ITEM ABBREVIATIONS ‐ JULY 1 LINC WORD/PHRASE 3000 4000 5000 6000 7000 8000 9000 2 MERCAPTOETHANOL 2 METHYLBUTANE 2 MICROGLOBULIN 2 WAY 2WAY 2‐WAY 3 D 3 WAY 3 WIRE 3M ATTEST 3M COMPLY 4 WAY 4 WIRE 5C PLUS 6 SHOOTER SAEED 6 WIRE 7 AMINOACTINOMYCIN D 700 SERIES 8 PLY 911 FIRST RESPONSE A A V IMPULSE SYSTEM A1 A2 AA AAA AAL AAMI AB ABC ABDOMEN ABDOMINAL ABDOMINAL AORTIC ANEURYSM WILL THIS WORD/PHRASE BE ABBREVIATED IN THE UMMC LAWSON ITEM MASTER/REQUISITION CENTER?

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HISTORY Since the introduction of liposuction several modifications have been made to the original concept to make it more effective and to reduce the incidence of complications. The original concept of removing excess fat from localised parts of the body is credited to Charles Dujarrier, who in 1921 attempted to remove subcutaneous fat by using a uterine curette from the calf and knees of a ballerina., However, an inadvertent injury to the femoral vessels resulted in the amputation of the dancer's leg. This unfortunate complication obviously dampened interest and curbed further development in this procedure for many decades. Complications From January 2007 to December 2012, we have done more than 600 cases of liposuction involving various parts of the body-abdomen, thighs, back, arms, calves, upper neck and lower face, chest, buttocks etc., All patients underwent SAL.

We have had a small number of patients with local complications and an even smaller number with systemic complications. We have also had our share of dissatisfied patients, although with experience we have been able to identify potentially difficult or problem patients with a fair amount of accuracy. Oedema and ecchymosis Swelling or oedema is anticipated after almost every liposuction procedure as a normal reaction of the human tissues to the actual surgical trauma of the cannula similar to the response of sterile inflammation that occurs after any trauma. This is usually controlled by the immediate use of a compression garment for a period of 4-6 weeks. This swelling will be apparent within 24-48 h after the procedure and continues to mildly increase for the first 10-14 days.

It is soft and mildly tender without any significant signs of inflammation. Thereafter, as the remnants of the infiltrated fluid, serum and broken down fat are absorbed by the body, the swelling changes to a more firm to woody consistency with no or minimal pain and discomfort by the end of 2-3 weeks. By the end of 4 weeks, parts of the operated swollen areas start to soften in patches until the entire area shows a consistent softening by the end of 6-8 weeks. Depending on the extensiveness of the operated area, the tissues tend to return to a normal pliant feel by 3 months after the procedure. Rarely, brawny post-operative oedema with unusual pain and discomfort persists beyond 6 weeks and according to Shiffman this may be due to excessive trauma to the tissues leading to an internal burn-like injury. This will then take a longer time to settle and may result in increased scarring, fibrosis and often surface contour irregularities. Excessive post-operative swelling after abdominal liposuction (day 7) Persistent oedema can also be related to pre-operative anaemia, reduced serum proteins and kidney malfunction all which are a contraindication to surgery.

If they are suspected post-operatively, significant anaemia needs to be corrected with blood transfusions if necessary, lowered protein levels with a high protein diet and kidney malfunction with the requisite nephrological measures. It is believed that PAL by reducing the surgeon's efforts and hence the resultant overall trauma to the tissues can reduce the post-operative swelling compared to SAL. On the other hand, it is commonly observed that the swelling after UAL is somewhat more than that seen with PAL or SAL.

Whether this is attributable to the heat generated by the ultrasonic probe or greater damage to lymphatics is a matter of debate. So some of the methods that are commonly employed to minimise post-operative oedema are.

Providing manual lymphatic drainage in the early post-operative period. In our experience gentle liposuctioning, an optimum compressive garment and early lymphatic drainage massage helps to accelerate the clearance of oedema.

In our series, 1.7% patients had significant persistent oedema post-operatively. All of them were managed conservatively with extended use of compression garment and massaging. In resistant cases, Shiffman advises repeat liposuction with adequate compression. Bruising and ecchymosis also occur in all liposuction patients immediately after the procedure, peaks by the end of 7-10 days, but generally disappear by 2-4 weeks after surgery. Unusually severe and persistent bruising/ecchymosis may be related to chronic smoking, use of blood thinners and abnormal bleeding/clotting profile. Very rarely, it may be related to bleeding from superficial veins damaged during the liposuction. Smokers must be clearly advised to stop smoking completely at least 3 weeks prior to major liposuction, blood thinners stopped with a physician's clearance at least a week prior to surgery and an abnormal bleeding/clotting profile corrected with Vitamin K injections or other appropriate means.

Any venous bleeding is best controlled with prolonged compression. Seromas The collection of serous fluid in a liposuctioned area may be due to excessive tissue trauma, following aggressive oversuctioning of a single area with extensive breaking of the fibrous tissue network leading to a single cavity formation or it may be due to significant damage to the lymphatics. In our experience if the compression garment given to the patient does not fit well or the patient repeatedly removes the garment and puts it back on, this also contributes to seroma formation. Some studies indicate that UAL is associated with a higher incidence of seromas., A localised serous collection is usually detected by the 5 th to 7 th post-operative day. At this stage, if additional padding is provided over the specific area within the compression garment then in many cases the seroma settles in 7-10 days. We have observed localised seromas in 3.5% of our cases.

Seromas are most common in the outer and posterior thighs and in the lower abdomen. We have also observed a unique seroma-like presentation when the fluid gravitates to the scrotum or labia following abdominal, especially pubic fat liposuction.

In our experience, this presents a more frightening spectacle than it actually is and it usually settles over 10 days to 2 weeks. When pubic fat liposuction is planned, patient is asked to anticipate this sequel so that he/she is not surprised.

We have managed to largely prevent this problem by restricting excessive mobility for the first 3 days after surgery and having the patients wear a snug fitting undergarment over the compression garment. On two occasions, persistent large serous collections in the scrotum were aspirated at 2 weeks followed by compression dressings and resolved uneventfully thereafter. Infection The occurrence of infection after liposuction is fortunately very rare and various authors report incidence of lesser than 1%.– In our experience of 600 cases, the incidence of infection in liposuction patients was 0.3%. Both our cases had small abscesses and patches of full thickness skin necrosis in the adjacent area. The most common local cause of such infection is the presence of a haematoma in the subcutaneous tissues with secondary bacterial contamination.

The most common systemic cause of infection is uncontrolled or poorly controlled diabetes. Pre-operative investigations must include blood sugar levels especially for patients above 30 years of age or with family history of diabetes mellitus. Diabetic patients must have good glycemic control peri-operatively to reduce this risk. According to Igra and Lanzer, patients with an immune-compromised state (sero-positive, oral corticosteroids etc.,) are less than ideal patients for liposuction.

They also recommend that patients should stop smoking at least 2 weeks prior to and 7 days after surgery. Toledo and Mauad recommends the use of peri-operative injectable antibiotics, followed for prophylactic oral antibiotics for 5-7 days in all cases of major liposuction. Basic surgical principles such as proper hand washing, sterile operating room conditions, good skin preparation and gentle tissue handling must be followed. Liposuction cannulae must be sterilised adequately-the cannulae must be washed properly to remove blood and tissue bits and dried well before autoclaving or sterilising them. There have been reports of atypical mycobacterium infection due to improperly sterilised cannulae. Any sign of infection-such as significant erythema, tenderness or blisters should be treated aggressively with culture sensitive antibiotics and closely observed for appropriate further management.

This may include opening the lipo-access incisions to allow drainage of collections, formal incision and drainage of abscesses, debridement of ischaemic and necrotic patches and regular dressings including use of negative pressure wound therapy/Vacuum-Assisted Closure. Incision sites. Illouz recommends that as a rule the contour should be slightly under-corrected to allow for post-operative fat lysis, which will amplify the result.

Pre-operatively, it is imperative to meticulously examine the patient in the upright position; in both static as well as dynamic states (i.e. With muscle contraction). Any asymmetry between the two sides, any already present contour irregularities and depressions must be pointed out to the patient, mentioned on paper and marked carefully.

This is especially relevant in the ‘increased risk’ areas mentioned above, such as when examining the trochanteric region to differentiate between a true and false saddle-bag. On contracting the buttocks, if the saddle bag reduces then it is a false saddle bag due to the weight of the buttocks. This would require liposuctioning of the lateral buttocks as well as the saddle-bags whereas a true saddle bag requires liposuction of the trochanteric region alone., In the banana fold area, over-correction especially of the deep layer of fat leads to buttock ptosis due to damage to the supporting fibrous tissue septae. Donofrio recommends liposuction of the superficial fat layer only in this region to avoid this complication, which is very difficult to correct.

Improper positioning of the patient may create false contours during the procedure, which may lead to over-correction. For example, Donofrio recommends that trochanteric liposuction should be done ideally in the lateral position with a wedge placed between the two thighs. A supine or prone position tends to exaggerate the bulges, leading to inadvertent over-liposuction. It is now well-established that use of microcannulae (diameter 3 mm or lesser) reduces the risk for over-correction as compared to larger cannulae as they remove fat in small pieces rather than in larger chunks, especially close to the skin surface. Incision sites often show depressions due to repeated passes with the suction staying on as the cannula is being withdrawn. This can be prevented by always switching off the suction before withdrawing the cannula. Although the criss-cross fanned out technique of liposuction is recommended for smooth and even contours, it can also be a double-edged sword.

If performed incorrectly, it may lead to depressions due to excess fat removal in the overlapped or common areas. Another example of undercorrection in abdomen - (a) Pre-operative (b) post-operative (red arrow showing undercorrected area and blue arrow showing hyperpigmentation) and (c) after touch-up liposuction As recommended by Toledo and Mauad, diligently assessing the areas by the pinch test and sweep test when liposuction is completed helps to identify any residual fat deposits. These deposits must be meticulously suctioned to improve the overall contours. Any corrective measures, for under-correction not detected during surgery, should be undertaken after a period of 6 months from the primary surgery. A touch-up liposuction is generally adequate to aspirate any remaining fat and further improve the contours.,. Redundant skin. As Illouz aptly put it-“It is not so much what is removed that is important, but what is left behind”.

Patients with poor skin elasticity should be forewarned about the risk for contour irregularities and suboptimal skin contraction. Similarly, pre-existing cellulite, indentations and scars should be documented properly. Intraoperatively, use of micro-cannulae and careful use of the criss-cross technique of liposuction are recommended to prevent waviness.– Keeping the cannula port on the underside of the cannula away from the overlying skin at all times is extremely important. Noting and keeping the position of the thumb rest on the cannula handle in the superior position at all times should be made a reflex.

Prolonged aspiration in one spot and excessive superficial liposuctioning should be avoided. Although superficial liposuction permits excellent skin retraction, Illouz recommended leaving at least a 5 mm layer of fat under the skin and on the fascia to prevent surface irregularities.

More recently, Gasparotti's recommends removal of deep layer of fat as well as the subdermal layer of fat without damaging the dermis., An unskilled surgeon may remove too much fat leading to surface irregularities. Jackson reminds us that – ‘defects on the table will be defects forever.’ Therefore, the liposuctioned areas must be carefully assessed after completion of liposuction using Toledo's method. Any contour irregularities detected should be primarily dealt with adequately as far as possible. Correcting contour irregularities in the presence of post-surgical scarring and fibrosis is often very difficult if not impossible.

Post-operatively, careful monitoring of the use of compression garment is recommended. A well-fitting garment enhances skin retraction. An ill-fitting garment especially associated with bad posture can also lead to surface irregularities. Therefore, we advise our patients about the correct method of using the compression garment, to limit folds and creases in the garment and regularly check if the garment is worn properly. Post-liposuction irregularities may be in the form of dimples, grooves, wrinkles or folds Figures and.

Surface dents due to excessive superficial liposuction persist on skin retraction and in the supine position. Dents due to fibrous adhesions to underlying muscle worsen on muscle contraction and dents due to skin redundancy may improve on supine position, but will definitely improve on skin retraction. In our experience, 8.2% of patients complained of post-liposuction surface irregularities. Another example of surface irregularities after abdominal liposuction-dent (blue arrow), deep groove (red arrow) due to improper use or ill-fitting compression garment in a case with pre-op skin laxity. Endermologie, external ultrasound or lymphatic drainage massages may assist in uniform removal of swelling and ensure smooth contours. Some indentations may be improved with the ‘liposhifting’ technique.

A combination of touch-up liposuction and AFT may be required for correction of other contour deformities–. Irregularities due to excessive fibrosis may require intralesional injections with 5-Flurouracil along with/without triamcinolone. Persistent cases may rarely require surgical removal of the fibrous mass along with AFT. Asymmetry Any pre-operative asymmetry should be pointed out to the patient and recorded adequately with measurements and photographs. Accordingly more or less fat may have to be removed from one side to balance the two sides.

Intraoperatively a member of the surgical team maintains a map of the liposuction areas and notes the amount of lipoaspirate from each area. This ensures symmetrical removal of fat from both sides and symmetrical contours. After completing liposuction, we routinely examine the areas visually as well as manually. We use the pinch test as well as the sweep test as described by Toledo and Mauad.

Asymmetry detected intraoperatively may be tackled by liposhifting, additional liposuction or re-injecting fat. According to Illouz, asymmetry that is detected post-operatively should be tackled after 6 months by similar techniques.

In our series, 2.7% cases complained of noticeable asymmetry. Skin laxity Skin in certain areas is especially prone to the development of redundancy or laxity after liposuction. This may be due to the amount of fat removed as well as lack of complete or optimum skin retraction. These areas include a large abdominal panniculus, bulky arms and medial thighs with lax skin.

In our experience, we have also encountered skin laxity issues after liposuction in the trochanteric as well as suprapatellar region. Patients with poor skin elasticity, excessive musculofascial laxity and large fat deposits, who may ideally require skin excision surgeries such as a tummy tuck or thigh lift or arm lift, but do not want the long incisions associated with these procedures and opt for only liposuction should be clearly forewarned of these sequelae after liposuction. A written informed consent should also mention this issue for medicolegal reasons. Patients with the possibility of residual skin laxity must also be informed that they would need to wear the compression garment for a longer period, beyond the usual 6 weeks up to 8-12 weeks to encourage/allow the maximum possible skin retraction to take place. Example of residual skin laxity after abdominal liposuction - (a) Pre-operative (b) post-operative (red and blue arrows showing residual skin laxity) (c) after abdominoplasty Various authors have reported excellent skin retraction and tightening using superficial liposuction techniques., According to these authors, liposuction in both superficial and deep layers of fat enables more effective removal of fat, effective skin retraction as well as improvement of cellulite. Gasparotti believed that in superficial liposculpture skin is an ‘active structural dynamic contributor to the body contouring process’ and not just a passive element., It has been suggested that the use of vertical tunnels in the extremities provides better skin retraction as compared to horizontal tunnels. Similarly, use of micro-cannulae stimulates better skin retraction after liposuction.

Recent studies also seem to indicate that UAL may also provide for effective skin retraction. In our series, we have had 4.2% of patients complaining of skin laxity after liposuction. All these patients had poor skin elasticity and had been forewarned of this possibility. Residual skin laxity was noted over the abdomen and thighs in all these patients.

Patients who are concerned about this residual laxity should be asked to wait for at least 6 months to 1 year before considering any further surgery, so that the inherent skin elasticity is given its fullest chance to work. Procedures such as abdominoplasty, brachioplasty and thigh plasty may be offered to the patient for correcting this skin laxity after liposuction. Quite often, the quantum of these procedures is significantly reduced following liposuction. For example, a patient who ideally required a full-fledged abdominoplasty due to a lax infraumbilical skin-fat apron and underwent only liposuction with suboptimal, but significant skin contraction may only require a mini-tummy tuck later. Similarly, a patient who needed a full-fledged arm-lift or thigh lift and opted for only liposuction, which resulted in suboptimal but significant skin contraction may only need surgery that involves incisions in the axilla and groin crease without the vertical long incision component.

The advantages of this multi-staged approach can also be explained to patients prior to the 1 st procedure so that they fully understand their choices and decide accordingly. Exogenous drugs e.g., intramuscular iron therapy, contraceptive pills, minocycline etc.

Therefore, post-operatively the compression garment should be checked regularly, effective sun screen must be used and unnecessary sun exposure should be avoided. Hyperpigmentation of the liposuctioned area is also often noted after UAL.

In our experience, we had 18.7% patients developing hyperpigmentation in the liposuctioned areas. A majority of these have been following thigh liposuction. Consequently, we forewarn all our thigh liposuction patients that they will develop hyperpigmentation post-operatively. However, in all cases the hyperpigmentation usually disappears by the end of a year after liposuction. Skin necrosis Patients who are chronic smokers and have not stopped smoking have a high incidence of skin necrosis after liposuction. Skin necrosis is more likely to occur with the use of sharp cannulae and with excessive superficial liposuction especially by turning the openings towards the skin surface. These factors lead to significant damage to subdermal plexus of vessels leading to skin necrosis.

Similarly, aggressive liposuction of the abdomen along with full abdominoplasty, large seromas or haematomas increase the risk of skin necrosis. Earlier reports indicated a higher incidence of skin necrosis with UAL., Primarily, this was due to the energy from ultrasonic probes causing burns especially if left at one place without movement for too long. It was also due to problems such as end-hitting and prolonged or intimate contact of ultrasound probes with the dermis. However, more recent studies indicate that with more experience and application of fundamental principles, the risk of skin necrosis with UAL is now significantly lesser.,– Once detected, treatment involves surgical debridement, antibiotics and hyperbaric oxygen therapy. In early stages when skin erythema is noted– hyperbaric oxygen therapy along with intradermal injection of oxygen has been reported to be helpful.

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In our series, skin necrosis was noted in 1% cases. In most cases, it was only superficial ischemia, which settled with minimal scarring. One patient required skin grafting to cover the defect following debridement. Another patient had secondary suturing after debridement. All other patients were adequately treated with minor debridement and wound healing occurred by secondary intention.

Neurological sequel Hypoaesthesia is very common after liposuction, but sensations generally return to near normal by the end of 1 year., Chronic pain is rare and may be due to a neuroma or due to injury to underlying fascia or muscle. Multiple injections of local anaesthetic may be helpful.

Unrelenting pain may require surgical release of scar with or without AFT. Long standing hyperaesthesia has been reported following UAL. This is due to damage to the phospholipids in the myelin sheath leading to depolarisation of the cutaneous sensory nerves.,. Umbilical deviation We have observed this unusual sequel in six patients following an abdominal liposuction.

The umbilical deviation is not apparent on the operating table following liposuction. However, it manifests by the time patient comes for suture removal (7 th post-operative day).

Although it improves to some extent over the subsequent months, it never returns to the midline spontaneously. Another interesting feature has been that the deviation is always to the right side of the abdomen. (a) Pre-operative, (b) umbilical deviation to the right side after liposuction We have hypothesised that this phenomenon is due to the drag exerted by the closure of compression garment. The compression garments were designed with a zipper on the right side alone. The umbilical stalk which is relatively less supported due to the removal of adjacent fat easily tilts to the right side as the patient tightens the compression garment towards this side.

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We have successfully overcome this problem by re-designing the compression garment with closure (hooks and zipper) on both sides. Furthermore, we apply additional padding over the umbilicus within the compression garment for a period of 7-10 days. This not only helps to stabilise the umbilical stalk during the early period of healing, but it also helps to push the navel into its ‘valley’.