Liposuction
Prior to liposuction, surgeons attempted removal of fatty deposits by surgical excision, the results were accompanied by unacceptable scarring. Introduced by Dr Illouz from France in the early 1980s, liposuction revolutionised the concept of body contour surgery. Advances in technology with new suction aspirators and cannulas have helped to refine the technique over the last decade.
Patient selection is important and obese patients are usually not candidates. Patients should have accepted nutritional consultation and exercise programmes before considering their adiposity recalcitrant.
Lifestyle or genetic make up are the major contributing factors to an unacceptable shape. Of course the media's pressure, especially on women, to be slender has resulted in people trying to seek an aesthetic ideal. 'You can't be too thin' is a popular maxim often held by females these days.
Most candidates for body contour liposuction have failed medical treatment or accepted their genetic make-up as the cause of their unacceptable shape.
Common areas of concern are the 'saddlebags', hips, buttocks, knees and inner thighs. Patients seek liposuction in an effort to refine their shapes according to popular fashions, or to reduce their torsos so that buying separates is not needed. As summer approaches, the fear of exposure during the warmer months brings them for consultation. Figures 1a and b show an example of saddlebag and inner thigh suction. Figures 2a and b show an example of abdominal suction in a male patient.
Trends in liposuction
Up to two litres of fat can be aspirated by liposuction without the need for autogenous blood transfusion.
Two major trends to optimise the results of liposuction are the tumescent technique and superficial liposuction.
The tumescent technique
The tumescent technique was developed to allow surgeons to remove larger volumes of fat under local anaesthetic, without the accompanying complications of haemodynamic instability or the need for general anaesthesia. The technique involves infiltrating the areas requiring suction with large volumes of diluted adrenaline solution.2
Normally up to 2,000 mL of fat can be aspirated without the need for autogenous blood transfusion. With the tumescent technique larger volumes can be aspirated without the fear of high blood loss.
Superficial liposuction
'Cellulite', commonly referred to as dimpling of the skin accompanied by fatty excess, was once regarded as permanent and uncorrectable by early techniques of liposuction. Newer superficial liposuction techniques have been used to treat cellulite and patients with flaccid skin.
Superficial liposuction involves breaking down fibrous adhesions and injecting fat into depressed areas just under the skin. In Australia, the body contours of most patients can be greatly improved with the standard procedures, which involve an outpatient or overnight stay and are performed under general or epidural anaesthesia. Up to 2,000 mL of fat can be removed safely. The aim of the procedure is not to remove too much fat, but to re-establish natural body curves appropriate to and desired by the patient. The removal of too much fat results in corrugations and flatness which are difficult to treat later.
Medical aspects of liposuction
Dietary habits, nutritional intake and exercise patterns should be assessed in the initial interview. A referral to an obesity clinic is an appropriate decision for some patients. Referral back to the general practitioner, if he or she has a special interest in this area, would also be appropriate. Diabetes should be ruled out.
Patients with isolated fatty deposits who are candidates for surgery need to have a preoperative haematological profile as blood loss is anticipated during the procedure. Autogenous blood donation is advised for those who may have more than 2,000 mL of fat removed. Oestrogen supplementation increases the risk of deep venous thrombosis in the liposuction patient.
Body sculpturing by surgical excision:
abdominoplasty, thighplasty,flankplasty and armplasty
Body sculpturing by surgical excision is indicated in patients who are not candidates for liposuction and who have excessively loose skin. In these patients skin needs to be resected. However, the surgical repairs must not rely totally on skin suturing alone. Deeper fascial structures are also supported surgically to lessen the tension in the skin and reduce subsequent scarring. During abdominoplasty, any accompanying diastasis recti and abdominal hernias are repaired concomitantly. Figures 3a and b show a patient after repair of diastasis recti.
Old surgical scars of the abdomen can be resected if isolated to the infiraumbilical region. Many abdomens are permanently disfigured from previous surgical scarring; this scarring can be resected if it is isolated to the infraumbilical region. Multiple pregnancies or large birth weight babies can cause a dehiscence of the lower abdominal musculature resulting in diastasis recti and ptosis of the abdominal viscera. The abdominoplasty procedure addresses this problem by repairing the abdominal wall. Figures 4 and 5 adjacent show results after conventional abdominoplasty surgery. Combined with the abdominoplasty procedures, judicious liposuction can be carried out at the same time.
The arms, thighs and buttocks are also reduced in those patients who have lost massive amounts of weight either from surgical banding or successful weight loss programmes.
Trends in body sculpturing by surgical excision
The major trends in body sculpturing by surgical excision have been to lessen the extent of scarring and to conceal scars in the intended lines of brief clothing. With the advent of endoscopic techniques, it is possible to achieve less scarring; however, striae and old scars cannot be dealt with by endoscopic surgery. As our population has become more obese, more patients are undergoing gastric banding, often with festoons of skin hanging; these need to be trimmed surgically using the procedures of panniculectomy, armplasty, thighplasty and buttockplasty.
The technique of reduction mammoplasty can be modified to allow for later breastfeeding.
Medical work up for body sculpturing by surgical excision
Abdominal hernias should be assessed preoperatively. Patients' bowel functions should be evaluated as well as their pain thresholds. This procedure requires general anaesthesia, usually two to four days' hospitalisation and has a risk of postoperative thrombophlebitis, especially if patients are obese or are taking oestrogen supplementation. The results achieve a remarkable flattening of the abdomen. The scar from the abdominoplasty usually fades with time and should be concealed in brief clothing.
Aesthetic breast surgery: reduction mammoplasty
Reduction mammoplasty is carried out in women of all ages, from those in their teenage years to the elderly. This procedure elevates the nipples, reduces the breast size, reshapes the ptotic breast and preserves the blood supply to the nipple areolar complex. In a younger female who wishes to breastfeed, the technique can be modified to allow for continuity of the nipple with a large segment of breast tissue.
Patients often present with symptoms of interscapular pain, intertrigo and shoulder notching from the brassiere straps. The procedure is carried out under general anaesthesia, usually with a one to two day hospital stay.
Trends in reduction mammoplasty
The major trend emanating from our European colleagues has been the reduction of scarring. Efforts to reduce the inferior midline or inframammary fold scars have resulted in less visible or narrower scarring. Figures 6a, b, c, and d show a patient before and after reduction mammoplasty.
The Bennelli procedure involves a 'round block' or cinching up suture around the nipple complex; it can completely eliminate the inferior and vertical scars which are an objection to the conventional reduction mammoplasties and mastopexies. This procedure is most ideal for mastopexy alone. However, small reduction mammoplasties can be managed through the periareolar incision. Figures 7a, b, and c show the result of Bennelli mastopexy with elimination of the inferior and horizontal scarring.
Medical work up for reduction mammoplasty
Prior to elective reduction mammoplasty, a family history of breast malignancy should be sought and mammography advised. A haematological profile is needed preoperatively. However, blood loss is usually minimal and a transfusion is virtually never anticipated. Nipple sensation will be reduced from the procedure and this should be pointed out to the patient.
Breast augmentation
Many patients now present with old silicone breast implants, wishing for them to be changed for new saline implants.
Probably no single plastic surgical procedure has received such media attention as breast augmentation; this was due to the US Federal Trade Commission's moratorium on silicon implants early in 1992.
Cases of immunological disease (adjuvant disease) were reputedly associated with liquid silicone implants. The question of a possible causal relationship resulted in an eventual suspension of liquid silicone implants except for breast reconstruction. Ongoing controversy and litigation have resulted in a drop in the number of patients seeking these breast augmentation procedures and many patients with old silicone implants now present, wishing for their implants to be changed to the newer saline ones or removed completely. Few patients have reported systemic illnesses or collagen diseases, but many have scarring or capsular contracture around these ancient implants.
Textured saline filled implants are still available and offer an altemative to silicone which is successful in most cases for breast augmentation. Many women are distressed by post- pregnancy breast degeneration or by the failure to develop their desired bust size by maturity. Unacceptable asymmetry is also present in about 5% of women. These patients gain significantly in self esteem after breast augmentation, which can be carded out as an outpatient procedure under general or intravenous sedation and local anaesthesia.
Trends in breast augmentation
Patients seeking breast augmentation should be self motivated rather than the subjects of undue pressure from a spouse or male companion.
The major trend in breast augmentation has been the abandonment of the silicone implant in favour of the saline implant. Implant surfaces are textured now to reduce the likelihood of capsular contraction around the implant which leads to firmness and distortion of the augmented breast. Figures 8 and 9 show patients before and after augmentation mammoplasty.
Medical considerations for breast augmentation
A family history of breast malignancy is sought and mammograms may be indicated prior to the procedure. Patients with autoimmune disease are not candidates for augmentation mammoplasty. Patients should be self motivated rather than the subjects of undue pressure from a spouse or male companion.
Male customised implants
Chest (pectoralis) implants for males are becoming more popular (Figures 10a and b). Pectoralis and calf implants are not uncommon requests, especially in amateur body builders or patients who have pectus excavaturn or a deficiency of their calf musculature secondary to polio or paediatric orthopaedic surgery. These are firm silicone implants and are not subject to the US Federal Trade Commission moratorium imposed on the liquid silicone breast implants.
Various sizes of implant are available; when inserted, they augment the size and volume of the pectoralis or calf muscles. There is a major trend for more male patients to seek cosmetic surgery. Facelifting, rhinoplasty and liposuction are common requests but zygomatic and chin implantations are also well established procedures for males.
Breast reconstruction after mastectomy
Probably no procedure embodies the patient's desire for an improved quality of life more than the request by a woman for breast reconstruction after mastectomy for malignancy. As less radical procedures are now more popular, reconstruction can be carried out more efficaciously using expansion techniques and textured saline implants. If more tissue has been removed in the mastectomy, as with the standard modified radical mastectomy procedure, distant or local flaps might be needed to provide missing tissue on the chest.
In cancer surgery, more emphasis has been placed on immediate breast reconstruction over the last five to 10 years.
It was popular during the late 1970s and early 1980s to use the latissimus dorsi flap, but its disadvantages were that it required an implant and also produced an undesirable scar on the back (Figures 1 la, b and c). However, it was a most reliable flap and there seemed to be no functional disturbance from the sacrifice of one latissimus muscle. The flap transferred skin and fat from the back and was set into the chest wall, under which was placed an implant. Figures 12a, b and c show a patient before and six years after latissimus flap breast reconstruction.
During the early 1980s the transverse rectus abdominis muscle flap (TRAM), with either one or both rectus muscles, was used to deliver skin and fat from the lower abdomen to the chest wall in a one-stage procedure and allowed the sculpturing of a new breast without the need for a breast implant (Figures 13a, b, and c). This operation was of a greater magnitude than breast reconstruction using the latissimus dorsi flap. The TRAM flap results were gratifying and enabled a new level of final result to be achieved. A second stage procedure was carried out about three months after the TRAM flap operation in which the opposite breast was balanced and the nipple areolar complex was reconstructed. Figures 14a, b, and c show the early result of second stage TRAM flap breast reconstruction.
Trends in breast reconstruction
Patients who have undergone mastectomy should not be discouraged from seeking reconstructive surgery as the psychological benefits are immeasurable.
More emphasis has been placed on immediate breast reconstruction over the last five to 10 years. Combining the efforts of the general surgeon in planning and resection, the reconstructive surgeon may simply place an expander or, if more major resection was planned, an immediate TRAM flap can be the procedure of choice. Microvascular- free TRAM flaps have been shown to be safe and flap failure is uncommon.
The use of expansion techniques, with either permanent expanders such as the Becker prosthesis or with textured saline implants and textured expanders, offer a simple solution for the patient who has no objection to a saline filled prosthesis. Not all patients are candidates for TRAM flaps due to their smoking habits, abdominal anatomy, abdominal scars or obesity.
Medical work up for breast reconstruction
The support of families and general practitioners is a very valuable asset for the patient contemplating cosmetic surgery.
Patients should have finished their chemotherapy programmes. Ideally, they should be disease-free on oncological work up for metastasis, which is mandatory. Patients should have a normal haematological profile. If the patient is to undergo a TRAM flap, autogenous blood should be donated preoperatively. The patient should not be discouraged from seeking reconstructive surgery as the psychological benefits are immeasurable. The restoration of self esteem is a valuable asset to any patient recovering from breast malignancy. Figures 15a and b show a 68-year-old female before and one year after TRAM flap reconstruction of the breast.
Summary
Cosmetic surgery has become a subspecialty in its own right. As a subspecialty of plastic surgery, it requires extra training and few opportunities exist in graduate programmes for exposure to the multitude of cosmetic procedures now practised. Most cosmetic surgeons have a strong background in general and reconstructive surgery, and a special desire to improve the quality of life of their patients.
Cosmetic surgery has high media exposure as TV and media personalities and movie stars are constantly asked to comment on their own cosmetic surgery. The public is intensely interested in cosmetic surgery and demands to be informed. Many other specialties provide services for the patient seeking cosmetic surgery; it is not the exclusive realm of plastic surgeons. Interspecialty co-operation rather than competition leads to better care of the appearance-impaired patient. The support of families and general practitioners is a very valuable asset for the patient anticipating cosmetic surgery.
References
1. Illouz Y.G. Body sculpturing by lipoplasty. Churchill Livingston, 1989.
2. Klein J.A. Tumescent technique for regional anaesthesia permits lidocaine doses of 35 mg/kg for liposuction. Journal of Dermatological Surgery and Oncology 1990; March: 248 - 263. |
