Liposuction Flashcards
1
Q
Describe the anatomy and physiology of fat
A
- Adipocytes derived from mesenchymal SC ->adipoblasts in 12th wk gestation
- infancy - hypertrophy of adipocyte
- 1-5yo - increase in # and size
- adolescence- increase size with no resulting wt gain
- adult - no increase in ##, just increasein storage
PHYSIOLOGY
- 2 receptors of adipocytes
- B2- Fat B gone - lipolysis
- A1 - lipogenesis, prevent lipolysis (DM, fasting, hypothyroid)
Organization
- in two anatomic layers on TORSO and PROXIMAL legs (not below knees/UE)
- Superficial layer - above scarpa’s fascia - condense lobulated fat compartmentalized with vertical septa, compacted - retinacula cutis are caused of celulite
- 1’cellulite - due to hypertrophy of adipocytes
- 2’ cellulite - due to ptosis of tissue
- Deep layer - between deep fascia nad scarpas fascia - less organized haphazard septa, areolar tissue
2
Q
How do you classify obesity
A
According to BMI
<18.5 underweight
18.5-25 normal weight
>25 overweight
>30-35 obese 1
35-40 obese 2
>40 obese 3
3
Q
What are etiologies and syndromes of obesity/adipose tissue
A
ETIOLOGIES
- Genetic predisposition: PW syndrome - high appetite
- Poor exercise/diet
- Endocrine: hypothyroid, cushing, hypopituatary, DM, PCOS
- Drugs (BCP, antidepressant)
SYNDROME
- prader willi syndrome
- Bardet Bield
- Fragile X
- Lipodystrophy
- Painful lipodystrophy
- Progressive lipodystrophy
- diabetic lipodystrophy
- Lipomatosis
- multiple symmetric lipomatosis (madelung)
- multiple knotty lipomatosis
- Acute panniculitis
4
Q
How do you assess a patient presenting for liposuction?
A
Hx
- Weight: age when gained, fluctuations, max/min, time maintained
- Methods: diets/exercise/drugs/surgical
- Hx of pregnancy, DVT, Fam Hx
- Goals/areas of concern
- Symptoms of endo D (hypo,pit,ova,thyroid, adrenal)
- PVD, CAD, CVA, DM, OA, HTN, coag/VTE, GI, intertrigo
- Smoking
- Nutritional state
- visit to nutritionist/gastric surgeon, psych
PE
- General : wt, Ht, BMI
- Endo D: myxedema, hair/skin changes, hirsutism
- distribution of weight deviating from ideal
- skin quality, turgor, elasticity
- Scar striae, surgical
- Rolls, asymmetries
- Areas of potential liposuction
- areas of non-liposuction /adherance
- pinch test
- intra vs extraperiotoneal fat/hernia
Investigations
- CBC, lytes, Cr, Urea, Alb, Pt/PTT, LFTs, lipid profile, TSH, cortisol
Treatment options
Non-op
- diet, exercise, behavior modification, drug therapy, referral to fam MD, nutritionist, psych, dietician, endocrin
Operative
- liposuction (Suction, physician, water ultrasound assisted)
- excisional lipectomy
5
Q
What are contraindications to SAL?
A
ABSOLUTE
- Medically unfit
- pregnant
- obese
- skin excess
- traumatic/multiple scars
- unrealistic expectations
- psyhcologically unfit
RELATIVE
- poor skin tone
- fat deposits in locations with poor response to SAL
- smokers
- poor wound healing
6
Q
How do you classify liposuction
A
BY TECHNIQUE
- mechanism: machine vs syringe
- energy: suction, ultrasound, laser
- deptg: superficial vs deep
- tumescnce: dry/wet/superwet/tumesecent
- volume: small to large (>5000c lipoaspirate)
7
Q
Describe the composition of liposuction tumescent solution
A
Hunstad
RL 1000cc
50cc of 1% lidocaine (500mg)
Epinephrine 1cc 1:1000
Na bicarb 12.5mg
Final concentration: 0.05% lidocaine, 1:1 000 000 epi
8
Q
Describe safety concerns with the use of lidocaine
A
- Max amount of lidocaine is 35mg/kg when used in highly dilute solutions (lidocaine <0.1%)
- in Hunstad solution - 50cc of 1% lidocaine in 1000L = 0.05% lidocaine concentration
- Max lido of 35mg/kg (not 7mg/kg is because
- slow absorption
- aspiration during lipo
- vasoconstriction (with epi)
- liposolubility of lidocaine
- Peak level of lido in plasma is 6-12h later
- if using >5000cc of tumescnet, reduce lidocaine concentration by half
- Lidocaine toxicity presents with perioral numbness/tingling, cardiac collapse
- Max dose of epinephrine is 10mcg/kg (0.01mg/kg)
- Not if PVD, hyperthyroid, CAD, pheochromocytoma, severe HTN
9
Q
Describe guidelines for fluid resuscitation with SAL
A
- WET (200-300cc per area)
- 1:1 IV fluid:aspirate intra-op and post-op
- monitor U/O
- if >2.5L lipo, Monitor Hb/Hct +/- transfuse
- SUPERWET (1:1 infiltration for expected aspiration)
- if <3L aspirate, no IV resus, minimal
- if >3L aspirate, 1:1 fluid resus, montior U/O
- TUMESCENT (2-3x infiltration for expected aspirate)
- no IV resus, minimal given, monitor U/O
If >5l aspirate, admit overnight for BP and U/O moniotoring
If <5L aspirate and outpatient, ensure voidign prior to discharge!
10
Q
What are advantages and disadvantages to SAL with superwet/tumescent technique vs Dry?
A
ADVANTAGE
- less blood loss
- less bruising/swelling
- more efficient removal of fat w small and large volume
- less effort required
- Improved analgesia
- reduced IV fluid resus
DISADVANTAGE
- Lidocaine/epinephrine toxicity
- fluid overload
11
Q
What are the zones of adherance
A
- Gluteal crease
- Lateral gluteal depression
- Distal lateral thigh
- Posterior inferior thigh
- Middle medial thigh
12
Q
Describe your operative plan for liposuction
A
MARKINGS
- pt standing; mark topography - areas for lipo, rolls, depressions
- confirm areas of non-lipo and lipo w pt
Anesthesia and room prep
- GEneral vs tumescent + iv sedation
- data recording sheet,pre-op photos
- SCDs, TEDs
Deep liposuction
- stab inciision in RSTL
- Infiltration as per superwet/tumescent
- Pretunnel
- avoid zones of adhrence (5)
- 2 directions perpendicular to one another
- aspiration with control using contrlat hand, 4-6mm cannula in general, proper positioni ng, not cephalad towards abdo/chest
- pinch test
- feather out at edge to blend
- record aspirate and infiltrate
Superficial lipo
- with caution
- lots of tunneling w small cannula
- helps w cellulite, skin contraction
Post-OP
- compression 3-6wk
- analgesic
- activity - early ambulation, normal activity 5 days, exercise 3-6wks
- massage
- Beware first dressing removal - vagal - vasodilation/trauma
13
Q
What are complications from liposuction
A
EARLY
Minor
- Transient hyperesthesia, hemosiderin deposits
- Transient asymmetries, irregularities
- Infection
- Seroma, Hematoma
- Wound: thermal injury, delayed healing
Major
- DVT/PE
- Fluid overload/underload - shock
- Infection
- Embolism fat/air
- Perforation of visceral organ
- Lidocaine toxicity
- DIC
LATE
- contour irregularity, asymmetry, dimpling, divot
- over/undercorrection
- dysesthesia
- pain along fascial planes
- ptosis (poor skin contraction)
- pseudobursa formation
14
Q
Fat embolism
Describe etiology, Diagnostic criteria, clinical features, management
A
- Etiology
- 2theories: FFA in blood are toxic to pneuomocytes/lung endothelium =>interstital hemorrhaging/edema/pneumonitis. OR fat lobule pshyically obstructs venous flow,platelet aggregation, emboli to brain, heart, lung
- Diagnostic Criteria - Major:
- pulmonary edema
- hypoxemia (PaO2<60)
- neurologic dysfunction
- petechiae vest distribution + subconj
- Clinical Features
- presents 24-72hs later!!!
- tachypnea, hypoxemia, hemoptysis
- petechial rash
- neurological dysfx
- fever tachycardia
- Labs: low plt, Hct, PaO2<60, DIC, high ESR, LFT abN
- CXR: bilat infiltrate (ARDS), ECG RBBB
- BAL - fat lobules in lavage
- Treatment
- supportive - oxygen/volume resus +/- albumin +/- steroids
15
Q
Lidocaine toxicity
Clinical features, Management
A
- Symptoms: HA, lightheaded, dizzy, metallic taste circumoral numbness/tingling => hallucinations, altered LOC, convulsions, CV/resp arrest
- Management
- 20% lipid emulsion
- Bolus 1.5cc/kg IV in FIRST minute
- then infuse 0.25cc/kg/min until cardiac response
- if no cardiac response, repeat 1- boluses
- double infusion to 0.5cc/kg/min if still low BP
- continue for 10mins once cardiac response
- Max 12cc/kg in first 30min
- 20% lipid emulsion
