semicircular line is weaker than above because of absence of the posterior rectus fascia Technique: – Short transverse suprapubic incision – Infraumbilical undermining and plication – Possible emerging role for endoscopic-assisted plication – ± adjunctive SAL

Excess fat, body sculpturing, liposuction Page 15 8.7 Abdominoplasty Technique: · Can be performed using a variety of horizontal incisions hidden in bikini area. · Typical: Transverse just above pubic hair, extends parallel to and just above inguinal folds, ending just inferolateral to ASIS · Many incisions described (See FIGURE 7): I. W-plasty (Regnault) II. Gull-Wing (Grazer) III. Horizontal with down curve laterally (Pitanguy) · Most patients require plication of musculoaponeurotic system · Guidelines for use of adjunctive SAL: o Do not suction upper quadrants or flanks- ie. avoid vascular zones II and III o Can suction hip rolls with caution 8.8 Truncal Lipectomy

Technique: FIGURE 7: Various incisions described for · Type of operation performed depends on location abdominoplasty. A-Pitanguy, B-Grazer, C- of patient’s obesity Callia, D-Regnault, E-Mladick. Most Toronto · Umbilicus is rarely transposed staff use something similar to E. · High morbidity 1. Belt lipectomy: For generalized adiposity encircling the torso & including the back and upper buttocks. After massive weight loss. 2. T-Excision: For upper medial obesity. 3. 3-Branched resection: Fleur-de-lis pattern for lower medial obesity with significant pannus. 8.9 Umbilicoplasty · Gold standard navel: pronounces dimple, invagination of surrounding tissue, superior hooding · At intersection of lines connecting superior iliac crests and xiphoid to pubic symphisis · Techniques: o Move existing umbilicus to new location o Circular fat plug excised with central tethering of skin to fascia (Baroudi) o V-flap shaped into a cone anchored to fascia (Sungawara) 8.10 Complications Early Late · Seroma (always 2 drains · Scars – visible / hypertrophic / dog ears McKay et al.) · Umbilicus: abnormal shape, abnormal · Hematoma position, scarring, necrosis · Infection · Contour irregularities / asymmetries · Skin necrosis · Hypesthesia / anesthesia (always occurs to · Fat necrosis some degree), including injury to lateral · Stitch abscess femoral cutaneous nerve · Wound dehiscence · DVT / PE · Perforated viscus

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9 UPPER BODY PROCEDURES · Breasts, lateral chest, upper back · Lower body procedures should be done first because these may sufficiently address upper body deformity · Procedures o Mastopexy, breast reduction, breast augmentation o Gynecomastia procedures- more apt to require skin excision o Lateral chest wall excision (lateral aspect of IMF up to axilla) o Back excision (transverse, within bra line, marked with arms abducted)

10 DERMOLIPECTOMY OF THE UPPER EXTREMITY Brachioplasty: dermolipectomy of the upper extremity for reducing arm circumference and tissue redundancy · Often the deformity extends onto chest wall following posterior axillary fold, as well as distally below the elbow- need to address these areas concomitantly

10.1 Classification · Regnault – based on the portion of the arm affected: I. Mild - proximal third of arm II. Moderate - proximal and middle third III. Major - entire arm 10.2 Indications and Contraindications Indications Contraindications · Motivated patient · Previous axillary dissection · Significant deformity · Heavy, thick, fat arms (SAL is a · Willing to accept obvious scars – visible in better option) short sleeves etc. · Active axillary hidradenitis 10.3 Preoperative Evaluation · Examine with arms abducted + elbows flexed · Evaluate adiposity vs. skin excess · Coefficient of Hoyer: ratio of anterior to posterior soft tissue of arm - Normal values: Age 10 years = 1 : 1 Age 70 years = 1 : 2.2 10.4 Surgery Goals: – Reduce skin envelope and subcutaneous tissue – Place scar in the most inconspicuous location in the medial arm Technique: – Mark with arm abducted + elbow flexed – Place incision medially along line connecting axillary dome to medial epicondyle – Consider axillary Z-plasty to prevent scar contracture – Dissect above superficial fascia to prevent cutaneous nerve injury – In massive weight loss patients, may dissect down to deep fascia in proximal 2/3 of upper arm, beware of antebrachial cutaneous nerve – Take less than you originally thought, no undermining

Excess fat, body sculpturing, liposuction Page 17 10.5 Complications Early Late · Wound dehiscence · Scars – visible / hypertrophic / dog ears · Seroma · Lymphedema · Infection · Contour irregularities · Skin necrosis · Asymmetries · Nerve injury

11 DERMOLIPECTOMY OF THE LOWER EXTREMITY

11.1 Etiology · fat excess · skin excess (¯ tone - aging and / or weight loss) · classic lipodystrophy · generalized skin flaccidity after massive weight loss 11.2 Classification (Grazer and Klingbeil, 1980)

Category Deformity / Area Treatment Type I Crural excess / medial thigh Thighplasty or SAL + skin resection Type II Trochanteric / saddle bag SAL Type III Gluteal recess SAL Type IV Composite of II and III SAL Type V Obesity SAL Type VI Asymmetry and trauma SAL Type VII Aging or atrophy Skin reduction

11.3 Surgery

Indications: – Surgically correctible deformity not amenable to liposuction FIGURE 8: Medial – Realistic patient thigh lift incisions and – Willing to accept complications and scarring resection. Deep lipo- suction of medial thigh Principles: – Mark patients standing fat deposit can be per- – Incisions placed in high-cut bikini lines, inguinal crease or gluteal formed at the same crease time (dotted line). – Suspension of Superficial Fascia System with permanent sutures (Lockwood) – Direct undermining through zones of adherence of superficial fascia for more distal transmission of lifting forces – Distal undermining as necessary with cannulas (indirect undermining) 11.3.2 Medial Thigh Lift Notes: – Usual deformity is redundancy of skin in middle-age – Improvement in upper half of thigh, not knee region Technique: – Upper incision: begins just medial to femoral triangle, runs 1 cm above inguinal crease, extending posteriorly to gluteal crease (see FIGURE 8:) – Inferior incision: do not over resect (2-4 cm width) – May include vertical V-wedge excision (closed as a T) must have low tension at closure along perineal crease or will lead to dehiscence or vulvar distortion – Excision: superior to adductor magnus dissect into subcutaneous fat (avoid lymphatic injury), posteriorly dissect down to investing fascia, undermine distally 4-5 cm

Excess fat, body sculpturing, liposuction Page 18 – Closure: Lockwood - Recommends anchoring of deep dermis of inferior skin flap to tough, inelastic deep layer of perineum – Colle’s fascia (better support against gravitational forces than classic skin-suspension medial thigh lift, apparently also prevents distortion of the vulva) 11.3.3 Buttocks Notes: – Isolated deformity is unusual – Redundancy lies within buttock above gluteal fold Technique: – Conservative fat resection to avoid flat buttock – Patient should avoid sitting for 2 weeks 11.3.4 Trochanter Notes: – Liposuction has largely replaced excision for isolated deformities – Frequently have coexistent buttock and medial thigh redundancy Technique: – Often performed in conjunction with other procedures FIGURE 9: Transverse flank/thigh/buttock lift. Lockwood recommends a combination of direct undermining (cross hatch) and indirect undermining with 11.3.5 Combined Deformities a cannula as necessary. No undermining is performed Notes: – Numerous techniques described near the gluteal vessels to maintain flap vascularity. – Use individualized approach – Careful patient selection important and adherence to principles Techniques: – Circular reduction: for thigh-buttock-trochanteric deformity with significant anterior redundancy – Vertical thigh extension: following massive weight loss – Transverse lift: for flank-thigh-buttock deformity, can be used in combination with medial thigh lifting – a “lower body lift” (FIGURE 10:) 11.4 Complications · Relatively common · Often associated with trochanteric reduction

Early Late FIGURE 10: Lower body · Wound dehiscence · Scars – visible / hypertrophic / lift. Closure lies within high- · Hematoma dog ears cut bikini lines. Again, a · Lymphocele/Lymphedema combination of direct · Infection undermining and discontin- · Skin necrosis · Contour irregularities uous undermining can be · Asymmetries used. · Deformities of vulva and labia · Relapse

Excess fat, body sculpturing, liposuction Page 19

12 BIBLIOGRAPHY Kenkel, Jeffrey M. Body Contouring. Selected Readings in Plastic Surgery. 9(38), 2003.

Brucker, M. and Barrall, D. Abdominoplasty, in Plastic Surgery Secrets, Ed: Weinzweig, J. Hanley and Belfus Inc. Philadelphia, USA, 1999.

Baran, S. Body Contouring, in Plastic Surgery Secrets, Ed: Weinzweig, J. Hanley and Belfus Inc. Philadelphia, USA, 1999.

Liposuction

Iverson RE et al. Practice Advisor on Liposuction. PRS 113(5) 1478-90. 2004

De Jong RH. Mega-Dose Lidocaine Dangers Seen in ‘Tumescent’ Liposuction. J of Clin Monit and Comput. 16(1) 77-9. 2000

Various authors. Ultrasound-assisted Lipoplasty, Part I. Clinics in Plastic Surgery. 26(2), 1999.

Various authors. Ultrasound-assisted Lipoplasty, Part II. Clinics in Plastic Surgery. 26(3), 1999.

Lee Y, Hong JJ, Bang C. Dual-plane lipoplasty for the superficial and deep layers. PRS 104: 1877, 1999.

Wolfort FG, Cetrulo CL, Nevarre DR. Suction-assisted lipectomy for lipodystrophy syndromes attributed to HIV-protease inhibitor use. PRS 104:1814, 1999.

Body Contouring

Kenkel JM. Body Contouring After Massive Weight Loss. PRS 117(1) January Supplement 2006

Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. PRS 102:545, 1998.

Markman B, Barton FE. Anatomy of the subcutaneous tissue of the trunk and lower extremity. PRS 80:248, 1987.

Matarasso, A. Abdominolipoplasty. Clin Plast Surg 16:289, 1989

Lockwood T. Superficial fascial system (SFS) of the trunk and extremities: A new concept. PRS 87:1009, 1991.

Lockwood T. High-lateral-tension abdominoplasty with superficial fascial system suspension. PRS 96:603, 1995.

Grazer FM. Suction-assisted lipectomy – Its indications, contraindications, and complications. In: Habal M (ed) Advances in Plastic and Reconstructive Surgery, Vol. 1. Chicago, Year Book, 1984.