– The leg is emptied of its blood with the help of an aseptic Esmarch bandage.
– The tourniquet is inflated to 30–35 mmHg.
– The Esmarch bandage is removed as soon as the tourniquet is inflated.
– The iIncision is at the selected accesses previously marked with a felt-pen marker.
– The adipose extraction should be fan-shaped, homogeneous, and regular.
Experience has enabled us to develop and codify all of the surgical maneuvers for a complete sculpture of the leg. Short (3–5 mm) incisions are used in the direction of the natural fold and in positions that permit the best access to the areas of liposculpture. Surgery is begun with the ankle at the end of the operation table, with the cosmetic surgeon seated on a stool. The excess fatty tissue of the anterior external space is emptied by an antero-external incision, followed by the antero-internal space of the ankle by an antero-internal incision, the internal retro-malleolar groove is hollowed out via a postero-internal incision, and the postero-internal space is treated. A posteroexternal incision of the ankle is used to hollow out the external retro-malleolar groove and the posteroexternal space is sculptured. Subsequently, with the cosmetic surgeon standing at the right of the table at knee level, the internal side of the knee towards the lower end is incised, which permits the sculpture of the whole internal face of the leg.
Moving to the left of the table, an incision and a fan-shaped extraction are performed in the direction of the anterior tuberosity of the tibia and the subfibular area and continuing without stopping, we return backwards to the right and upwards to the left supero-internal space. With the leg flexed, its external face is treated via an external incision of the knee. With the leg in extension and in internal rotation, while the cosmetic surgeon is standing at the end of the table, there is access to the external subfibular adipose lump, to the external edge of the fibula, and, with the knee in flexion, to the external superior space of the knee.
The supra-fibular space of the knee can be aspirated either in flexion or in extension via a fibular incision, then turning interiorly towards the superior internal space of the knee and the internal subfibular adipose lump. The same fanlike gesture permits the passage from the vastus externus to the tibial crest. Lastly, via a posterior incision of the calf with the hip flexed, the knee in extension, and the foot held in flexion by the assistant, the Achilles’ tendon, the calf, and the subpopliteal space can be precisely sculptured. The leg is transformed and sculptured according to the patient’s request. During the surgical procedure, a notice of the elapsed time is given every 10 min. Whether the incisions are closed or not depends on the cosmetic surgeon’s habits. The measurements of the leg circumference are taken again, noted, and photographs are taken at the end of the operation. They will serve as a reference for a procedure on the other leg. The fat collected is pure yellow without any blood. It takes approximately 30 - 40 min to do one leg and the other leg is operated on in a similar fashion. A large aseptic operative field isolates the opposite leg. Compression is mandatory before removing the tourniquet. It consists of an elastic bandage by a double stocking for varicose veins (70 deniers) and then by a superposed elastic band of Biflex type. When the tourniquet is released, the capillary pulse of the toes is closely monitored after cutting off the stocking at toe level. The fat volumes extracted from each space are noted during the operation in order to aspirate the same amounts on the other leg.
The immediate postoperative course is usually simple, with pain remaining moderate in spite of the large amounts of adipose tissue extracted. Edema and ecchymosis are practically absent. Patients are authorized to get up the next day. The day after liposuction surgery it is possible for stage III patients to go home, while one or two more days may be necessary for stage IV and V patients. Sutures are removed between the eighth and the tenth days. Postoperative visits are made on days 1, 2, 6, 12, and 30. Compression devices are kept on for 1–2 months.
The authors observed five undesirable events. They were diverse in nature, but none of them were really serious or unresponsive to appropriate therapeutic actions. The worst adverse reaction was in a patient who developed a paralysis of the popliteus externus. The latter was attributed to the slipping of the elastic bands due to movements of the knee. This induced a compression of the external popliteal branch of the sciatic nerve. Since then, we have abandoned the use of two elastic bands applied directly to the skin. We prefer compression by a pair of tights for varicose veins. The elastic bands put in place at the end of the intervention are then definitely removed o1 h later. One case of a unilateral cellulitis was observed in a diabetic patient. The infection was treated and rapidly cured by several small cutaneous discharge incisions combined with antibiotics. A case of major edema occurred after a large adipose extraction (1,500 ml) in one patient who returned to work the next day, in spite of our advice not to do this. The edema regressed after 3 months and the result after 1 year remained excellent. In two cases, in the course of the operation the tourniquet let go on one leg. In one of these cases, the liposuction surgery was continued without putting the tourniquet back.
The immediate postoperative consequences were simple for the side where the tourniquet stayed in place but there was more edema, pain, and ecchymosis in the leg where the tourniquet let go. Thus, we had the unsolicited opportunity to compare the two methods. In the other case, the blood of the leg was reemptied by the use of an Esmarch bandage and the tourniquet was reinflated. The aspiration was carried on including both the adipose tissue and the extravasated blood. In this case, the immediate postoperative reactions were the same for the two legs.
In our series of patients we did not control the results of the treatment by comparing the classical technique on one leg and the technique under tourniquet on the other leg, except for one case. Obviously, such a comparative approach would be of interest for a more rigorous evaluation of the procedure. With respect to the complications, the authors observed a rate of 3.4% in 150 cases. There was no occurrence of life-threatening or otherwise major adverse events. In a review of the literature looking for potential complications associated with the use of pneumatic tourniquet, one can find mention of hemodynamic and biological changes such as an increase of the PCO2 and a decrease of the PO2. These changes are rare and, when present, are temporary, and follow the release of the tourniquet. Most often, this occurred in older patients. Phlebitis and pulmonary embolism represent the most frequently reported complications because of the use of the tourniquet. These problems have been reported by orthopedic surgeons, who are the main ones to use pneumatic tourniquets. Our logical theoretical response is that if there is no blood there will be no clot. Correct emptying of the blood of the lower limb before inflating the tourniquet is mandatory and can avoid the formation of clots since the vessels are emptied of their blood. Liposuction under tourniquet offers several significant advantages:
– No infiltration of solution is necessary. This not only permits a valid appraisal of the quantity of fat extracted, but also a satisfactory sculpture because of the absence of injection-induced modification of the form of the leg to be operated upon.
– The absence of bleeding during the surgical procedure prevents the modification of the anatomical form that would occur by infiltration of the tissues. It thus permits a sculpture that corresponds to the precise image of the final result.
– Ecchymosis is rare and only minor.
– Pain and postoperative edema are practically absent, which permits early walking and a reduced length of hospital stay.
– Patients can rapidly return to their socio-professional activities, usually 1 week after the operation. Liposuction under tourniquet also presents a few drawbacks:
– The absence of local anesthesia leads to the prescription of larger amounts of analgesics generally administered during the first postoperative hours.
– The duration of the procedure is limited by the use of the tourniquet. We voluntarily limit this time to 1 h. This is usually sufficient to achieve a complete sculpture of the leg. For large extractions, cannulas of larger gauge are used and touchups are left for a second operation.
– This technique does not permit the treatment of areas above the tourniquet during the same operating time, leaving them to be operated on secondarily by the classical technique.
Liposuction under a pneumatic tourniquet of the leg permits the treatment of zones that are known to be difficult and of which the indication has been challenged up to now. The results obtained over a 7-year period of time were most satisfying esthetically with the precision of the sculpture of the leg having never been achieved before. The unexpected functional improvement has led to a better understanding of the physiopathology of the heavy legs syndrome and of lipoedema.
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