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Liposuction Skin Contraction: Case Reports of Success and Danger Areas
Robert A. Yoho, M.D.
Liposuction of the abdomen area can produce skin contraction that may yield excellent results even in obese patients. This requires careful thinning of the fat layer, using 3mm spatula cannulas toward the end of the case. The dermis must be treated with care, then the skin positioned appropriately with sticky foam in order to create proper shape. Aggressive action with larger cannulas can unfortunately produce skin slough in some cases, however. Mini-abdominoplasty may be appropriate occasionally after these cases. Full abdominoplasty may be problematic for skin integrity.
Experienced liposuction surgeons are aware that skin retraction can occur after liposuction, especially in the abdominal area. The author has found that even an overhanging panniculus can be treated effectively with liposuction. Although liposuction, especially in older patients, may alter skin texture, contours can be improved. There is little risk of infection, skin necrosis, or other morbidity in patients undergoing liposuction surgery. A minituck can always be performed after the initial liposuction, if there is residual loose skin. Full abdominoplasty after aggressive liposuction should be avoided.
MATERIALS AND METHODS
Tumescent anesthesia was used with 0.1mg% lidocaine and 1:1 million epinephrine removing 1L fluid for each liter of fluid injected. Moderate sedation was utilized with titrated doses of Demerol (up to 100mg), 10 mg Valium, and 100 mg ketamine. Intravenous fluid was used in each case, usually 2L or less.
All cases were initially debulked with 4mm cannulas. Although many of the cases were performed with "keel cobra" cannulas, the author now favors the highly effective spiral cannulas available from Byron (Tucson, AZ) or KMI (Anaheim, CA). Because of a high complication rate, the author has abandoned the use of 5 and 6 mm cannulas. To minimize irregularities, the liposuction is "fine-tuned" with a 3 mm three-hole spatula cannula. Operating time using two surgeons was under 1.5 h. Reston foam was used for 4 days to position and hold the tissues in the new contracted position.
FIG. A. A 60-year-old woman with large panniculus and lipodystrophy. B. Flattening of the abdomen following liposuction of the abdomen in two sessions.
Skin retraction without skin damage can be a consistent result. The skin layers must be thinned enough to allow contraction but not cause significant injury. If too much fat is left, contraction is not adequate and the desired cosmetic result cannot be achieved. The technique requires a "feel" that needs to be developed through experience with many procedures. The old "pinch" technique may be too conservative in some cases. The author uses a 0.5 inch pinch test depending on the patent's needs. A0.25 inch pinch test is usually too aggressive and may result in skin necrosis. Vigorous "stripping" massage sometimes helps, depending on the density of the tissues, and the less likely to cause complications than prolonged cannula liposuction. Occasionally, an irregular area is "fined-tuned" using the cannula without suction toward the end of the case. The surgeon must be alert to remove the fat appropriately deep to Scarpa's fascia. The surgeon should be able to differentiate between abdominal wall fascia, felt by palpation, and thick deep fat yet to be suctioned, felt by the pinch test.
LIPOSUCTION SKIN CONTRACTION
FIG. 2. A. A 39-year-old woman with large panniculus and lipodystrophy of the abdomen. B. Postoperative improvement in the hangingpanniculus.
A 60-year-old woman had 4.15 L total aspirate with 2.9 L fat removed above the waist followed by removal of 2.0 L total aspirated below the waist 6 months later. Her skin retraction was excellent but poor skin texture resulted (Fig.1) She, however, considered that this was a good tradeoff to obtain an improved shape.
A 39-year-old woman with large abdominal panniculus had 7.0 L total aspirate with 4.9 L fat removed above the waist. There was excellent skin retraction and skin texture was relatively well preserved (Fig. 2). The overhanging panniculus was removed by liposuction alone.
A 55-year-old woman had 8.2 L total aspirate with 5.7 L fat liposuctioned from above the waist. Skin retraction was excellent and the skin texture relatively well preserved. (Fig.3). The hanging panniculus was resolved.
A 39-year-old woman underwent aggressive abdominal liposuction and did well except for residual overhanging skin that she wished to have treated surgically. Abdominoplasty was performed 18 months later by an experienced surgeon using a conservative technique with very little tension on the skin flap. The skin superior to the pubic symphysis was noted to by dusky on the third day postoperatively. Multiple daily hyperbaric oxygen treatments were given at 2 atm with 100% oxygen for 1.5 h at a time. The area became necrotic (Fig 4) and was debrided on the 15th postoperative day. The open wound, initially 4 by 6 inches, healed over a few months with a scar less than 2 inches in diameter.
A 65-year-old man underwent liposuction of the abdomen that removed 5.3 L total aspirate with 3.7 L of fat. Despite aggressive thinning of the abdominal wall fat, there remained a persistent flap of overhanging skin the lower abdomen. This was conservatively resected elliptically without undermining 8 months later. There wound healed unevenly and the patient was pleased with the results.
Despite the seeming simplicity of liposuction, surgical techniques widely vary. Cannula characteristics, inclusion sites, the strength and aggressiveness of the surgeon, and tumescent technique all contribute to the quality of the result. The surgeon's perception of the aesthetic design before and during the case is critical and different quality. Quality can only be consistently achieved with long and proper training, especially with hands-on experience.