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Archive for the ‘liposuction’ Category

Technical Strategies – Perioral Mound Microliposuction

Friday, February 9th, 2018

 

Defatting of the face is very different than the body. Due to the location of vital motor nerves, the more fibrous nature of facial fat and its very discrete locations, facial fatting is much more limited. While it is possible to selectively remove small areas of facial fat, it is not possible to have a more generalized and significant effect.

One such facial area that can be defatted is the perioral mound area. Often confused with the location of the buccal fat pad, this is a small collection of subcutaneous fat overlying the buccinator muscle just to the side of the mouth. It merges into the more inferior jowl fat which is also a subcutaneous fat layer. Patients often do not like the fullness that it creates in this facial area.

The perioral mound area can be treated by liposuction. Entering through a small incision just inside the corner of the mouth the area is easily accessed and treated. The key is that the traditional size liposuction cannula should not be used as it is too big. Even cannulas used for the neck can remove fat too much quickly or leave an irregular contour.

I prefer to perform perioral mound liposuction with a very small size cannula at the diameter of 1 to 1.5mm. The best cannula to use is actually not a liposuction aspiration cannula at all but a fat injection cannula. With just one hole on one side of the end of the cannula, it can be remarkably effective at removing fat from a small area like the perioral mounds with little to no risk of causing surface irregularities. This can be called therefore perioral mound microliposuction.

While the volume of fat extraction from the perioral mounds is small (1 to 3ccs per side) it can have a very visible reductive effect.

Dr. Barry Eppley

Indianapolis, Indiana

Guidelines for Reducing Major Complications in Liposuction

Saturday, December 23rd, 2017

 

Liposuction remains the most common cosmetic body contouring procedure, both in terms of numbers of patients and body areas treated. While the overwhelming numbers of patients who undergo the procedure do well, there is always the risk of an adverse medical event. The invasive nature of the procedure with instrument introduction and the infusion of large amounts of fluid and tissue extraction make for traumatized internal tissues over an often large body surface area. This is what makes it truly unique from almost all other body contouring operations.

Death and major medical problems from liposuction are very rare. Patients understandably are very concerned about these possibilities and such few adverse events give liposuction a notoriety that no other plastic surgery procedure has. The risk of death for liposuction in some studies has been quoted as 1 in 5,000. (0.0002%) While this statistically seems very low, such a number for a cosmetic procedure seems high. What are these specific major medical events and how can they be prevented?

In the October 2017 Global Open edition of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘Strategies for Reducing Fatal Complications in Liposuction’. The authors conducted a literature review based on a search cross-indexing the terms Liposuction, Major Complications ad Death from which 39 articles were found to evaluate. They found five serious complications from liposuction including  thromboembolic disease, far emboli, pulmonary edema, lidocaine toxicity and intra-abdominal violation.

Pulmonary embolism is the most common cause of death in liposuction. Its prevention comes down to assessing the risk of deep vein thrombosis (DVT) in the patient for which the Caprini scale is the most widely used preoperative assessment. For those patients at higher risk by this assessment scale (3 or higher) , the use of high-molecular weight heparin begun 12 hours after surgery and continued for up to ten days after surgery is one proven chemoprophylaxis treatment.

Bowel perforation by the cannula violating the abdominal wall is the one potential lethal mechanical injury. While largely technique related, patients with abdominal wall defects from prior surgeries and unrepaired/repaired hernias are recognized preoperative risks. While all patients undergoing abdominal liposuction will have abdominal pain afterwards, suspicion must be high for this possibility of such pain seems unusually different. Very early intervention for the treatment of bowel perforations can prevent major sepsis and death.

The large infiltration of fluids (Hunstad solutions) immediately prior to liposuction creates the risk of too much fluid given (potentially causing pulmonary edema) and/or causing side effects from the medications in the introduced fluid. (lidocaine and epinephrine) To avoid fluid overload the ratio of infused fluids to the total liposuction aspirate should be considered. This ratio consists of replacing just under 2mls per cc of liposuction aspirate liposuction volumes of under 5,000 cc and closer to 1 ml per cc for liposuction volume greater than 5,000 ccs.

The lidocaine in tumescent liposuction solutions runs the risk of creating systemic toxicity. Since the peak plasma concentration of lidocaine does not occurs for a long time after surgery (8 to 10 hours) due to the effects if epinephrine, any toxic side effects will often only occur when the patients is beyond monitored medical care. The historic guideline for lidocaine dosing is 7mg/kg when used with epinephrine but studies have shown that concentrations between 35 and 55?mg/kg can be used safely in liposuction infusions.

Epinephrine is used in liposuction solutions to decrease bleeding and prolong the effects of the lidocaine for local anesthesia purposes. It is standard practice to use 1mg of epinephrine for each 1 liter of infused solution. (up to 10mg total dosing) Epinephrine levels during liposuction peak a few hours after infusion and their plasma levels often triple what normally occurs. Thus patients who may be at risk for epinephrine sensitivity or the development of cardiac events should have preoperative cardiac evaluation.

Small fat emboli from liposuction are not rare and has been reported to occur in almost 10% of the patients having the procedure. (although most do not cause a problem) A fat macroemboli is where a fragment of tissue has been introduced inside a vein which is then carried back towards the lung via the vena cava causing a potential thromboembolism due to mechanical obstruction. This risk is greatest when liposuction is done to harvest tissue for at injections of the buttock regions. Since almost all liposuction procedures of any quantity create a lipid macroglobulinemia there is always the risk for causing fat emboli syndrome. This syndrome occurs due to vessel irritation from fat microemboli in the blood stream whose risk is increased in low intravascular fluid volumes. Adequate fluid hydration is the known preventative measure.

One method to reduce most of these risks in liposuction is to limit the fat volume extracted. While this runs contrary to what the patient ideally wants and for the buttocks augmentation procedures where maximal extracted fat is usually needed, keeping the aspirated volumes to 5 liters or less helps reduce risks of fluid overload and pharmacologic toxicities.

This paper provides an excellent overview of the known practices that help reduce the risk of major complications in liposuction of the body.

Dr. Barry Eppley

Indianapolis, Indiana

Does Large Volume Liposuction Have Medical Benefits?

Sunday, December 3rd, 2017

 

Liposuction is a well known subcutaneous fat removing technique that has proven to be very effective. It can be so effective that large volume liposuction became commonly practiced until its potential adverse effects and complication rates came to light and safe amounts of maximum removal became established. (5 liters) While not a weight loss technique, removal of large fat amounts does raise the question of whether it may have medical benefits as well. Since fat is a very metabolically active tissue does its reduction have any positive benefits on metabolic and cardiovascular health.

In the December 2017 issue of the Annals of Plastic Surgery an article was published entitled ‘Influence of Large-Volume Liposuction on Metabolic and Cardiovascular Health: A Systematic Review’. In this review paper the authors looked at published reports of studies where large volume liposuction was performed (as defined as greater than 3.5 liters) as well as patient’s cardiovascular risk factors, inflammatory cytokines and insulin resistance/sensitivity measured. Twelve (12) studies were identified that were prospectively conducted. A total of over 350 patients were included in these studies of which the mean body mass was around 30. The mean volume of fat removed was over 7 liters. Seven of the studies showed a decrease in total cholesterol levels with an overall mean reduction of 0.2  mmol/L from 4.6 to 4.4 mmol/L. Leptin was shown to significantly decrease in 4 studies, and TNF-? was reported to be lower in  two studies. Adiponectin was show to significantly increase in two studies. IL-6 in two studies. Most of the studies evaluated insulin sensitivity, two included patients with type II diabetes. Six of the ten studies reported improvement in insulin sensitivity.

Ultimately the question being posed/studied is whether liposuction improves one’s health? Does removing a large volume of fat in a very short period of time have medical benefits? It is tempting to think (hope) so. But the evidence to support that contention is tenuous at best. Some of these studies offer conflicting data or positive changes that are relatively small. Certainly an immediate reduction in one’s fat volume would improve some of the metabolic markers studied. But whether those changes lead to a lower risk of cardiovascular disease or the need for less insulin in diabetics remains to be definitively proven. These potential benefits must be weighed against the risks of surgery which are increased in these larger volume liposuction patients.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Safe Limit of Fat Removal in Liposuction

Wednesday, November 29th, 2017

 

Liposuction is the most commonly performed cosmetic body contouring procedure, both by number of patients and body surface area. It has undergone a lot of technical improvements over the past third-five years from patient indications to the technical equipment needed to perform it.

While understandably viewed as an aesthetic procedure, its traumatic impact on the body is often overlooked. The small skin entrances for the introduction of the fat-sucking cannulas belies the generalized injury to the subcutaneous tissues which has been treated. The trauma to the fatty tissues and all that runs through it is considerable. Any patient that has had the procedure can testify that its recovery is usually greater than they could have anticipated both in terms of swelling and bruising and the time it takes for its resolution.

The trauma to the body and how it responds to it has been well appreciated with the most extreme form of it in large volume liposuction. This term has become known as any amount of fat removal that exceeds five (5) liters. When fat is removed in a singe setting at greater than this volume, the effects on the body result in fluid shifts and blood loss that can result in potentially major complications. At the least it prolongs the recovery time and can take more than month after surgery for the patient to feel more normal again. Numerous adverse outcomes from the 1990s, when large volume liposuction became popular, proved that whether it can be done should be preceded by whether it would be done.

If one wants a large amount of fat removed it should be done in stages given that liposuction is an elective procedure.  While the five liter limit is not an absolute, as it should really be based on body weight or even body surface area, it does serve as a good clinical guideline.

Dr. Barry Eppley

Indianapolis, Indiana

The Safety and Effectiveness of Perioral Mound Liposuction

Sunday, November 19th, 2017

While liposuction is widely used over many body areas, its applications to the face are much more limited. Between the far fewer isolated fat pockets and the location of motor nerve branches, facial liposuction is a fairly limited technique for fat reduction outside of the neck.

One facial area that can have liposuction done is that of the perioral mounds. As the name implies, it lies to the side of the mouth. It is an area of subcutaneous fat that lies between the skin and the buccinator muscle. It is often confused with that of the buccal fat pads and is a primary reason that buccal lipectomies can be unsuccessful due to a misdiagnosis. The buccal fat pad is a discrete encapsulated fat pocket that sits right under the cheekbones but does not extend down to the horizontal level of the mouth. (except in the rare instance of buccal fat prolapse)

The pooches or mounds besides the mouth can be a source of aesthetic dissatisfaction. While they can occur in faces of all sizes, they equally occur in thin faces where it is harder to imagine such a discrete fat collection could occur. Why they develop is not known but time fat is needed in this area to separate the underlying muscle from the skin.

Perioral mound liposuction is often viewed as not possible or safe due to facial nerve branches.  But an anatomic analysis of this area shows that there are not facial nerve branches in this part of the face. The nerve free zone of the lower face is below a line drawn from the earlobe to the mouth corner, a vertical line than drawn down to the jawline and the jawline traced posteriorly back up to the earlobe. The perioral mound area lies in the anterior half of this demarcated facial region.

Perioral mound liposuction is performed with a small cannula through a mucosal incision just inside the corner of the mouth. Fat is removed above the buccinator muscle in a fan-like fashion from the mouth corner. It takes some time and persistence to work the area as it is not like that of larger fat areas like the abdomen. It is a smaller more fibrous fat collection which is measured in single digit cc volumes.

Fat removed from the perioral mounds can be strained and measured. The volume removed is usually between 2 to 3ccs of fat per side. That may not sound like much but is all it takes to reduce a prominent facial fat mound.

Perioral mound liposuction is a safe technique for selective facial fat reduction. Having performed the procedure in over 50 patients, no case of facial nerve weakness has ever occurred. While small in volume extraction it is effective for the discrete subcutaneous fat collection by the sides of the mouth.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Power-Assisted Liposuction Buffalo Hump Reduction

Saturday, October 21st, 2017

 

Background: The buffalo hump deformity is a well known collection of fat in the back of the neck. It is a seemingly unusual place to develop a fatty collection given that it is a body area that is associated with becoming ‘fat’. But there is a congenital fat pad in the upper back known as the dorsocervical fat pad and an increase in its size may be a sign of excessive weight, a symptom of some diseases or a drug side effect.

Drug side effects that are known to increase cause lipodystrophy of the dorsocervical fat pad, the most recognized of which are some AIDS-treating medications. The other much more used drug that causes this effect are steroids including prednisone. Through an induced redistribution effect fat is directed to accumulate in the dorsocervical fat pad.

The formation of an increased upper back fat  pad causes multiple aesthetic and functional symptoms. The aesthetic deformity is obvious even though it is on the back rather than in the front of the neck. A hump in the upper back is not natural nor aesthetically pleasing. Its mass effect also causes neck movement restrictions and discomfort. In some patients they complain about difficulty sleeping due to the mass on the back of their neck.

Case Study: This 50 year-old female had developed a modest buffalo hump after years of taking steroids for her pulmonary condition. (asthma) While she was able to get  off this medication, the fatty collection did not recede. While it was not as large as many buffalo humps, it was still aesthetically disturbing.

Under general anesthesia and in the prone position, the upper back/neck fat collection was treated with power-assisted liposuction. (PAL) This was done in a cross-tunneling technique, removing a total of 225cc of fatty aspirate.

Regardless of the cause, buffalo humps do not recede or go away even when its etiology is eliminated. Liposuction is preferred over open excision as it is just as effective and avoids the risk of serum formation.

Highlights:

1) Buffalo humps come in a variety of sizes and causes.

2) Long term steroid use is known to cause more modest buffalo hump deformities.

3) Power-assisted liposuction is an effective aspiration technology for the fibrofatty tissue of buffalo humps.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Knobby Knee Liposuction

Saturday, October 14th, 2017

 

Background: Excess fat collections can occur all over the body. Some may occur from excess calories (e.g., abdomen) while others occur as part of one’s development. (e.g.,

arms) But regardless of its source, most fatty areas can be successfully treated by liposuction for contour improvement.

Liposuction of the lower extremities is the second most common area requested for treatment after the abdominal/waistline area. This is almost exclusively a female request and historically consisted of the inner and outer thighs. But as liposuction has become more advanced, contour reduction and shaping has extended to the knees down to the ankles. It is no surprise that successful lower extremity liposuction shaping works just as below below the knees as it does above it.

The knees may be a small body area but they have an important aesthetic role in the lower extremities. Being situated midway between the upper and lower leg, they provide an aesthetic breakpoint in the leg. Their inner and outer contours provide a break in the linear line of the leg. A slight outward curve of the knee provides an appealing curvature as long as it is not too prominent. When fatty collections of the inner knee become excessive, they are known as knobby knees.

Case Study: This 42 year-old female wanted to reshape her ‘knobby knees’. Even though she was not overweight she always had  prominent inner knees which stuck out.

Under general anesthesia, she had power-assisted liposuction (PAl) using a 3mm cannula performed on the inner knee. Fat removal extended upward into the inner thigh and into the concavity of the area between the knee and the upper calf muscle for optimal contouring. A total of 200cc of aspirate was removed in each inner knee.

The Inner knees is often overlooked or forgotten as a liposuction treatment area. In reality it is one of the most successful body areas to treat with liposuction because there is little chance of creating a contour deformity and there is also little risk of loose skin afterwards. Conversely the biggest aesthetic risk is under resection leaving too much fat and an inadequate reduction.

Highlights:

  1. The inner knees is a small but effective body area to treat wth liposuction.
  2. An aggressive liposuction approach to treating knee lipodystrophy is needed to make a visible difference.
  3. The area above the knee  as well as below above the calf muscle is need to create shape to the inner knee contour.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Facial Reshaping Surgery with Chin Augmentation and Facial Fat Removal

Friday, September 15th, 2017

 

Background: The round face is often characterized by soft tissues excesses and bony deficiencies. It takes a combination of both tissue issues to create a round or convex facial shape. Very often the lower jaw/chin is short or deficient and the lack of a bony projection is the linchpin to this type of facial shape. While such a facial shape may be adorable as an infant or young child, it is often not perceived so in adulthood.

When the chin is short, the debate is often between that of an implant or a sliding genioplasty. There are advantages and disadvantages to either chin augmentation method. But the round or fuller face usually has a fuller submental fad pad and attached neck muscles that are relatively short. Moving the chin forward in the round face has the advantage of stretching out the attached neck muscles and improving the shape of the neck even if liposuction or a submentoplasty are still going to be performed.

The other component of the round face is excessive fat. While removing facial fat alone rarely changes one’s facial shape entirely, it still has a valuable role in facial reshaping surgery. Facial fat removal maximally consists of addressing the three main compartments of the buccal space, perioral mound/jowls and that in the neck..

Case Study: This young female had a very round face and short chin. She had an orthodontically corrected Class II occlusal relationship.

Under general anesthesia she had a 10mm sliding genioplasty advancement combined with buccal lipectomies, perioral and neck liposuction for an overall facial reshaping effort.

Her after surgery results showed a dramatic change in her facial shape with a better defined chin and jawline and much thinner looking face.

The combination of bony augmentation and fat reduction can produce a diametric facial effect which leads to a significant change in one’s facial shape.

Highlights:

  1. Significant facial reshaping often requires a combination of bony augmentation and fat reduction.
  2. A sliding geniopslasty helps the fuller neck by stretching out attached neck muscles.
  3. The combination of buccal lipectomies and personal and neck liposuction are the most fat reduction that can be done in the round face.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Severe Double Chin Correction

Friday, August 25th, 2017

 

Background: The lower face is perceived by the shape and projection of the chin and the cervicomental angle. A fairly well defined neck angle and a discernible chin are positive facial features regardless of age, gender or ethnicity. This speaks to the popularity of such plastic surgery procedures like chin augmentation and neck liposuction which strive to achieve these individual facial improvements.

A well known lower facial aesthetic deformity is the double chin. This does not occur because one really has two chins, it just looks like one does. The real chin is usually horizontally short but creates the upper part of the double chin. The second ‘chin’ is a fat and skin roll in the upper neck that sits below the bony chin. It is more recessed than the bony chin and thus creates a double roll in profile, like a set of stairs, into the lower neck. The double chin often appears as part of an overall facial lipodystrophy in its more severe form.

Case Study: This 25 year-old female had a rounder fuller face and a double chin in profile. The chin was horizontally short due to a more recessed lower jaw and a high mandibular plane angle. She also had a hyperactive mentalis muscle due to the short chin.

Under general anesthesia, a 10mm sliding genioplasty was performed from an intraoral approach to improve her chin projection and stretch out the submental area. Submental/neck liposuction and buccal lipectomies were also done to help deround her face as well,.

Her result shows the dramatic change that can occur from the diametric movements of increased shin projection and decreasing the cervicomental angle.While both tissue movements are concurrently helpful, the biggest influence is from the sliding genioplasty.

As the chin bone is brought forward it carries with it the genioglossus and geniohyoid muscle. This creates a tissue stretch in the upper neck and helps elevate the ‘second chin’ of the double chin. This is an effect that is not created by the placement of a chin implant on the bone. Which is why in cases of severe double chin cortrection the sliding genipoplasty is the preferred approach to implants even though it is far less initially appealing to do so.

Highlights:

  1. The double chin is always associated with a short lower jaw projection and a thicker fatty neck.
  2. ]The diametric movements of stretching out the chin and pulling back on the neck creates the best double chin correction.
  3. The best chin augmentation for the severe double chin is a sliding genioplasty as the bone movement lengthen the neck muscles as well.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Large Buffalo Hump Reduction

Thursday, August 3rd, 2017

 

Background: The buffalo hump is a descriptive term that universally applies to a discrete collection of fat on the back of the neck. Looking at the American bison it is easy to see why it has its name with the massive shoulders of the animal being amongst its most distinct features. But unlike the bison, the human buffalo hump is not muscle but fat.

The dorsocervical collection of fat in humans both unusual and distinct for two reasons. First, it is not a typical location for fat to deposit as it is not known for being a metabolic depot site. It may reflect the congenital location of brown fat which is known to be present in newborns but diminishes with age. Secondly what activates the enlargement of the dorsocervical fat pad is not precisely known. Certain medications and illnesses are associated with its development but it can also occur in people who do have these drug or disease associations.

Case Study: This 22 year-old male presented for treatment for his large buffalo hump deformity. He was a large adult man (almost 300lbs) but he did not have any of the associated triggers for its development. It caused him neck pain and restricted his neck extension. He was also socially embarrassed by it.

Under general anesthesia and in the prone position,  a three-hole liposuction approach was used. Using power-assisted liposuction with baskets as well as smooth round-tipped cannulas the very dense fibrofatty tissue was aggressively treated with an aspirate volume of just under one liter. (900ccs)

His immediate result during surgery showed the degree of improvement which largely made the back of his neck flat again. Unfortunately there are no good methods of after surgery compression for the back of his neck so he will have considerable swelling which will take more than a month to return to this intreoperative result.

The traditional method of buffalo hump reduction was open excision. Due to its very dense fibrofatty tissue it was felt that liposuction could not get an adequate reduction. And if one was using traditional ‘elbow-driven’ liposuction this would still hold true. But today’s many power-driven liposuction technologies make it possible to reduce denser and more fibrous fatty areas like the buffalo hump. While not every case has such dense fibrous fat many buffalo humps do.

Highlights:

  1. The buffalo hump deformity is an abnormal development of fat in the dorsocervical fad pad.
  2. It is a often a dense fibrofatty tissue that requires a mechanized or energy-driven liposuction method for removal.
  3. An open excision of the buffalo hump can usually be avoided.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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