liposuction

Question 1

describe ideal candidate for liposuction

Answer 1

already at ideal body weight though disporportionate adiposity causing contour deformity
realistic expectations
no body dysmorphia etc
no significant medical comorbidities

Question 2

Areas to avoid with liposuction (to prevent contour irregularities)

Answer 2

lateral gluteal depression
infragluteal fold
inferolateral iliotibial tract
mid medial thigh
infragluteal triangle

Question 3

absolute CI to tumescent liposuction

Answer 3

severe obesity
hoping for weight loss effect
body dysmorphia
untreated psychiatric illness
excess scarring in the target areas
pregnancy

Question 4

relative CI to tumescent liposuction

Answer 4

moderate obesity
poor wound healing (eg Ehlers Danlos)
hypertrophic / keloidal scarring
coagulation/ bleeding disorders
allergy to LA
AE to adrenaline 
significant medical illness
unstable psychiatric condition

Question 5

indications for liposuction

Answer 5

contour irregularities
lipohypertrophy
lipomas
Cushingoid buffalo hump
gynaecomastia
Dercum disease
lipomas, familial multiple lipomas
axillary hyperhidrosis/ bromhidrosis
lymphoedema

Question 6

Advantages of tumescent liposuction vs traditional liposuction

Answer 6

awake patient
minimal blood loss due to adrenaline
minimal bruising
minimal pain post proecdure (LA can last as long as 24H)
dressings/support garments for shorter period (1-3 wks vs 4-6 wks)
return to work earlier
lignocaine has bacteriostatic properties (less risk infection)
less risk of dimpling appearance
no reported deaths

Question 7

Pre-procedure assessment - history + examination

Answer 7

Comorbidities (medical, psychological)
RFs for complications (infection, scarring, AEs from the LA, clotting, bleeding)
Medication history
Allergies
Smoking
Social/return to work etc
Examination factors
- BMI, striae, cellulite, actinic damage, scars, loose/excess skin
PHOTOGRAPHS

Question 8

Pre-procedure Ix

Answer 8

FBC, ELFTs, coags, Hep B/C/HIV, HCG

Question 9

Tumescent recipe

Answer 9

1L saline
50ml 1% lignocaine (500mg)
1ml 1:1000 adrenaline (1mg or 1:1000000)
2.5-10ml sodium bicarbonate (8.4%)
OR
1L Ringer solution
50ml 1% lignocaine
1ml 1:1000 adrenaline

Question 10

Maximum dose of lignocaine with tumescent anesthetic

Answer 10

55mg/kg if healthy

35mg/kg if RFs

Question 11

Method

Answer 11

equipment + staff
ability to mx emergency
markings done while pt is standing (insertion sites)
equipment - infiltration + suction cannulae, tubing, blade, gauze, pump
IV access
Sterile prep + pt positioning
Warm tumescent solution
Incise access points (under usual LA)
insert cannula
infiltrate <100ml/min w slow advancement, fan approach looking for firm induration/blanching
leave for 15-20 mins
liposuction - aggressive thinner cannulae first then less aggressive, apperture away from dermis (leave superficial fat)
End point is increasing bloody aspirate, gritty feeling, flaccid appearance, lack of suctioned fat

Question 12

cannulae differences

Answer 12

multiple holes at the tip = more aggressive (more fat but more trauma + bleeding)

smaller diameter + blunt ends + fewer proximal holes away from tip = less aggressive, less trauma

Question 13

complications

Answer 13

• immediate - pain, blood loss, heart arrhythmias, vasovagal, tachycardia, hypothermia
• acute - prolonged oedema (normal response), ecchymoses
• short term - infection, necrosis, pigmentary changes, scarring, skin necrosis, paraesthesia, neuroma, asymmetry, skin laxity, surface irregularities, haematoma, seroma
• longterm - suboptimal result, weight gain, scarring, over-correction, under-correction, asymmetry, sensory nerve impairment
• serious - DVT, visceral perforation, fulminant infection, fat embolism (usually 24-72H), pulmonary oedema

Question 14

What temparature does cryolipolysis use

Answer 14

• 10 deg for 35-60 mins

- need 1-3 sessions, 2 months apart

Question 15

how does cryolipolysis work?

Answer 15

triggers a panniculitis - apoptosis of adipocytes –> destroyed fat cleared by macrophages

• inflammation peaks at 2 weeks, lasts 3 months

Question 16

ideal patient for cryolipolysis

Answer 16

• soft discrete bulges of fat
• optimal weight
• not obese
• no significant medical conditions, prior surgery in the area, cold-induced conditions

Question 17

Adverse effects of cryolipolysis

Answer 17

• intraoperative - pain, vasovagal
• acute - pain, erythema, bruising, sensory changes, swelling
• longterm - inefficacy, asymmetry, paradoxical fat HYPERPLASIA

Question 18

What are other options for contouring/ fat reduction

Answer 18

• High intensity Focused US
• MR contouring
• laser assisted
• chemical adipocytolysis
• radiofreqency tx
• carboxytherapy

Question 19

How dose High Intensity Focused US work?

Answer 19

• generates heat at target sit –> coagulative necrosis of adipocytes + collagen remodelling
• tissue temperature 56 deg C

Question 20

AEs if HIFU?

Answer 20

pain, erythema, oedema, brusing, muscle weakness, paraesthesia

Question 21

T/F Fat reduction techniques have the risk of causing altered lipid homeostasis

Answer 21

F - not thought to

Question 22

Benefits of radiofrequency (eg truSculpt) technique for fat reduction

Answer 22

Better skin tightening effects so good for patients with more skin laxity

Question 23

How does radiofrequency treatment work for fat reduction

Answer 23

heat to 42-45 deg C over 20-30mins - epidermis cryo spray to protect

Question 24

How does MR contouring work (high intensity focused electromagnetic technology HIFEM)

Answer 24

also improves muscle tone
stimulates muscle contractions (20000 pulses in 30 mins
Triggers fat lipolysis

Question 25

What is carboxytherapy

Answer 25

JAAD Aug 18 paper

- insufflation of CO2 into fat - unknown MOA ?microcirculation changes - damage of adipocytes due to oxidative effect