|
From the initial consultation to the final "after"
photographs, there are a myriad of subtle details that
enhance patient outcome and satisfaction. Planning allows
for a synchronous expectation for the patient and the
physician. This article delineates the components of
our very successful liposculpture program.
The initial consultation is oriented to educate the
patient about the principal of volume reduction and
the ensuing changes in surface anatomy.
The details of the tumescent technique
and its alternatives are discussed. The postoperative
regime is reviewed in detail and the physiologic reasons
are strongly emphasized. The patient is advised of all
postoperative expectations and asked for their full
cooperation in facilitating their recovery process.
We have found daily exercise, q.i.d. heat and vigorous
massage of the treated areas to be essential in shortening
the recovery period, as well as improving the contour
and appearance of the patients' skin.
|
|
|
|
1. Cross-section of skin,
underlying fat and muscle
prior to Liposculpture
|
2. After
filling the fat layer with tumescent anesthesia
|
|
|
|
3. After multiple passes with a liposuction
instrument
|
4.
Diminished fat layer after compression of the treated
areas |
A preoperative visit with the R.N. is utilized to emphasize
avoidance of substances that inhibit hemostasis and
further reinforce the importance of patient compliance
with the postoperative regimen. We have found it very
important to emphasize avoidance of Vitamin E in reducing
intraoperative and postoperative hemorrhage, as well
as postoperative bruising and ecchymosis.
The vast majority of our liposuction cases are performed
under sedation with Demerol and Versed. The intramuscular
route of administration is very successful at relieving
patient apprehension and discomfort, while avoiding
the complications associated with intravenous administration
of these same drugs. Over the past three years, in over
1,000 cases, we have had no significant adverse events
and only two patients required intravenous Narcan to
reverse respiratory depression. Paramount to this method
is to ensure that all patients intake a meal (300-600
calories) 1-2 hours prior to their procedure.
Because of the prevalence of general anesthesia and
NPO requirements, we have found it necessary to emphasize
this point to the extreme. Patients are questioned upon
their arrival at our office as to their p.o. intake
and, if insufficient, we supply them with an "energy
bar" with water. Our experience has shown relative
hypoglycemia to result in nausea, reduction in pain
tolerance, tachycardia, tremor, orthostatic hypotension,
anxiety and prolongation of the effects of sedation
and tumescent anesthesia. Adhering to the preceding
regimen results in intraoperative emesis of less than
1 in 300 patients. By report, emesis in the first 24
hours postoperatively is approximately 1 in 50 to 1
in 100 patients.
Intraoperative monitoring is increasingly mandated by
state laws. Our routine is NIBP, pulse oximetry, I.V.
access and, most importantly, constant communication
with the patient. New California law ambiguously requires
some form of electrocardiogram. This contradicts the
good evidence of a marked delay (12-24°) in the
peak concentration of lidocaine given via the tumescent
technique.
Some practitioners have found that anatomic
sites require different concentrations of lidocaine
to control pain. In our experience, optimizing blood
glucose, utilizing I.M. sedation and delivering tumescence
via multiple infiltration cannulae results in exceptional
anesthesia for most patients. The percentage of patients
who require such quantities (1-10 cc) of supplemental
tumescence is approximately 20%. Eighty percent of all
patients tolerate the procedure without installation
of any additional anesthetic. Over the past three years
only two patients have had a localized area ( no greater
than 4cmx4cm ) which could not be anesthetized to allow
for completion of the procedure.
**Performance of safe and tolerable liposuction requires
rigid adherence to proper mixing and administration
of the tumescent solution. The R.N. instills the components
into either 1 liter or 3 liter bags of normal saline
while witnessed by a medical assistant or surgical technologist.
The bags are then labeled, witnessed and checked by
the surgeon prior to infusion. Warming of the solution
to near body temperature will decrease patient discomfort
and side effects.
**In our practice we have developed a device to reduce
infiltration time by 1/3 to 1/2. The common peristaltic
pump is used to deliver the solution to silicone tubing,
which is then split via a T-connector to two separate
infiltration handles. We use 14g infiltration cannulae
and have noted that the amount of fluid per given time
is the arbiter of patient discomfort. Using two separate
cannulae cuts the rate of flow in half at each site
while allowing up to two times the rate of total volume
infiltration. Previous to this development, our average
infiltration time was 55-70 minutes. Since implementing
the T-split and double handle infiltration, our average
infiltration time is 30-36 minutes with no increase
in patient discomfort.
Removal of fat media 2-3 mm cannulae or the STARS oscillating
(PAL) system requires an average of 40-60 minutes. Patients
are then dressed in the elastic compression garments
inclusive of absorptive pads. During the afternoon and
evening of surgery patients are often mildly "lightheaded"
and only minimal activity with assistance is advised.
The day following surgery we instruct patients to shower
without their compression garments with the goal of
expressing the maximal amount of tumescent and postoperative
fluids. The removal of the fluids is essential to hasten
recovery while minimizing discomfort. The prostaglandins,
lactic acid and blood products will create pain and
inflammation proportional to the volume retained beyond
the first 24 hours.
Exercise and application of heat and massage
are instituted immediately to maximize endorphins, neovascularization
and restoration of lymphatic drainage. Aggressive utilization
of drainage techniques will result in near complete
drainage within 24 hours postoperatively. When drainage
is minimal, removal of the compression garment is mandated.
In our experience 98% of all patients avoid postoperative
narcotic pain medication by following the mechanical
prescriptions.
The first postoperative day is marked by a two to four
mile walk, which serves to enhance drainage while relieving
soreness and discomfort. Removal of the compression
garment within the first 36 hours after surgery has
been demonstrated in both our experience and in studies
to be advantageous in the restoration of lymphatic and
vascular flow in the body.
Throughout the first postoperative month the patient
is asked to exercise daily, apply q.i.d. heat (five
minutes per session) and massage four to six times per
day. The puncture sites are allowed to drain freely.
It is usual that the most inferior sites have minimal
drainage by 36 hours postoperatively. Most superiorly
located puncture sites are no longer draining by 12
hours after surgery. Optimal healing requires t.i.d.
application of poly-antibiotic ointment covered with
"bandaides" from the time of drainage sensation
until a scab no longer has the tendency to form at the
puncture site.
The first six to eight weeks after surgery are marked
by fluctuating and random sites of induration. These
represent sites of inflammation and healing most of
which resolve eight weeks postoperatively.
Our follow-up appointments are scheduled for one week,
one month and four months postoperatively. Photos are
taken at the one-month and four-month visits. These
photographs (digital images) are reviewed with the patient
before soliciting their assessment of change and satisfaction
with the procedure. For our group the touchup rate has
averaged 6-10% over the last three years. ( The nationwide
touchup rate average is approximately 40%. )
Long-term follow-up includes two common complications.
Puncture sites may display either hyperpigmentation
or neovascularity. We have found Triluma cream and sclerotherapy
versus IPL successful in reducing the undesirable discolorations.
We have found that most medical education revolves around
the specific techniques employed during liposuction
surgery. It is our experience that the details of patient
education, adherence to safe practices and patient cooperation
(pre and postoperatively) are of the utmost importance
in assuring the good outcome desired by both patient
and physician. Our group likes to think of all surgeries
as made up of many design components. Failure to complete
or deliver on any of these elements will almost certainly
result in a less desirable outcome.
To learn more go to Dr. Jeffrey McClanahan's
specialist
page or directly to his website at www.cliniskin.com.
return to articles
index page
|
