The procedure is then performed using the syringe for harvesting fat for later grafting. I use the Coleman needle for this portion of the procedure. This fat is decanted and placed in syringes for later use. My present technique does not include washing or centrifuging the fat. The serum and fluid are discarded after the fat has risen to the top. The oil layer on the very top can either be aspirated or absorbed in a sterile gauze wick. Once as much fat as is felt to be needed has been obtained, liposuction is performed in the deeper fat in the routine manner using the vacuum pump. The one area in which I first work superficially is the inner thigh. Superficial liposuction can be performed in most areas of the body. The level at which to work, according to Luiz Toledo of Brazil, depends on the region, the problem and the skin tone.
The abdomen is the area of the body most commonly treated by liposuction. Both sexes have a thinner more athletic torso as one of their primary goals. The abdomen is one of the areas that beginning liposuction surgeons choose for their initial cases. Unfortunately, the abdomen can be one of the most difficult areas to achieve optimal results. When evaluating a patient for liposuction the distinction should be made between omental or visceral fat and fat in the subcutaneous tissue. We must explain to them that liposculpturing cannot change their contour if the bulk of their fat is visceral or omental. The application of the Matarasso classification is useful when evaluating the abdomen. The aesthetic appearance, however, can be altered with liposculpturing. For most class IV cases liposuction is initially performed and then abdominoplasty is done after a few months. The reason for this is often the extent of the abdominoplasty can be reduced and occasionally the necessity for abdominoplasty may be unnecessary. In type III cases, liposculpture and a crescent-tuck abdominoplasty are combined with or without rectus plication. It is important to examine the patient in the standing position and evaluate for rectus laxity, diastasis recti and hernias. The patient should also be examined in the diving, sitting and supine positions with the head elevated. By using these positions one will be able to determine the excess fat to be removed as well as the presence of diastasis recti and/or muscular laxity. Using the Klein pump, infiltration of the tumescent fluid is accomplished. The amount of fluid injected is equal to the amount of aspirate removed. With routine or mechanically assisted liposuction aspiration is initially performed in the deeper planes first. It is extremely important to know exactly where your cannula is at all times.
The opposite hand from the one moving the cannula must always be in contact with the tip of cannula. This can be accomplished with the hand in the flat position or by use of the pinch maneuver around the cannula. It is also important that the cannula remains parallel to the skin and underlying musculature at all times. Once the deeper fat has been reduced then one can move superficially. In the deeper planes the 3.0–3.7-mm cannulas are usually used. Occasionally, in the very obese abdomen, a 4.0-mm cannula is utilized in the deeper planes. The routine cannulas used are of the multiple- holed, ventral three-holed and the Saylan semispatula three-holed type. Presently, I am performing mechanically assisted liposculpture. It is important to note that once the abdomen has been reduced in the deeper planes smaller cannulas up to 2.0 mm are used to carry out superficial liposuction. The depth is controlled very carefully by the operator in order to thin the superficial layer. The end point of superficial liposuction has been accomplished when there is a small uniform amount of fat around the cannula and a smooth even feel and appearance of the skin. One can lift the cannula or carry out the pinch test to evaluate this depth. Once superficial liposuction has been accomplished one can feel the deeper fat to determine if further deep liposuction is required. The ideal result will be a smooth abdomen free of bulges or indentations. The upper abdomen presents a different challenge when compared with the lower abdomen.
The fat in the upper abdomen is contained within a significantly denser, more fibrous matrix. If this upper abdominal fat is not removed the patient will be left with a heavy upper abdominal fat pad that will yield a sagging upper abdomen with bulges that are unattractive. In this area liposculpture must be carried out in both the superficial and the deep planes taking care to work over the costal margins. The maneuver that I use in this area is to push down on the ribs and elevate the cannula just under the subcutaneous tissue being very careful to note that cannulas are over and not under the costal margin. To prevent unattractive fibrous attachments that can produce a pleating appearance, the crisscrossing radial pattern of liposuction initially described by Dolsky and Fournier is required. My personal technique is to use the multiple-holed small cannula and to follow this with a one-holed small, flat spatula. The fat around the periumbilical area is resistant to removal but must be removed to prevent the “donut” appearance of residual fat around the umbilicus. For safety of the patient and to prevent intra-abdominal perforation through an undetermined hernia it is important to place the index finger of the opposite hand in the umbilicus. This maneuver will prevent inadvertent perforation as well as help define the fat that needs to be removed in this area. The final part of the sculpturing procedure of the abdomen is the compression, which I feel gives support and allows for contracture during the postoperative phase. Postoperative care is very important for the final result. Foam compression is presently used in addition to the girdle-type garment and an abdominal elastic binder. Foam is used for the first 4 days and then just the garment and the binder.
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