The absolute number of adipose cells varies during childhood. After a rapid increase during puberty, the genetically determined number becomes fixed. With obesity, the lamellar layer can increase its thickness much more than the areolar layer. In obese patients, it may be eight to ten times thicker than in normal-weight people, while the areolar tissue may only double in thickness. The only way to reduce the hypertrophic fatty layer is to destroy it in vivo or to take it out of the body. We can do that either invasively (liposuction) or non-invasively with the help of energy-dependent devices or chemically.
Adipose tissue "fattening" or localized fatty deposits with resultant body contour deformities result from adipose cell hypertrophy rather than hyperplasia. The transcutaneous delivery of ultrasound, radiofrequency, tissue cooling, low-level laser, physical massage, or a combination of these modalities) are marketed recently as a non-invasive fat reduction device. All devices have different characteristics influencing suitability for a particular practice, such as operator dependence, delegation capabilities, maintenance, and consumables. These devices lack the evacuation phase that is inherent to liposuction, so a physiologic macrophage-mediated phagocytic process accomplishes fat clearance.
Buttocks Reduction Liposuction and Lipofilling-Egyptian Buttocks.pptxOsama Moawad
Obese, Egyptian, Arabic, or African female buttocks are characterized by; upper buttock hypertrophy leading to the shelving effect with increased projection in the anteroposterior above the mons pubis level, and the overall volume is usually disproportionate to the remainder body. Obese patients want to reduce or lessen volume, shelving, and projection but never ask for flattening the entire area. The buttocks contain deep fat deposits with relatively little fibrous tissue content and are amenable to all forms of liposuction. One can achieve a pleasing esthetic buttock by liposuction of the surrounding areas and attention to "gender ideal" muscular shape/ mass, fat distribution, and adherent areas. In our patients, we routinely improve the contour of the buttock, lower back, hips, and lateral thigh.
Liposuction is a surgical procedure that removes excess fat from specific areas of the body. During the procedure, a small incision is made, and a thin tube called a cannula is used to suction out the fat. Liposuction can be used to contour and reshape the body, but it is not a weight loss solution or a substitute for a healthy lifestyle.
Thighs, Knees, and Lower Legs Liposuction.pptxOsama Moawad
Opinions regarding the ideal proportions of the female figure have varied widely through time and across cultures. In the current era, the aesthetic appeal of long legs seems to transcend culture. Artists portray long legs as attractive and defined. Many prospective liposuction patients want this "look." The thigh should be evaluated as a complete esthetic unit from the waistline to the knee circumferentially. In small volumes, circumferential thigh liposuction should be considered in patients with either lateral or medial lipodystrophies. However, in large volumes, Liposuction should be done in stages, reducing the degree of edema-induced venous stasis and the risk of thromboembolic venous disease as the untreated portion of the thigh provides cushioning lymphatics that compensate for the impaired lymphatic drainage in the treated.
Liposuction is usually performed in the fatty layer superficial to the platysma in the neck, an extremely safe region devoid of vital neurovascular structures. Fat is present in the area that extends between the sternocleidomastoid muscles from the mandibular border to the thyroid cartilage region. More fat is present inside the anterior cervical triangles at the submental and submandibular neck levels. Ideal candidates for neck liposuction are patients with isolated fat deposits, good skin tone, and minimal platysmal laxity. In appropriately selected patients, liposuction of the neck using tumescent local anesthesia can effectively remove fatty deposits with excellent skin redraping and contraction.
There is no question that obesity is the largest epidemic of the 21st century. This explains the explosion of the different methods of weight loss support; chief among them, the utilization of bariatric surgery. Learn how body contouring after major weight loss improves the shape and tone of the underlying tissue that supports fat and skin and removes excess sagging fat and skin.
Liposuction Complications and its Management.pptxOsama Moawad
Although many people view it as a simple and benign procedure, it can be associated with significant morbidity, especially large-volume liposuction. Physicians should limit the lipoaspirate to less than 5% of the body weight and treat less than 30% of the body surface in one session. The ideal situation involves a selected patient treated by a well-trained surgeon and anesthesiologist, the team working in a fully equipped, certified, and accredited facility with a well-trained operating room and recovery room staff. Unfortunately, complications can vary from mild postoperative nausea and vomiting to DVT/pulmonary embolism (P.E.) and even death. The onset of complications can be classified into the perioperative period (0–48 h), early postoperative period (days 1–7), and late postoperative period (1 week to 3 months). Major risk factors for developing severe complications are multiple procedures, poor standards of sterility, excessive infiltration and intoxication from lidocaine or adrenaline, excessive removal of fatty tissue with volume depletion in the third space, permissive postoperative discharge, and selection of unfit patients.
Body contouring after massive weight loss. DR. M HossamMohamed Hossam
Body contouring for the massive loss is a challenge to achieve the ideal technique for the specific deformity at the proper timing with the least complications
Patients present for arms contouring are classified according to the scheme proposed by Teimourian and Malekzadeh. Arm liposuction is done in all categories as a primary procedure or/ and in combination with brachioplasty. The goal of the liposuction surgeon is to reduce the bulk of fat all over the arm without creating a masculine appearance for female patients. Liposuction of the arm varies according to the amount of fat excess and the location and severity of skin redundancies. Although most complaints will be the inferior aspect of the arm, slenderizing (circumferential), the entire arm will produce a more optimal result.
Buttocks Reduction Liposuction and Lipofilling-Egyptian Buttocks.pptxOsama Moawad
Obese, Egyptian, Arabic, or African female buttocks are characterized by; upper buttock hypertrophy leading to the shelving effect with increased projection in the anteroposterior above the mons pubis level, and the overall volume is usually disproportionate to the remainder body. Obese patients want to reduce or lessen volume, shelving, and projection but never ask for flattening the entire area. The buttocks contain deep fat deposits with relatively little fibrous tissue content and are amenable to all forms of liposuction. One can achieve a pleasing esthetic buttock by liposuction of the surrounding areas and attention to "gender ideal" muscular shape/ mass, fat distribution, and adherent areas. In our patients, we routinely improve the contour of the buttock, lower back, hips, and lateral thigh.
Liposuction is a surgical procedure that removes excess fat from specific areas of the body. During the procedure, a small incision is made, and a thin tube called a cannula is used to suction out the fat. Liposuction can be used to contour and reshape the body, but it is not a weight loss solution or a substitute for a healthy lifestyle.
Thighs, Knees, and Lower Legs Liposuction.pptxOsama Moawad
Opinions regarding the ideal proportions of the female figure have varied widely through time and across cultures. In the current era, the aesthetic appeal of long legs seems to transcend culture. Artists portray long legs as attractive and defined. Many prospective liposuction patients want this "look." The thigh should be evaluated as a complete esthetic unit from the waistline to the knee circumferentially. In small volumes, circumferential thigh liposuction should be considered in patients with either lateral or medial lipodystrophies. However, in large volumes, Liposuction should be done in stages, reducing the degree of edema-induced venous stasis and the risk of thromboembolic venous disease as the untreated portion of the thigh provides cushioning lymphatics that compensate for the impaired lymphatic drainage in the treated.
Liposuction is usually performed in the fatty layer superficial to the platysma in the neck, an extremely safe region devoid of vital neurovascular structures. Fat is present in the area that extends between the sternocleidomastoid muscles from the mandibular border to the thyroid cartilage region. More fat is present inside the anterior cervical triangles at the submental and submandibular neck levels. Ideal candidates for neck liposuction are patients with isolated fat deposits, good skin tone, and minimal platysmal laxity. In appropriately selected patients, liposuction of the neck using tumescent local anesthesia can effectively remove fatty deposits with excellent skin redraping and contraction.
There is no question that obesity is the largest epidemic of the 21st century. This explains the explosion of the different methods of weight loss support; chief among them, the utilization of bariatric surgery. Learn how body contouring after major weight loss improves the shape and tone of the underlying tissue that supports fat and skin and removes excess sagging fat and skin.
Liposuction Complications and its Management.pptxOsama Moawad
Although many people view it as a simple and benign procedure, it can be associated with significant morbidity, especially large-volume liposuction. Physicians should limit the lipoaspirate to less than 5% of the body weight and treat less than 30% of the body surface in one session. The ideal situation involves a selected patient treated by a well-trained surgeon and anesthesiologist, the team working in a fully equipped, certified, and accredited facility with a well-trained operating room and recovery room staff. Unfortunately, complications can vary from mild postoperative nausea and vomiting to DVT/pulmonary embolism (P.E.) and even death. The onset of complications can be classified into the perioperative period (0–48 h), early postoperative period (days 1–7), and late postoperative period (1 week to 3 months). Major risk factors for developing severe complications are multiple procedures, poor standards of sterility, excessive infiltration and intoxication from lidocaine or adrenaline, excessive removal of fatty tissue with volume depletion in the third space, permissive postoperative discharge, and selection of unfit patients.
Body contouring after massive weight loss. DR. M HossamMohamed Hossam
Body contouring for the massive loss is a challenge to achieve the ideal technique for the specific deformity at the proper timing with the least complications
Patients present for arms contouring are classified according to the scheme proposed by Teimourian and Malekzadeh. Arm liposuction is done in all categories as a primary procedure or/ and in combination with brachioplasty. The goal of the liposuction surgeon is to reduce the bulk of fat all over the arm without creating a masculine appearance for female patients. Liposuction of the arm varies according to the amount of fat excess and the location and severity of skin redundancies. Although most complaints will be the inferior aspect of the arm, slenderizing (circumferential), the entire arm will produce a more optimal result.
Breast Liposuction (Female vs. Male).pptxOsama Moawad
Breast reduction liposuction has gradually evolved into a primary or secondary modality for treating breast hyperplasia. Enlargement of the breast as the result of localized deposits of subcutaneous fat, primarily with normal or slightly increased glandular breast tissue, is known as pseudo-gynecomastia in male patients.
Bariatric surgery is gaining popularity worldwide. The number of surgeries has increased by almost 10 times in the last decade and almost 14000 bariatric surgery were performed last year in India.
A presentation by Dr Jacob Chisholm on Developments In Gastrointestinal Therapies.
Jacob Chisholm is an upper gastrointestinal and general surgeon with an interest in weight loss and metabolic surgery. Jacob received his undergraduate degree (MBBS) from the University of Adelaide, a postgraduate research degree (Masters of Surgery) from Flinders University and is a Fellow of the Royal Australasian College of Surgeons. He trained in surgery at the Royal Adelaide and Flinders Medical Centre before completing a bariatric fellowship in 2007. Jacob was appointed chief surgical resident at Flinders Medical Centre in 2008 and has been a consultant surgeon at that institution since 2010. Jacob joined the Adelaide Bariatric Centre in 2010.
Confronted with a rising incidence of increasingly overweight and frankly obese individuals, many interventions have continued to be sought for by the scientific community to address this.
Bariatric surgery – improving life, longterm.Jia Maheshwari
Going under the scalpel, may be the last resort for some obese people but it certainly has many advantages besides losing weight and increased self-esteem. Sleep apnea can be driven away too. Ditto for depression, anxiety and scores of other mindblocks in daily life situations which require interacting and networking with people.
Airbrush Liposculpture(R) offers a faster and safer alternative to bariatric ...Robert Cucin MD JD FACS
A white paper with some case studies illustrating how serial liposuction with the Airbrush(R) Liposculptor as a combined modality therapy can offer an end run to a better body and healthy metabolism in weeks rather than years.
Decoding Facial Aging. An In-Depth Exploration of Aging Hallmarks.pptxOsama Moawad
The aging process is a multifaceted phenomenon influenced by many biological, environmental, social, and psychological factors. Within this intricate web of influences, the hallmarks of aging interact in a sophisticated network, highlighting the nuanced nature of biological aging. By adopting an interdisciplinary approach and utilizing innovative methodologies, researchers can pave the way for groundbreaking discoveries in aging research. Examining research findings across various physiological systems, such as skin, adipose tissue, connective tissue, skeletal muscles, and facial tissues, allows us better to understand the cellular and molecular underpinnings of facial aging. Incorporating a comprehensive and interconnected approach into patient assessments, treatment planning, preventive guidance, therapeutic applications, continuing education, and collaborative research efforts can optimize the outcomes of aging-related interventions. Aging research presents immense opportunities for advancing our understanding of aging and developing creative strategies to promote healthy aging and overall well-being.
Functional Anatomy of Facial Muscles. An Injector Eye. Part Two.pptxOsama Moawad
The facial muscles are a group of about 20 muscles that lie under the skin and control facial expressions. They also help with chewing and moving the ears, eyes, nose, and mouth. The facial muscles are innervated by the facial nerve (CN VII) and supplied by the facial artery. The facial muscles can be divided into five groups: muscles of the mouth, nose, eyelid, cranium, neck, and external ear.
Facial muscles are responsible for facial expressions, but they also influence the shape and contour of the face over time. The constant activity of facial muscles, combined with their eventual reduction in strength, changes the appearance of the face. They also influence the distribution and loss of subcutaneous fat, contributing to the facial volume. The effect of facial muscles on aesthetics and aging of the face is a complex topic that involves various factors. The author recommends investigating the relationship between adipose tissue facial muscles further.
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Similar to Surgical Fat Reduction (liposuction) Part I.pptx
Breast Liposuction (Female vs. Male).pptxOsama Moawad
Breast reduction liposuction has gradually evolved into a primary or secondary modality for treating breast hyperplasia. Enlargement of the breast as the result of localized deposits of subcutaneous fat, primarily with normal or slightly increased glandular breast tissue, is known as pseudo-gynecomastia in male patients.
Bariatric surgery is gaining popularity worldwide. The number of surgeries has increased by almost 10 times in the last decade and almost 14000 bariatric surgery were performed last year in India.
A presentation by Dr Jacob Chisholm on Developments In Gastrointestinal Therapies.
Jacob Chisholm is an upper gastrointestinal and general surgeon with an interest in weight loss and metabolic surgery. Jacob received his undergraduate degree (MBBS) from the University of Adelaide, a postgraduate research degree (Masters of Surgery) from Flinders University and is a Fellow of the Royal Australasian College of Surgeons. He trained in surgery at the Royal Adelaide and Flinders Medical Centre before completing a bariatric fellowship in 2007. Jacob was appointed chief surgical resident at Flinders Medical Centre in 2008 and has been a consultant surgeon at that institution since 2010. Jacob joined the Adelaide Bariatric Centre in 2010.
Confronted with a rising incidence of increasingly overweight and frankly obese individuals, many interventions have continued to be sought for by the scientific community to address this.
Bariatric surgery – improving life, longterm.Jia Maheshwari
Going under the scalpel, may be the last resort for some obese people but it certainly has many advantages besides losing weight and increased self-esteem. Sleep apnea can be driven away too. Ditto for depression, anxiety and scores of other mindblocks in daily life situations which require interacting and networking with people.
Airbrush Liposculpture(R) offers a faster and safer alternative to bariatric ...Robert Cucin MD JD FACS
A white paper with some case studies illustrating how serial liposuction with the Airbrush(R) Liposculptor as a combined modality therapy can offer an end run to a better body and healthy metabolism in weeks rather than years.
Decoding Facial Aging. An In-Depth Exploration of Aging Hallmarks.pptxOsama Moawad
The aging process is a multifaceted phenomenon influenced by many biological, environmental, social, and psychological factors. Within this intricate web of influences, the hallmarks of aging interact in a sophisticated network, highlighting the nuanced nature of biological aging. By adopting an interdisciplinary approach and utilizing innovative methodologies, researchers can pave the way for groundbreaking discoveries in aging research. Examining research findings across various physiological systems, such as skin, adipose tissue, connective tissue, skeletal muscles, and facial tissues, allows us better to understand the cellular and molecular underpinnings of facial aging. Incorporating a comprehensive and interconnected approach into patient assessments, treatment planning, preventive guidance, therapeutic applications, continuing education, and collaborative research efforts can optimize the outcomes of aging-related interventions. Aging research presents immense opportunities for advancing our understanding of aging and developing creative strategies to promote healthy aging and overall well-being.
Functional Anatomy of Facial Muscles. An Injector Eye. Part Two.pptxOsama Moawad
The facial muscles are a group of about 20 muscles that lie under the skin and control facial expressions. They also help with chewing and moving the ears, eyes, nose, and mouth. The facial muscles are innervated by the facial nerve (CN VII) and supplied by the facial artery. The facial muscles can be divided into five groups: muscles of the mouth, nose, eyelid, cranium, neck, and external ear.
Facial muscles are responsible for facial expressions, but they also influence the shape and contour of the face over time. The constant activity of facial muscles, combined with their eventual reduction in strength, changes the appearance of the face. They also influence the distribution and loss of subcutaneous fat, contributing to the facial volume. The effect of facial muscles on aesthetics and aging of the face is a complex topic that involves various factors. The author recommends investigating the relationship between adipose tissue facial muscles further.
Functional Anatomy of Facial Muscles. An Injector Eye. Part One.pptxOsama Moawad
The facial muscles are a group of about 20 muscles that lie under the skin and control facial expressions. They also help with chewing and moving the ears, eyes, nose, and mouth. The facial muscles are innervated by the facial nerve (CN VII) and supplied by the facial artery. The facial muscles can be divided into five groups: muscles of the mouth, nose, eyelid, cranium, neck, and external ear.
Facial muscles are responsible for facial expressions, but they also influence the shape and contour of the face over time. The constant activity of facial muscles, combined with their eventual reduction in strength, changes the appearance of the face. They also influence the distribution and loss of subcutaneous fat, contributing to the facial volume. The effect of facial muscles on aesthetics and aging of the face is a complex topic that involves various factors. The author recommends investigating the relationship between adipose tissue facial muscles further.
The Skin Functional Anatomy and Aging. An Injector Eye. Part Two light.pptxOsama Moawad
We live in an "era of injectables." facial fillers and botulinum toxin injections have become popular in facial surgery over the past decade, as they offer remarkable aesthetic benefits with little recovery time. In "The Skin Function Anatomy and Aging In an Injector Eye" course, you will learn about what will help you understand how the skin, the subcutaneous fat, and the facial muscles interact to produce facial expressions and support the facial structure. You will also learn how aging affects the skin's function and how it impacts our well-being and attractiveness. These are the essential factors that influence the results and safety of facial injections.
Whether you aim to treat a disease or reverse signs of aging, you need to understand the functional anatomy of the skin and the various factors that can affect its function. Knowing will help you apply existing knowledge or discover a novel way to achieve your goals and minimize potential complications that might arise.
The Skin Functional Anatomy and Aging. An Injector Eye. Part One.pptxOsama Moawad
We live in an "era of injectables." facial fillers and botulinum toxin injections have become popular in facial surgery over the past decade, as they offer remarkable aesthetic benefits with little recovery time. In "The Skin Function Anatomy and Aging In an Injector Eye" course, you will learn about what will help you understand how the skin, the subcutaneous fat, and the facial muscles interact to produce facial expressions and support the facial structure. You will also learn how aging affects the skin's function and how it impacts our well-being and attractiveness. These are the essential factors that influence the results and safety of facial injections.
Whether you aim to treat a disease or reverse signs of aging, you need to understand the functional anatomy of the skin and the various factors that can affect its function. Knowing will help you apply existing knowledge or discover a novel way to achieve your goals and minimize potential complications that might arise.
Injectables Adipose Tissue. Past Present and Future.pptxOsama Moawad
Injectable adipose tissue is a versatile and promising material for various applications in cosmetic, functional and regenerative surgery. In this presentation, I will provide an overview of the history, the current state and the future prospects of this technique, based on my own experience that spans over three decades. I will also discuss the evidence-based practice and the challenges and opportunities of using injectable adipose tissue in different surgical settings.
You will see some before and after examples of the outcomes of injectable adipose tissue in cosmetic, functional and regenerative surgery.
Surgical Fat Reduction (liposuction). Part II.pptxOsama Moawad
Liposuction is the most performed cosmetic surgery in the world. Furthermore, it has become an essential complementary technique to enhance the aesthetic result of many other procedures, such as cervicoplasty, reduction or augmentation mammoplasty, abdominoplasty, brachioplasty, thigh lift, and postbariatric body contouring. Amenable to Liposuction are the face, neck, breast, arms, abdomen, mons pubis, back, hips, buttocks, thighs, knees, calves, and ankles. The genetic determination of lipodystrophy (a localized abnormality of body fat distribution) means it is diet and exercise-resistant. It results from adipose cell hypertrophy rather than hyperplasia. Its correction mandates surgical interventions. Surgical fat reduction or Liposuction corrects deep and superficial fat accumulations and, thus, remodels the face, neck, breast, and body contour deformities. It should be carried out in the lamellar layer if one desires long-term results.
Liposuction of the back primarily reduces subcutaneous fat and results in skin retraction, more so in the upper back than in the lower back, due to the thicker skin and more fibrous fat found in the upper back. Suction lipectomy of the lumbar, flanks, and upper back unmasks and enhances the buttock region. Liposuction of the back often nicely complements abdomen liposuction in men and in women to give a more global improvement in the torso with improvement in the waistline. Liposuction of the upper back is an excellent complement to the arm, and breast lifts, while lower back liposuction will complement the abdomen, buttocks, and thigh lifts.
Surgical Fat Reduction (liposuction). Part II.pptxOsama Moawad
The newer liposuction methods aim to disrupt the fatty cell membrane – liquefaction – to enable more efficient fat removal.
Outcomes may be further enhanced by a degree of dermal injury, which promotes cutaneous retraction.
However, one should remember that any trauma under the skin risks collateral damage with the subcutaneous layer richly supplied by delicate vascular, neural, and fibrous supporting systems.
Liposuction techniques can be classified as superficial vs. deep, syringe vs. machine, and standard vs. energy assistant cannula. I will mention these techniques emphasizing syringe reduction liposuction and a technique I call external ultrasound-power assistant liposuction (U-PAL).
The Science of the Subcutneous Adipose Tissue.pptxOsama Moawad
Dermatologists studied the panniculus adiposus (subcutaneous fat) as a metabolic depot, insulation, and buffer against trauma. In addition, it has endocrine effects and a role in local and systemic inflammation. Adipose tissue is a specialized connective tissue involved in the synthesis and storage of fat. It is mainly composed of specialized cells (adipocytes) enmeshed in a structural network of collagen fibers. The fat stored in adipose tissue comes from dietary fats or is produced in the body. Adipose tissue includes numerous anatomic depots. In adults, it is located beneath the skin (subcutaneous fat), around internal organs (visceral fat), in bone marrow (yellow bone marrow), in breast tissue, and in deposits between the muscles and in other organs. In humans, the distribution of adipose tissue varies due to genetics, age, sex, race, and, for some depots, sensitivity to hormones and glucocorticoids.
From Adding (1997) to Removing Fat (2022). The Liposuction Journey.pptxOsama Moawad
As a dermatologist, I was fascinated with Dr. J. Fulton's videos (American dermatologist and medical researcher who co-invented Retin-A) in the early nineties and how he treated patients suffering from acne scars (having acne scars himself). He used all available resurfacing techniques, i.e., chemical peels, dermabrasion, and ablative CO2 lasers. What drew my attention was fat grafting. I dreamed of filling those atrophic scars resistant to resurfacing techniques. I realized the paradigm shift of volume surgery to treat those scars. In 1996 I attended Dr. Sydney Colman's course (Lipo-structure: A New Paradigm for Micro-infiltration. New York). I bought his tools (cannulas and vac-Lock 10 ml syringes) and decided to do it! It was a great chance to learn from the master of fat grafting.
• In recent years, the usefulness of trichoscopy (scalp dermoscopy) (videodermatoscopy) has been reported for diagnosing hair loss diseases. This method allows viewing of the hair and scalp at X20 to X160 magnifications. Characteristic trichoscopy features of alopecia areata are black dots, tapering hairs (exclamation mark hairs), broken hairs, yellow dots, and short vellus hairs. In androgenetic alopecia (AGA), hair diameter diversity (HDD), perifollicular pigmentation/peripilar sign, and yellow dots are trichoscopically observed. In all cases of AGA and female AGA, HDD, more than 20%, which corresponds to vellus transformation, can be seen. In cicatricial alopecia (CA), the loss of orifices, a hallmark of CA, and the associated changes including perifollicular erythema or scale and hair tufting were observed. Different hair shafts variation such as vellus, terminal, micro-exclamation mark type, monilethrix, Netherton type, and pili annulati hairs can be seen . The number of hairs in one pilosebaceous unit can be assessed. Healthy Hair follicles variation healthy, empty, fibrotic ("white dots"), filled with hyperkeratotic plugs ("yellow dots"), or containing dead hair ("black dots"). Abnormalities of scalp skin color or structure include honeycomb-type hyperpigmentation, perifollicular discoloration (hyperpigmentation), and scaling are also seen with the help of trichoscopy.
Tattoo laser removal. what's up after 25 yearsOsama Moawad
• There is a need to increase awareness in the youth today regarding increased risks of tattooing when carried out in potential unsterile environments.
• Tattoo parlors should also be educated about the risks involved and the importance of using proper infection control procedures.
• Better regulation of tattoo inks and dyes can help ensure safe application and ease of removal, but it is currently lacking.
• Lasers are the established gold standard for tattoo removal, but employing the appropriate device and technique does not always guarantee a successful outcome. QS lasers are created technologies against blue, black, red, and green tattoos, with varying degrees of effectiveness. Other colors can be challenging to treat, although outcomes using fractional resurfacing and picosecond lasers are promising. Multi-pass treatments are a new approach for faster and more effective removal of tattoo pigments.
• The mechanisms responsible for variable responses of cosmetic tattoos to laser treatment are numerous and often interrelated.
• The laser industry and the tattoo practitioner are on different poles
The art of non surgical facial skin rejuvenationOsama Moawad
Aging of the skin can be divided into two main categories: intrinsic aging, due to genetic factors characterized by laxity and deep rhytides, and aging due to ultraviolet (UV) damage, termed photoaging or photodamage, characterized by dyschromia, elastosis, fine rhytides, redness, spider veins, surface changes, and keratoses. The old face is the consequence of several concurrent factors, including skin laxity, soft tissue ptosis, and volume loss. The First step for successful treatment is to diagnose skin problems; dark spots, red spots, pimples, scars, wrinkles or skin folds with advanced diagnostic tools such wood’s light, polarized light, videodermoscope, dermatoscope, and venoscope according to your skin condition.
Improving the condition of the skin is most commonly done with resurfacing procedures, laser and light therapy, daily skin care, and ultraviolet (UV) protection. Correction of soft tissue ptosis is usually surgically treated with a brow lift, mid face lift, and lower face rhytidectomy or non-surgically by energy-based technologies such as radiofrequency or ultrasound. To recapture youth, the lost volume must be restored by means at our disposal.
Dermatologists have an increasing number of modalities to improve the appearance of aging skin, including injectable botulinum toxins and dermal fillers, non-ablative and ablative laser treatments, chemical peels, and a diverse array of topical agents, including prescription retinoids and bleaching agents and nonprescription cosmeceuticals. A joint approach is considered ideal for many patients.
The goal of type 1 rejuvenation is the optimization of epidermal turnover, and uniform chromo¬phore distribution is achieved with visible lasers, light, fractional radiofrequency, chemical peels, microdermabrasion, and skin care products.
Type 2 rejuvenation is more profound, and tar¬gets decreased collagen, disorganized glycosaminoglycans, and elastin, manifested by superficial rhytides and is best treated with non-ablative mid infrared lasers, and intense pulsed light (IPL).
Rejuvenation type 3 is most in-depth and targets deep dermal collagen disorders and skin laxity; here comes the role of fractional lasers, radiofrequency, infra-red light, ultrasound are the most effective). For each of these rejuvenation goals, various energy-based technologies are available. Loss and redistribution of sub-¬dermal fat in aging is handled with liposuction and Liquid face lift (Botox, fillers, and fat.
Monopolar radiofrequency. a new tool for non surgical skin tightening and bod...Osama Moawad
Monopolar radiofrequency delivers the electric current to the skin. The epidermis is spared by applying a cooling spray that protects it from the heating while dermis is then heated uniformly and volumetrically. Partial collagen denaturation occurs which leads to collagen contraction and skin tightening. More tightening follows due to a natural wound healing response that triggers new collagen formation and further skin contraction. Aside from wrinkles reduction, successful treatment of moderate to severe cystic acne, acne scarring, and cellulite. Radiofrequency technology continues to advance rapidly, providing dermatologists with an expanding array of skin rejuvenation techniques that result in few adverse effects and minimal downtime for patients. Everybody is a good candidate for RF, but it is of special significance to those who do not like invasive surgical intervention, and who is still young for surgery.
It has been written that ‘‘there is no single disease which causes more psychic trauma, more maladjustment between parent and children, more general insecurity and feelings of inferiority and greater sums of psychic suffering than does acne vulgaris.’’ Acne scars lead to emotional debilitation, embarrassment, poor self-esteem, social isolation, preoccupation, low confidence, altered social interactions, body image alterations, identity difficulties, anger, frustration, confusion, unemployment, lowered academic performance, exacerbation of the psychiatric disease, anxiety, or depression. Treatment of the real scars resulting from acne must reflect several considerations by the physician. Cost of treatment, the severity of lesions, physician goals, patient expectations, side-effect profiles, psychological or emotional effects to the patient, and prevention measures should all play a role. The purpose of any intervention is for improvement, not for a total cure or perfection. The therapies/techniques used for the treatment of acne scars are to be individualized, taking into consideration many factors like age, gender, Fitzpatrick skin phototype, site of injuries, clinical type of acne scars, grading of scars, socioeconomic constraints, psychological and physical health of the patient, etc. Various treatment modalities available for acne scars are topical therapies, chemical peelings, micro-needling or microdermabrasion, subcision, autologous ⁄ non-autologous dermal fillers, fractioned ⁄ non-fractionated lasers, ablative/nonablative lasers, pigment or vascular-specific lasers, pigment transfer techniques, and minor surgical procedures. Many times, a combination of these modalities must obtain satisfactory results in an individual patient.
In a novel approach, Prof. Moawad performs liposuction of the axilla as an effective treatment for axillary hyperhidrosis, as a local surgical procedure, apocrine glands, as well as eccrine glands, are removed by the liposuction technique through one or two tiny incision holes without the sacrifice of overlying axillary skin. The success of this technique may be due to the disruption of the nerve supply to the sweat glands and the removal or destruction of the apocrine organs that are present in high density in the axilla. With proficiency in the technique, Prof Moawad performs this procedure successfully with few complications and low recurrence rates. New bipolar RF devices can destroy the eccrine glands by process of thermolysis at the interface of the deep dermis and subcutis while minimizing damage to the surrounding tissue Fractional microneedle radiofrequency (FMR) treatment appears to be a new safe and effective treatment alternative for moderate to severe primary axillary hyperhidrosis. Prof Moawad suggests It is repeated sessions of FMR be considered to achieve a complete response
ADVANCED BOTOX COURSE.PART II. HOW TO INJECT BOTOX SAFELY?Osama Moawad
We are truly in an “era of injectables,” with access to a varied armamentarium of products that yield dramatic aesthetic results with minimal recovery downtime. From its first published mention as an aesthetic treatment for glabellar lines in 1992, the use of commercially available BoNT type A (BoNTA) has captivated healthcare professionals and lay people alike. The availability of newer BoNTA formulations, with more expected in the near future, poses an exciting opportunity for aesthetic practitioners to reach an ever expanding potential patient base and provide increasingly refined treatment. Critical to this endeavor, is the ability to use BoNTA to its best effect; this requires, at minimum, an understanding of the scientific profile and physical characteristics of commercially available agents, but just as important are an understanding of the patient-specific factors that will determine the treatment plan. In addition, the ability to integrate consideration of each patient’s individual needs into the development of a personalized treatment strategy.
THE ART OF NON SURGICAL SKIN REJUVENATIONOsama Moawad
Looking great in public is hard. Whether you are trying to look your best for job interviews or just get attention, MSI Peel is the way to go. MSI Peel involves a variety of skin treatments, including steam, masks, exfoliation, extraction, cosemceuticals,, PRP, peels, LED, IPL, laser, ultrasound and radiofrequency.Skin penetration enhancement techniques have been developed to improve bioavailability and increase the range of topical drugs for which transdermal delivery techniques are a viable option such mesogun, dermal roller or electroporation. MSI PEEL is a comprehensive anti-aging, anti acne, scar treatment program that uses the state of art in aesthetic medicine. It is tailored exactly to your, skin condition, need and expectation.
Heat in skin rejuvenation. Light, Laser, RadiofrequencyOsama Moawad
Thermal treatment using optical energy for various types of dermatologic problems has become very popular over the past 20 years. Light-based therapies with lasers and intense pulse light (IPL) technologies have been increasingly used in aesthetic medicine for epilation, removal of vascular and pigmented lesions, reduction of fine wrinkles, and acne treatment
Although effective for a broad range of dermatological indications, limitations also have been realized with light-based therapies. One of the main limitations is that optical energy must penetrate the epidermis to reach the depth of the targeted site. Optical energy is absorbed by melanin chromophores in the epidermis and hair shafts, and hemoglobin in blood. In photoepilation, light-colored hair is particularly difficult to remove because it has low levels of melanin and, therefore, may not absorb enough energy to achieve thermal destruction of the hair follicle. Conversely, high pigmentation of the epidermis also poses a problem because it may absorb too much energy, potentially causing adverse effects such as burns and hyperpigmentation. Wrinkles respond poorly to treatment with optical energy because collagen fibers do not contain chromophores. These limitations have stimulated investigators to look for new forms of energy that satisfy the principle of selective thermolysis but are devoid of the main disadvantage of optical energy for dermatological applications; that is, a strong interdependence between treatment efficacy/safety and chromophore levels in the epidermis. The use of radiofrequency (RF) for selective electrothermolysis has been found to produce a highly efficient thermal effect on biological tissue. Different from optical energy, RF energy is dependent on the electrical properties of the tissue rather than on concentration of chromophores in the skin for selective thermal destruction of targeted sites.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
1. Liposuction and Cosmetic Surgery
10/21/2022
1
email:
askprof@moawadskininstitute.com
Liposuction is the most performed
cosmetic surgery in the world.
• Furthermore, it has become an essential
complementary technique to enhance the
aesthetic result of many other procedures,
such as cervicoplasty, reduction or
augmentation mammoplasty, abdominoplasty,
brachioplasty, thigh lift, and post-bariatric
body contouring.
2. Surgical Fat Reduction (liposuction): The Need
• It corrects deep and superficial fat
accumulations and thus remodels
the face, neck, breast, and body
contour deformities.
• It should be carried out in the
lamellar layer if one desires long-
term results. results.
10/21/2022 email: askprof@moawadskininstitute.com 2
3. Liposuction and Cosmetic Surgery
• Areas amenable to liposuction
are:
• Face & neck
• Breast
• Arms
• Abdomen
• Mons pubis
• Flanks & Hips
• Back
• Buttocks
• Thighs
• Knees
• Calves and Ankles
10/21/2022 email: askprof@moawadskininstitute.com 3
Liposuction is the most performed aesthetic surgery in the world.
4. Liposuction and
Cosmetic Surgery
10/21/2022
4
email:
askprof@moawadskininstitute.com
• Liposuction is the initial surgical approach of
choice for pseudo-gynecomastia, gynecomastia
macromastia and gigantomastia.
• In true gynecomastia, and female breast
however, there is an increase in the gland volume
with a dense fibrous and vascular stroma, making
suction more difficult.
• Liposuction combined with traditional
resection mammoplasty allows gynecomastia and
gigantomastia volume reduction before excision.
• It will refine further the results after the
surgery, in a more effortless surgery, less
complication and better aesthetic results.
5. Liposuction and
Cosmetic Surgery
• Eccrine glands are located at the superficial
subcutaneous plane.
• At first, a starch-iodine test helps identify
the area of excessive sweating
• Liposuction has been safely and effectively
performed for many years
• There are several different treatment
techniques.
10/21/2022 email: askprof@moawadskininstitute.com 5
6. Liposuction and
Cosmetic
Surgery
• Mons pubis lipodystrophy and “Buried" penis” in fatty men
result in embarrassment and sexual dysfunction that can be
treated safely with liposuction
10/21/2022 email: askprof@moawadskininstitute.com 6
7. Liposuction and
Cosmetic Surgery
email: askprof@moawadskininstitute.com
• Lipedema is characterized by
bilateral symmetrical and
localized subcutaneous fat
deposits of the buttocks and
lower limbs.
• It causes significant physical
disability, fatigue, pain, and
difficulty wearing shoes and
boots.
• liposuction provides good
aesthetic results, improving
the proportion between the
upper and lower body and
reducing painful symptoms,
especially at the lower limb
articulations, ensuring better
mobility.
10/21/2022 7
8. Liposuction and
Cosmetic Surgery
• Lipodystrophies represent a group of rare
diseases characterized by selective body fat loss
with altered body fat amount and/or
repartition that can be either generalized or
partial, associated with insulin resistance, type
2 diabetes, dyslipidemia, liver steatosis,
polycystic ovaries, acanthosis nigricans, and
cardiovascular complications
• The excess adipose tissue from the chin, buffalo
hump, and vulvar region can be removed by
liposuction. Autologous adipose tissue
transplantation or implantation of dermal fillers
can improve facial appearance.
10/21/2022 email: askprof@moawadskininstitute.com 8
9. Liposuction and
Cosmetic Surgery
email: askprof@moawadskininstitute.com
• Lymphedema consists of the
accumulation of lymphatic fluid
in dermis and subcutaneous
tissue
• The chronically accumulated
lymphatic fluid causes
cutaneous dermal thickening,
hypercellularity, and
progressive fibrosis.
• Lipids accumulate in adipocytes
and macrophages, secondary
to local lipid transport from
limited lymph flow, resulting in
increased adipose tissue.
• liposuction provides good
aesthetic and functional long-
term results with a minimum
complication rate.
10/21/2022 9
Lymphedema
10. Liposuction and
Reconstructive
Surgery
• One of the liposuction's first non-cosmetic clinical
applications was the aspiration of a giant lipoma
without leaving a visible scar.
• Simple surgical excision remains the primary and
most effective treatment. However, removing large
or multiple lesions may be problematic and result in
significant objectionable scars.
• Liposuction can also be a helpful solution for
treating multiple lipoma syndromes and multiple
familial lipomatosis associated with some genetic
pathology.
10/21/2022 email: askprof@moawadskininstitute.com 10
11. Liposuction and
Reconstructive
Surgery
1
1
• Musculocutaneous or fasciocutaneous flaps
are widely used to reconstruct various defects
• Liposuction usually allows thinning of the
subcutaneous tissue without the risk of flap
necrosis and reduces the number of revision
procedures required to achieve optimal
aesthetic and functional results.
10/21/2022
email: askprof@moawadskininstitute.com
13. Liposuction
and Obesity
• Liposuction in obesity is worthwhile to
consider as a reasonable alternative to
other medical and surgical slimming
methods offering immediate compliance to
lower caloric intake and higher physicality.
• It improves body contour and image.
• It reduces cardiovascular risk factors such
as obesity, systolic blood pressure, and
plasma insulin.
10/21/2022 email: askprof@moawadskininstitute.com 13
14. Liposuction and Obesity
• On the other hand, obesity is ASA III type; patients with B.M.I.> 35 impart a threefold to
fourfold risk from anesthesia, prone to sleeping apnea, infections, poor wound healing, and
deep vein thrombosis.
• The risk of complications increases as the volume of aspirate and the number of anatomical
sites treated increase.
10/21/2022 email: askprof@moawadskininstitute.com 14
16. Patient
Selection
• Liposuction is contraindicated in pregnant patients or poor general
medical health, patients with morbid obesity, large pannus hanging
over the thigh, cardiopulmonary disease, body image perception
issues, unrealistic expectations, wound healing difficulties, or who
have extensive or poorly located scars.
10/21/2022 email: askprof@moawadskininstitute.com 16
17. Patient
Selection
• Liposuction patients often present with
different expectations, concerns, and
complaints.
• Some expectations are more than can be
delivered by the surgeon. For example, patients
interested in losing a few pounds overnight
without maintaining a proper diet and exercising
are not good candidates for liposuction surgery.
• Find out their reason for liposuction and if
they are doing it for themselves or others, such
as their spouse or boyfriend. The surgery must
purely be done for themselves.
• Liposuction surgery does not make a
depressed patient well, but it will bring
happiness to a healthy patient.
• Beware of the dysmorphic personality, where
the patient dwells on a problem that does not
exist, and the surgeon can never satisfy that
patient.
10/21/2022 email: askprof@moawadskininstitute.com 17
18. Medical History
• A detailed medical history should be
obtained, including allergies, tobacco
use, diabetes, massive weight loss,
previous surgery, previous liposuction,
and a complete detailed list of
medications and supplements.
• It would be best if you stopped;
aspirin, NSAIDs, hormonal therapy, oral
contraceptives, beta-blockers,
antidepressants, and calcium channel
blockers.
• Smoking should be discontinued at
least two weeks before surgery.
• Anyone older than fifty years of age or
with a significant medical history
should be referred for preoperative
clearance by an internist or
cardiologist.
10/21/2022 email: askprof@moawadskininstitute.com 18
19. The American Society of
Anesthesiologists’ (ASA)
Physical Status Classification
Class I A healthy patient without systemic medical or psychiatric illness, excluding the very young and
ancient fit with good exercise tolerance
Class II A patient with a mild systemic disease but no functional limitations; has a well-controlled disease of
one body system (i.e., controlled hypertension or diabetes without systemic effects, cigarette smoking
without chronic obstructive pulmonary disease, and mild obesity
Class III A patient with severe systemic disease that is not considered incapacitating (obesity) significantly
increases the risk of any form of anesthetic, poor wound healing, increased risk of infection, deep
vein thrombosis, sleep apnea, and occasional death. The risk of complications increases as the
volume of aspirate and the number of anatomical sites treated increase.
Elective surgery patient should be Class I or II
10/21/2022 email: askprof@moawadskininstitute.com 19
20. Laboratory Tests
• Laboratory tests will be based on medical history and
physical examination.
• A chemistry profile, a complete blood count, and a
platelet assessment are mandatory
• Some surgeons may wish to obtain screening for H.I.V.
and Hepatitis.
• Massive weight loss patients should evaluate as any
excisional-type body contouring procedure
• An ultrasound or computed tomography (C.T.) scan
may further clarify abdominal hernia and prevent
potential perforation of an organ during liposuction.
10/21/2022 email: askprof@moawadskininstitute.com 20
21. Physical Examination: Body Mass Index (BMI)
• Calculating body mass index (BMI) is paramount to patient safety and follow-up visits
• It is well known that morbid obesity (BMI > 35) imparts a threefold to fourfold risk from anesthesia.
10/21/2022 email: askprof@moawadskininstitute.com 21
22. Patient
Examination
• The physical exam is best performed
before a full-length mirror and requires the
physician to evaluate that area
circumferentially
• Findings may be challenging to interpret
in obese individuals, males, or patients with
multiple scars
• The importance of looking good without
clothing identifies the patients who will
mandate smooth skin as a critical
component of their procedure
• If this is less important, it may open up
other options for the patient to look better
in clothing.
10/21/2022 email: askprof@moawadskininstitute.com 22
23. Physical Examination
Using the BMI, the surgeon can
objectively classify a patient's
obesity as one of the following:
• Class I: Lean range (18.5–19.9)
• Class II: Optimal (average) (20–25)
• Class III: Overweight range (25.1–29.9)
• Class IV: Obese range (30–34.9)
• Class V: Morbidly obese range (35–39.9)
• Class VI: Extremely obese (40 or greater)
10/21/2022 email: askprof@moawadskininstitute.com 23
24. Physical
Examination
• Skin tone and quality should be
assessed, and differences between
excisional procedures and liposuction
should be discussed with the patients.
10/21/2022 email: askprof@moawadskininstitute.com 24
25. Physical Examination
email:
askprof@moawadskininstitute.com
• The fact that cellulite will
not improve with
suctioning may worsen and
that no improvement in
superficial contour
irregularities is possible
with liposuction alone,
usually combined with fat
grafting.
10/21/2022 25
26. Physical
Examination
email:
askprof@moawadskininstitute.com
• The patient should know
that the body is not
symmetric, and the
markings will be slightly
different on the two sides
of the body.
• The surgeon should pinch
the excess fat, and if the
patient has asymmetry, this
should be pointed out to
the patient and recorded
with good photographs.
10/21/2022 26
27. Physical
Examination
Findings may be
challenging to interpret in
obese individuals
• Symmetry and Scars
• Skin quality and
cellulite
• Fat, muscle, and Bone
• Gender Variations
10/21/2022 email: askprof@moawadskininstitute.com 27
28. Preoperative Markings
• I use a color-coded topographic
type of marking for areas of
lipodystrophy and contour
deformities. Transition areas are in
green color, and Zones of
adherence and places to avoid are
marked with red or hash marks.
• The central ring is the most area
to liposuctioned and at a deep
level; as I move to the peripheral
rings, I aspirate less and move
more superficial blinging nicely
with the surrounding areas.
10/21/2022 email: askprof@moawadskininstitute.com 28
29. Preoperative
Markings
• Access sites are used for both Infiltration
of local anesthesia and lipoaspiration.
• It must allow me to treat multiple areas ,
cross-hatched cannula patterns, and
passing at various directions and depths.
• Using extra sites decrease the risk of
access site is being over-sectioned.
• It should be in well-hidden places such
as hair and creases, skin folds, or a previous
scars.
10/21/2022 email: askprof@moawadskininstitute.com 29
Transition
zone
Access Site
30. Markings Male Vs. Female
Attention must be paid to "gender ideal" muscular shape/ mass and fat
distribution
10/21/2022 email: askprof@moawadskininstitute.com 30
31. Preoperative
Markings
• Mark Dynamic areas in the
full range of muscular
contraction to yield natural
results
email:
askprof@moawadskininstitute.com
10/21/2022 31
32. Medical Photography is a Must
Imaging is An educational Tool
High Medical Photograph: anterior, posterior, oblige and lateral
Consent Form must be Signed
10/21/2022 email: askprof@moawadskininstitute.com 32
33. Patient
Education
• One of the essential parts of the preoperative
consultation is emphasizing to patients that
liposuction has two parts. Fat removal is easily
understood, the unpredictability of skin retraction far
less so, but vital for a result satisfactory to both
parties.
• Often questions are asked during the consultation
as to how many sizes of clothing will be reduced. Or
how many pounds would be lost after the liposuction
surgery? It should be explained to the patient that
there is no way that it can be predicted how many
sizes an individual will reduce in clothing or how many
pounds will be lost.
10/21/2022 email: askprof@moawadskininstitute.com 33
34. Patient
Education
• Often patients want many areas
liposuctioned in one session.
• It should be explained to the patient that
the maximum amount of liposuction that
can be performed in an outpatient surgical
facility at one time is 5 l. Patients will have
a faster recovery and minimal
complications.
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35. Patient Education
• The patient must understand that surgery, on average, does not achieve perfect results, and
further refinement might be needed
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36. Patient
Education
• The patient and physician should discuss
the procedure, alternative treatments,
financial obligations (including further
surgeries if required), and complications
and risks. It is crucial to have the informed
consent read and signed at the
preoperative visit.
10/21/2022 email: askprof@moawadskininstitute.com 36
37. Second
Preoperative
Visit
• A follow-up visit is typically
scheduled 2–3 weeks after the initial
consultation.
• The second visit allows for
addressing recovery time, pain control,
bruising, and postoperative changes,
which will help strengthen the patient's
confidence in the procedure and
decrease the likelihood of any
uncertainties or surprises within the
perioperative period.
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38. Location of Liposuction
• Liposuction is performed in three outpatient settings: hospitals, free-
standing ambulatory surgery centers, or office-based surgery facilities. The
operative location is determined after careful patient evaluation,
assessment of the complexity of the operation, and the appropriate
evaluation of medical comorbidities.
• It is up to the surgeon to choose the optimal surgical setting for each
patient undergoing liposuction.
• Office-based surgery has several potential benefits over hospital-based
surgery, including cost containment, ease of scheduling, and convenience
for patients and surgeons.
• It was found that hospital-based liposuction had three times the rate of
malpractice settlements compared with office-based liposuction surgery
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39. Location of
Liposuction
• Surgical procedures are associated with several
physiologic stressors, including the development of
hypothermia, blood loss, malignant hyperthermia,
and deep vein thrombosis.
• Taking precautions against such stressors will lead to
thoughtful decision-making regarding the type of
anesthesia used, the safety of combining multiple
procedures, and the duration of the procedure(s) to
maximize patient safety and enhance postoperative
recovery.
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40. Perioperative Days
• Prophylactic antibiotics are recommended for all extensive volume
liposuction. A 5-day course (500 mg/d), one day preoperatively followed by
250 mg once daily for days 2–5) of Zithromax is user-friendly. Patients skip
the day of surgery if intravenous antibiotics are utilized.
• The patient will have a shower on the morning of surgery with antibacterial
soap.
• Patients are told to wear loose-fitting clothing and cover their bedcover
sheets with plastic sheets or bags because drainage should be expected for
the initial 24–36 h.
• If tumescent anesthesia only will be used by the patient, a light breakfast is
allowed on the morning of surgery.
• However, patients with sedation or general anesthesia are told to avoid
drinking or eating starting at midnight before surgery.
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41. The Day of Surgery
• Surgical consent signed
• Preoperative pictures
• All clothing, jewelry, contact lens, and any dentures are
removed
• Areas of liposuction are appropriately marked.
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42. The Day of Surgery
• Preventative measures against
hypothermia include warming the wetting
solutions and prep, increasing the room
temperature, and using warming devices.
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43. The Day of
Surgery
• Pedal or calf compression devices are
also applied in the holding area to assist
DVT prophylaxis.
• It should be considered for longer body
contouring cases and those involving
multiple sites.
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44. Intraoperative
Time
• It is helpful to have the circulating
nurse maintain an accurate liposuction
data sheet to facilitate consistent and
accurate communication between the
surgeon, the anesthesiologist, and the
operating room team.
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45. Patient
Positioning
email:
askprof@moawadskininstitute.com
• Patient positioning depends on the
area or areas that need to be treated,
other procedures the patient will be
undergoing, the patient's body
habitus/B.M.I., and surgeon
preference.
• It is better to have excellent and
efficient positioning allowing better
contouring of the areas from several
access points and directions to
achieve the most significant aesthetic
results and avoid serious
complications.
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46. Patient
Positioning
• Up to 70% of the contouring can be performed in the prone position,
including liposuction of the arms, back, hips/flanks, lateral, posterior, and
medial thighs.
• Patients in the prone position are subjected to pressure changes over
the forehead, malar areas, iliac crest, and bony prominences of the arms
and legs.
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47. Patient
Positioning
• The remainder of the trunk and extremities can be addressed with the
patient in the supine position, including arms, abdomen, anterior medial
thighs, and knees.
• Pressure points in the supine position include the occiput, scapula,
posterior iliac crest, sacrum, and heels.
• This position does not have significant effects on the cardiopulmonary
systems.
10/21/2022 email: askprof@moawadskininstitute.com 47
48. Patient
Positioning
• The lateral decubitus position most closely resembles the normal standing
position, allowing contouring to match the position the patient sees
themselves in a mirror, accessing the flanks, lateral back, buttocks, thighs, and
lower legs.
• All pressure points should be well-padded. Brachial plexus injuries can
occur if the arm is abducted >90°.
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49. Tumescent Local
Anesthesia (TLA)
• In 1985 Jeffrey Klein, a San Juan Capistrano,
California dermatologist, performed his first case
using the original tumescent local anesthesia (T.L.A.)
formula: short-acting lidocaine, epinephrine, and
bicarbonate, diluted in a physiologic saline solution.
• All liposuction solutions are kept at a temperature
of 38°C.; the epinephrine is added to the wetting
solution just before infiltration.
• Lidocaine and epinephrine total doses are varied
according to the anatomic site to be treated, e.g.,
neck, back, or breast, and the total volume of
anesthetic solution injected.
10/21/2022 email: askprof@moawadskininstitute.com 49
50. Tumescent Local Anesthesia (TLA)
email:
askprof@moawadskininstitute.com
• The invention of tumescent local anesthesia (T.L.A.) was
to perform liposuction surgery on an outpatient basis since
most dermatologists in the United States did not have
hospital privileges to perform liposuction.
• It was a secondary observation to experience a
dramatically reduced rate of complications in liposuction.
• Local anesthesia constituents differ primarily according
to fluid volume and infiltration/aspiration ratios.
• The ratio of infiltration to aspiration is approximately
2:1—-1:1 for large-volume suctioning.
• For more minor procedures, the proportions are higher
up to 10:1, i.e., 1000 mL of infiltration to 100 mL of
aspirate.
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51. Tumescent Local
Anesthesia (TLA)
• The traditionally recommended maximum dose of lidocaine
with epinephrine is 7 mg/kg; however, in the liposuction setting,
the safety of lidocaine in concentrations >35 mg/kg and as high
as 55 mg/kg in large-volume cases. Later, Patrick Lillis published
data explaining that 55 to 90 mg/kg body weight would be safe.
• Medications that increase lidocaine levels include oral
contraceptives, beta-blockers, and tricyclic antidepressants.
• Lidocaine provides analgesia for up to 18 h postoperatively.
• Lidocaine may also contribute to the extremely low incidence
of infection seen in liposuction because of its bacteriostatic
effect.
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52. Tumescent Local Anesthesia (TLA)
• The epinephrine dosage used in infiltrating solutions varies and may range from 1:100,000 to
1:1,000,000, depending on the anatomic sites treated and the infused infiltrate volume.
• It is recommended that epinephrine doses not exceed 0.07 mg/kg, although doses as high as
10 mg/kg have been used safely. Most commonly, epinephrine in 1 mg with 1/1000 dilution is
injected into a 1-L bag.
• . Vasoconstriction also decreases the lidocaine absorption rate, potentiating the local
anesthetic effect.
• The epinephrine may also increase the cardiac output, which, in turn, hastens the hepatic
metabolism of the lidocaine.
• The blood-tinged infranatant of the true tumescent liposuction aspirate has a hematocrit of
less than 1%. Less than 12 mL of whole blood is lost per liter of fat extracted
• With its vasoconstrictive properties, epinephrine is the key to minimal blood loss during
liposuction.
• However, epinephrine should not be given to patients with cardiovascular diseases.
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53. Tumescent Local
Anesthesia (TLA)
• Sodium bicarbonate is necessary to
neutralize the acidic pH of
commercially available lidocaine,
eliminating the stinging and burning
sensation and in return, the need for
narcotic analgesia or sedation.
• Ten milliequivalents of sodium
bicarbonate are added per liter of the
most tumescent formulation.
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54. Tumescent
Local
Anesthesia (TLA)
• The lidocaine solution is first placed into the incision site through a sharp
25-gauge needle; incisions are then made with a No. 11 blade.
• The incisions for infiltration of anesthetic solutions are usually the same for
harvesting fatty tissue.
• These incisions are just large enough (usually 2 mm) to permit insertion of
the tip of the harvesting cannula.
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1 2
55. Tumescent Local
Anesthesia (TLA)
• Tumescent fluid in prepared bags is delivered through the tubing with a
motor-driven pump at a slow infusion rate (<50 mL/min) attached to
infiltration cannula in large cases.
• Alternatively, tumescent fluid is delivered through a syringe attached to
multi holes infiltrating microcannula in minor cases.
Pump Infiltration
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Syringe Infiltration
56. • The volume of fluid infiltration depends on the tissue characteristics. Lighter fat, such as the abdomen, is more distensible and
takes up more volume, while dense tissues, such as the back, are less distensible and fill more quickly with infiltration fluid.
• Rapid infusion is undesirable because it tends to be less uniform, resulting in suboptimal hemostasis and anesthesia.
Lighter fat, is more distensible and takes more volume
Dense fat is less distensible and takes less volume
Tumescent Local Anesthesia (TLA)
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57. Tumescent Local
Anesthesia (TLA)
• Infiltration is carried first into the
superficial subcutaneous fat in sensitive
areas.
• Later deep infiltration use is easily
tolerated, even in challenging fibrous areas.
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58. Tumescent Local
Anesthesia
• The operating hand should move
forward slowly and deliberately to fill
between fat lobules at every level.
• The other hand palpates the tissue from
the surface, constantly aware of the
location of the tip of the cannula.
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59. Tumescent Local Anesthesia (TLA)
email:
askprof@moawadskininstitute.com
• Clinically, TLA fluid will lead to
maximum firmness of the skin
surface, a" state of tumescence.
• Firmness, a slight "orange
peel," fountain sign, and tissue
blanching are considered clinical
endpoints of infiltration in the
accurate tumescent technique.
• The wetting solution should
be allowed 30 min before
suctioning to reach its maximum
effect.
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60. Tumescent Local
Anesthesia.
• Fluid infiltration will lead to the first step of an
"interseptal hydrodissection“
• Since these tissue planes offer the lowest resistance
for the T.L.A., fluid to spread; after a short time,
depending on the rising interstitial tissue pressure, the
T.L.A. fluid will penetrate the fascia. It will surround the
fat lobules called "paralobular distribution."
• Increasing amounts of fluid will cause the fat lobules to
absorb the T.L.A. fluid, leading to "intralobular
penetration."
• After more and more liquid is added, the full extent of
all the fat levels is flooded by the T.L.A. fluid, which after
30 minutes of diffusion, leads to a "homogenization" of
the fat tissue.
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61. Tumescent Local
Anesthesia
• The tumescent fluid will compress the blood vessels,
facilitating the vasoconstrictive action of epinephrine, and
will make them a smaller target and less likely to be
traumatized by concurrent liposuction.
• The sensory nerves are also stretched, making the
accompanying lidocaine effective.
• Infiltrating the fat layer magnifies its volume and defects
so that the desired fat sculpting can be accomplished with
greater accuracy and better feathering of edges.
• Expanding the fat layer can also create a safety cushion,
elevating the target work area away from underlying vital
structures.
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62. Tumescent Local
Anesthesia
• If the skin surface shows softness,
additional fluid infiltration is indicated to
stabilize tissue during the liposuction surgery.
• Alternatively, a well-trained assistant
stabilizes the tissue manually by horizontal
fixation.
• It is important not to distort the tissue or
change the correct anatomical conditions to
prevent over-suctioning specific areas.
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63. Tumescent Local
Anesthesia
• This situation is advantageous where there
is little room for error, such as in medial thighs
and jowls.
• After withdrawing the cannula, a band-aid is
placed to stem the fluid flow from the incision
site.
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Awake Patient
64. Tumescent Local
Anesthesia
• I prefer to use tumescent local anesthesia
alone (awake liposuction) for; minor cases,
single sites, revisions, touch-ups, and fat
extraction.
• The result is complete fat removal with
less traumatic injury to delicate structures
of fatty tissue; this is crucial for both
liposuction results (fat left) or the need for
it later, whether for immediate contour
correction or the next step in lipofilling.
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65. Large Volume
Liposuction
• The AACS 2000 Guidelines for Liposuction
Surgery state that the maximal volume
extracted may rise to 5,000 ml of
supernatant fat in the ideal patient with no
comorbidities.
• Currently, conservative guidelines limit
the total volume of supernatant fat aspirate
to less than or equal to 4 l in liposuction
cases.
• The guidelines also state that the
recommended volumes aspirated should be
modified by the number of body areas
operated on, the percentage of body surface
area worked on, and the percentage of body
weight removed.
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66. Large Volume
Liposuction
• The guidelines also state that
the recommended volumes
aspirated should be modified by
the number of body areas
operated on, the percentage of
body surface area worked on,
and the percentage of body
weight removed.
• The risk of perioperative
morbidity and mortality
increases with the increasing
time and size of the procedure.
10/21/2022 email: askprof@moawadskininstitute.com 66
Buttocks Lipofilling
67. Large Volume
Liposuction
• Two options are available to
decrease the risk of lidocaine toxicity
in large-volume liposuction cases.
• The first is to reduce the
concentration of lidocaine in the
wetting solution.
• The second is to use smaller volumes
of infiltrating by applying the superwet
technique rather than the tumescent
technique.
10/21/2022 email: askprof@moawadskininstitute.com 67
68. Large Volume
Liposuction
• Although lengthy operations are prone to complications, it is
safer to Inject by section, i.e., one area is infiltrated and
extracted while the other is injected.
10/21/2022 email: askprof@moawadskininstitute.com 68
Left Buttock is done
70. Large Volume
Liposuction
• Alternatively, the
extraction is performed
using two suction machines
simultaneously.
10/21/2022 email: askprof@moawadskininstitute.com 70
Fat Extraction
71. Large Volume
Liposuction
• The patient's body mass index and the
potential physiologic consequences of
tissue loss should be considered to ensure
that the volume of aspirate removed is
proportional to the patient's overall size
and medical condition.
• A urine catheter is placed for the
expected liposuction volume greater than 4
liters.
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72. Large Volume
Liposuction
The following formula aids in
fluid management for these
patients.
• Maintain fluid throughout the
procedure and manage it based on
vital signs and urine output.
• Employ the superwet infiltration
technique.
• Administer crystalloid replacements,
0.25 mL for each milliliter of
lipoaspirate over 5 L.
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73. Large Volume
Liposuction
7
3
• For me, liposuction is "large" when it is over 5,000
mL.
• I try not to extract over 10,000 mL per session.
• I always stay below the 55 mg/kg body weight
range regarding lidocaine.
• Now the anesthesia has reached its peak.
• The skin looks blanched and firm.
10/21/2022
email: askprof@moawadskininstitute.com
74. Adjunctive
Anesthesia
Several adjunctive types of anesthesia
are used during liposuction
procedures, including
• General anesthesia.
• Epidural anesthesia.
• Spinal anesthesia.
• Sedation/analgesia.
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75. Adjunctive
Anesthesia
Many factors influence the usage of
adjunctive anesthesia decision
including:
• Expected lipoaspirate.
• Length and extent of the
procedure.
• Patient positioning.
• Surgeon preference.
• Anesthesiologist preference.
• Overall health of the patient.
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Editor's Notes
LIPOSUCTION AESTHETIC INDICATIONS
Liposuction is the most performed cosmetic surgery in the world. Furthermore, it has become an essential complementary technique to enhance the aesthetic result of many other procedures, such as cervicoplasty, reduction or augmentation mammoplasty, abdominoplasty, brachioplasty, thigh lift, and post-bariatric body contouring.
Surgical Fat Reduction. The Need
It corrects deep and superficial fat accumulations and thus remodels the face, neck, breast, and body contour deformities.
It should be carried out in the lamellar layer if one desires long-term results.
Liposuction and Cosmetic Surgery
Areas Amenable to Liposuction are the face, neck, breast, arms, abdomen, mons pubis, back, hips, buttocks, thighs, knees, calves, and ankles.
Liposuction and Cosmetic Surgery
Liposuction is the initial surgical approach of choice for pseudo-gynecomastia, gynecomastia macromastia and gigantomastia. In true gynecomastia, and female breast however, there is an increase in the gland volume with a dense fibrous and vascular stroma, making suction more difficult. Liposuction combined with traditional resection mammoplasty allows gynecomastia and gigantomastia volume reduction before excision. It will refine further the results after the surgery, in a more effortless surgery, less complication and better aesthetic results.
Liposuction and Cosmetic Surgery
Eccrine glands are located at the superficial subcutaneous plane.
At first, a starch-iodine test helps identify the area of excessive sweating
Liposuction has been safely and effectively performed for many years
There are several different treatment techniques.
Liposuction and Cosmetic Surgery
Mons pubis lipodystrophy and “Buried" penis” in fatty men result in embarrassment and sexual dysfunction that can be treated safely with liposuction
Liposuction and Ablative and Reconstructive Surgery
Lipedema is characterized by bilateral symmetrical and localized subcutaneous fat deposits of the buttocks and lower limbs.
It causes significant physical disability, fatigue, pain, and difficulty wearing shoes and boots.
liposuction provides good aesthetic results, improving the proportion between the upper and lower body and reducing painful symptoms, especially at the lower limb articulations, ensuring better mobility.
Liposuction and Cosmetic Surgery
Lipodystrophies represent a group of rare diseases characterized by selective body fat loss with altered body fat amount and/or repartition that can be either generalized or partial, associated with insulin resistance, type 2 diabetes, dyslipidemia, liver steatosis, polycystic ovaries, acanthosis nigricans, and cardiovascular complications
The excess adipose tissue from the chin, buffalo hump, and vulvar region can be removed by liposuction. Autologous adipose tissue transplantation or implantation of dermal fillers can improve facial appearance.
Liposuction and Cosmetic Surgery
Lymphedema consists of the accumulation of lymphatic fluid in dermis and subcutaneous tissue
The chronically accumulated lymphatic fluid causes cutaneous dermal thickening, hypercellularity, and progressive fibrosis.
Lipids accumulate in adipocytes and macrophages, secondary to local lipid transport from limited lymph flow, resulting in increased adipose tissue.
liposuction provides good aesthetic and functional long-term results with a minimum complication rate.
Liposuction and Ablative and Reconstructive Surgery
One of the liposuction's first non-cosmetic clinical applications was the aspiration of a giant lipoma without leaving a visible scar.
Simple surgical excision remains the primary and most effective treatment. However, removing large or multiple lesions may be problematic and result in significant objectionable scars.
Liposuction can also be a helpful solution for treating multiple lipoma syndromes and multiple familial lipomatosis associated with some genetic pathology.
Liposuction and Reconstructive Surgery
Musculocutaneous or fasciocutaneous flaps are widely used to reconstruct various defects
Liposuction usually allows thinning of the subcutaneous tissue without the risk of flap necrosis and reduces the number of revision procedures required to achieve optimal aesthetic and functional results.
Liposuction and Reconstructive Surgery
Revision of surgical scars.
Tracheostomy, colostomy, and urostomy in great obese patients, in which the stoma could be occluded by excessive fatty tissue surrounding it.
Liposuction and Obesity
Liposuction in obesity is worthwhile to consider as a reasonable alternative to other medical and surgical slimming methods offering immediate compliance to lower caloric intake and higher physicality.
It improves body contour and image.
It reduces cardiovascular risk factors such as obesity, systolic blood pressure, and plasma insulin.
Liposuction and Obesity
On the other hand, obesity is ASA III type; patients with B.M.I.> 35 impart a threefold to fourfold risk from anesthesia, prone to sleeping apnea, infections, poor wound healing, and deep vein thrombosis.
The risk of complications increases as the volume of aspirate and the number of anatomical sites treated increase.
Patient Selection
Appropriate candidates for liposuction are not morbidly obese, are of stable weight, and should commit to the necessary diet, exercise, and lifestyle changes before surgery.
Patient Selection
Liposuction is contraindicated in pregnant patients or poor general medical health, patients with morbid obesity, large pannus hanging over the thigh, cardiopulmonary disease, body image perception issues, unrealistic expectations, wound healing difficulties, or who have extensive or poorly located scars.
Patient Selection
Liposuction patients often present with different expectations, concerns, and complaints.
Some expectations are more than can be delivered by the surgeon. For example, patients interested in losing a few pounds overnight without maintaining a proper diet and exercising are not good candidates for liposuction surgery.
Find out their reason for liposuction and if they are doing it for themselves or others, such as their spouse or boyfriend. The surgery must purely be done for themselves.
Liposuction surgery does not make a depressed patient well, but it will bring happiness to a healthy patient.
Beware of the dysmorphic personality, where the patient dwells on a problem that does not exist, and the surgeon can never satisfy that patient.
Medical History
A detailed medical history should be obtained, including allergies, tobacco use, diabetes, massive weight loss, previous surgery, previous liposuction, and a complete detailed list of medications and supplements.
It would be best if you stopped; aspirin, NSAIDs, hormonal therapy, oral contraceptives, beta-blockers, antidepressants, and calcium channel blockers.
Smoking should be discontinued at least two weeks before surgery.
Anyone older than fifty years of age or with a significant medical history should be referred for preoperative clearance by an internist or cardiologist.
The American Society of Anesthesiologists’ (ASA) physical status classification
Class I
A healthy patient without systemic medical or psychiatric illness, excluding the very young and ancient fit with good exercise tolerance
Class II
A patient with a mild systemic disease but no functional limitations; has a well-controlled disease of one body system (i.e., controlled hypertension or diabetes without systemic effects, cigarette smoking without chronic obstructive pulmonary disease, and mild obesity
Class III
A patient with severe systemic disease that is not considered incapacitating (obesity) significantly increases the risk of any form of anesthetic, poor wound healing, increased risk of infection, deep vein thrombosis, sleep apnea, and occasional death. The risk of complications increases as the volume of aspirate and the number of anatomical sites treated increase.
Laboratory Tests
Laboratory tests will be based on medical history and physical examination.
A chemistry profile, a complete blood count, and a platelet assessment are mandatory
Some surgeons may wish to obtain screening for H.I.V. and Hepatitis.
Massive weight loss patients should evaluate as any excisional-type body contouring procedure
An ultrasound or computed tomography (C.T.) scan may further clarify abdominal hernia and prevent potential perforation of an organ during liposuction.
Physical Examination: Body Mass Index (BMI)
Calculating body mass index (BMI) is paramount to patient safety. Body mass index (BMI) is paramount to patient safety as morbid obesity (BMI > 35) imparts a threefold to fourfold risk from anesthesia. BMI is important for long-term trends during follow-up visits.
Patient Examination
The physical exam is best performed before a full-length mirror and requires the physician to evaluate that area circumferentially
Findings may be challenging to interpret in obese individuals, males, or patients with multiple scars
The importance of looking good without clothing identifies the patients who will mandate smooth skin as a critical component of their procedure
If this is less important, it may open up other options for the patient to look better in clothing.
The body mass index (BMI)
Using the BMI, the surgeon can objectively classify a patient's obesity as one of the following:
Class I: Lean range (18.5–19.9)
Class II: Optimal (average) (20–25)
Class III: Overweight range (25.1–29.9)
Class IV: Obese range (30–34.9)
Class V: Morbidly obese range (35–39.9)
Class VI: Extremely obese (40 or greater)
Physical Examination
Skin tone and quality should be assessed, and differences between excisional procedures and liposuction should be discussed with the patients.
Physical Examination
The fact that cellulite will not improve with suctioning may worsen and that no improvement in superficial contour irregularities is possible with liposuction alone, usually combined with fat grafting.
Physical Examination
The patient should know that the body is not symmetric, and the markings will be slightly different on the two sides of the body.
The surgeon should pinch the excess fat, and if the patient has asymmetry, this should be pointed out to the patient and recorded with good photographs.
Physical Examination
Findings may be challenging to interpret in obese individuals
• Symmetry and Scars
• Skin quality and cellulite
• Fat, muscle, and Bone
• Gender Variations
Preoperative Markings
I use a color-coded topographic type of marking for areas of lipodystrophy and contour deformities. Transition areas are in green color, and Zones of adherence and places to avoid are marked with red or hash marks.
The central ring is the most area to liposuctioned and at a deep level; as I move to the peripheral rings, I aspirate less and move more superficial blinging nicely with the surrounding areas.
Preoperative Markings
Access sites are used for both Infiltration of local anesthesia and lipoaspiration.
It must allow me to treat multiple areas , cross-hatched cannula patterns, and passing at various directions and depths.
Using extra sites decrease the risk of access site is being over-sectioned.
It should be in well-hidden places such as hair and creases, skin folds, or a previous scars.
Markings Male Vs. Female
Attention must be paid to "gender ideal" muscular shape/ mass and fat distribution
Preoperative Markings
Mark Dynamic areas in the full range of muscular contraction to yield natural results.
Medical Photography is a Must
Imaging is An educational Tool
High Medical Photograph: anterior, posterior, oblige and lateral
Consent Form must be Signed
Patient Education
One of the essential parts of the preoperative consultation is emphasizing to patients that liposuction has two parts. Fat removal is easily understood, the unpredictability of skin retraction far less so, but vital for a result satisfactory to both parties.
Often questions are asked during the consultation as to how many sizes of clothing will be reduced. Or how many pounds would be lost after the liposuction surgery? It should be explained to the patient that there is no way that it can be predicted how many sizes an individual will reduce in clothing or how many pounds will be lost.
Patient Education
Often patients want many areas liposuctioned in one session.
It should be explained to the patient that the maximum amount of liposuction that can be performed in an outpatient surgical facility at one time is 5 l. Patients will have a faster recovery and minimal complications.
Patient Education
The patient must understand that surgery, on average, does not achieve perfect results, and further refinement might be needed
Patient Education
The patient and physician should discuss the procedure, alternative treatments, financial obligations (including further surgeries if required), and complications and risks. It is crucial to have the informed consent read and signed at the preoperative visit.
Second Preoperative Visit
A follow-up visit is typically scheduled 2–3 weeks after the initial consultation.
The second visit allows for addressing recovery time, pain control, bruising, and postoperative changes, which will help strengthen the patient's confidence in the procedure and decrease the likelihood of any uncertainties or surprises within the perioperative period.
Location of Liposuction
Liposuction is performed in three outpatient settings: hospitals, free-standing ambulatory surgery centers, or office-based surgery facilities. The operative location is determined after careful patient evaluation, assessment of the complexity of the operation, and the appropriate evaluation of medical comorbidities.
It is up to the surgeon to choose the optimal surgical setting for each patient undergoing liposuction.
Office-based surgery has several potential benefits over hospital-based surgery, including cost containment, ease of scheduling, and convenience for patients and surgeons.
It was found that hospital-based liposuction had three times the rate of malpractice settlements compared with office-based liposuction surgery
Location of Liposuction
Surgical procedures are associated with several physiologic stressors, including the development of hypothermia, blood loss, malignant hyperthermia, and deep vein thrombosis.
Taking precautions against such stressors will lead to thoughtful decision-making regarding the type of anesthesia used, the safety of combining multiple procedures, and the duration of the procedure(s) to maximize patient safety and enhance postoperative recovery.
Perioperative Days
Prophylactic antibiotics are recommended for all extensive volume liposuction. A 5-day course (500 mg/d), one day preoperatively followed by 250 mg once daily for days 2–5) of Zithromax is user-friendly. Patients skip the day of surgery if intravenous antibiotics are utilized.
The patient will have a shower on the morning of surgery with antibacterial soap.
Patients are told to wear loose-fitting clothing and cover their bedcover sheets with plastic sheets or bags because drainage should be expected for the initial 24–36 h.
If tumescent anesthesia only will be used by the patient, a light breakfast is allowed on the morning of surgery.
However, patients with sedation or general anesthesia are told to avoid drinking or eating starting at midnight before surgery.
The Day of Surgery
Surgical consent signed
Preoperative pictures
All clothing, jewelry, contact lens, and any dentures are removed
Areas of liposuction are appropriately marked.
The Day of Surgery
Preventative measures against hypothermia include warming the wetting solutions and prep, increasing the room temperature, and using warming devices.
The Day of Surgery
Pedal or calf compression devices are also applied in the holding area to assist DVT prophylaxis.
It should be considered for longer body contouring cases and those involving multiple sites.
Intraoperative Time
It is helpful to have the circulating nurse maintain an accurate liposuction data sheet to facilitate consistent and accurate communication between the surgeon, the anesthesiologist, and the operating room team.
Patient Positioning
Patient positioning depends on the area or areas that need to be treated, other procedures the patient will be undergoing, the patient's body habitus/B.M.I., and surgeon preference.
It is better to have excellent and efficient positioning allowing better contouring of the areas from several access points and directions to achieve the most significant aesthetic results and avoid serious complications.
Patient Positioning
Up to 70% of the contouring can be performed in the prone position, including liposuction of the arms, back, hips/flanks, lateral, posterior, and medial thighs.
Patients in the prone position are subjected to pressure changes over the forehead, malar areas, iliac crest, and bony prominences of the arms and legs.
Patient Positioning
The remainder of the trunk and extremities can be addressed with the patient in the supine position, including arms, abdomen, anterior medial thighs, and knees.
Pressure points in the supine position include the occiput, scapula, posterior iliac crest, sacrum, and heels.
This position does not have significant effects on the cardiopulmonary systems.
Patient Positioning
The lateral decubitus position most closely resembles the normal standing position, allowing contouring to match the position the patient sees themselves in a mirror, accessing the flanks, lateral back, buttocks, thighs, and lower legs.
All pressure points should be well-padded. Brachial plexus injuries can occur if the arm is abducted >90°.
Tumescent Local Anesthesia
In 1985 Jeffrey Klein, a San Juan Capistrano, California dermatologist, performed his first case using the original tumescent local anesthesia (T.L.A.) formula: short-acting lidocaine, epinephrine, and bicarbonate, diluted in a physiologic saline solution.
All liposuction solutions are kept at a temperature of 38°C.; the epinephrine is added to the wetting solution just before infiltration.
Lidocaine and epinephrine total doses are varied according to the anatomic site to be treated, e.g., neck, back, or breast, and the total volume of anesthetic solution injected.
Tumescent Local Anesthesia (TLA)
The invention of tumescent local anesthesia (T.L.A.) was to perform liposuction surgery on an outpatient basis since most dermatologists in the United States did not have hospital privileges to perform liposuction.
It was a secondary observation to experience a dramatically reduced rate of complications in liposuction.
Local anesthesia constituents differ primarily according to fluid volume and infiltration/aspiration ratios.
The ratio of infiltration to aspiration is approximately 2:1—-1:1 for large-volume suctioning.
For more minor procedures, the proportions are higher up to 10:1, i.e., 1000 mL of infiltration to 100 mL of aspirate.
Tumescent Local Anesthesia
The traditionally recommended maximum dose of lidocaine with epinephrine is 7 mg/kg; however, in the liposuction setting, the safety of lidocaine in concentrations >35 mg/kg and as high as 55 mg/kg in large-volume cases. Later, Patrick Lillis published data explaining that 55 to 90 mg/kg body weight would be safe.
Medications that increase lidocaine levels include oral contraceptives, beta-blockers, and tricyclic antidepressants.
Lidocaine provides analgesia for up to 18 h postoperatively.
Lidocaine may also contribute to the extremely low incidence of infection seen in liposuction because of its bacteriostatic effect.
Tumescent Local Anesthesia
The epinephrine dosage used in infiltrating solutions varies and may range from 1:100,000 to 1:1,000,000, depending on the anatomic sites treated and the infused infiltrate volume.
It is recommended that epinephrine doses not exceed 0.07 mg/kg, although doses as high as 10 mg/kg have been used safely. Most commonly, epinephrine in 1 mg with 1/1000 dilution is injected into a 1-L bag.
. Vasoconstriction also decreases the lidocaine absorption rate, potentiating the local anesthetic effect.
The epinephrine may also increase the cardiac output, which, in turn, hastens the hepatic metabolism of the lidocaine.
The blood-tinged infranatant of the true tumescent liposuction aspirate has a hematocrit of less than 1%. Less than 12 mL of whole blood is lost per liter of fat extracted
With its vasoconstrictive properties, epinephrine is the key to minimal blood loss during liposuction.
However, epinephrine should not be given to patients with cardiovascular diseases.
Tumescent Local Anesthesia
Sodium bicarbonate is necessary to neutralize the acidic pH of commercially available lidocaine, eliminating the stinging and burning sensation and in return, the need for narcotic analgesia or sedation.
Ten milliequivalents of sodium bicarbonate are added per liter of the most tumescent formulation.
Tumescent Local Anesthesia (TLA)
The lidocaine solution is first placed into the incision site through a sharp 25-gauge needle; incisions are then made with a No. 11 blade.
The incisions for infiltration of anesthetic solutions are usually the same for harvesting fatty tissue.
These incisions are just large enough (usually 2 mm) to permit insertion of the tip of the harvesting cannula.
Tumescent Local Anesthesia (TLA)
Tumescent fluid in prepared bags is delivered through the tubing with a motor-driven pump at a slow infusion rate (<50 mL/min) attached to infiltration cannula in large cases.
Alternatively, tumescent fluid is delivered through a syringe attached to multi holes infiltrating microcannula in minor cases.
Tumescent Local Anesthesia (TLA)
The volume of fluid infiltration depends on the tissue characteristics. Lighter fat, such as the abdomen, is more distensible and takes up more volume, while dense tissues, such as the back, are less distensible and fill more quickly with infiltration fluid.
Rapid infusion is undesirable because it tends to be less uniform, resulting in suboptimal hemostasis and anesthesia.
Tumescent Local Anesthesia
Infiltration is carried first into the superficial subcutaneous fat in sensitive areas.
Later deep infiltration use is easily tolerated, even in challenging fibrous areas.
Tumescent Local Anesthesia
The operating hand should move forward slowly and deliberately to fill between fat lobules at every level.
The other hand palpates the tissue from the surface, constantly aware of the location of the tip of the cannula.
Tumescent Local Anesthesia
Clinically, TLA fluid will lead to maximum firmness of the skin surface, a" state of tumescence.
Firmness, a slight "orange peel," fountain sign, and tissue blanching are considered clinical endpoints of infiltration in the accurate tumescent technique.
The wetting solution should be allowed 30 min before suctioning to reach its maximum effect.
Tumescent Local Anesthesia
Fluid infiltration will lead to the first step of an "interseptal hydrodissection“
Since these tissue planes offer the lowest resistance for the T.L.A., fluid to spread; after a short time, depending on the rising interstitial tissue pressure, the T.L.A. fluid will penetrate the fascia. It will surround the fat lobules called "paralobular distribution."
Increasing amounts of fluid will cause the fat lobules to absorb the T.L.A. fluid, leading to "intralobular penetration."
After more and more liquid is added, the full extent of all the fat levels is flooded by the T.L.A. fluid, which after 30 minutes of diffusion, leads to a "homogenization" of the fat tissue.
Tumescent Local Anesthesia
The tumescent fluid will compress the blood vessels, facilitating the vasoconstrictive action of epinephrine, and will make them a smaller target and less likely to be traumatized by concurrent liposuction.
The sensory nerves are also stretched, making the accompanying lidocaine effective.
Infiltrating the fat layer magnifies its volume and defects so that the desired fat sculpting can be accomplished with greater accuracy and better feathering of edges.
Expanding the fat layer can also create a safety cushion, elevating the target work area away from underlying vital structures.
Tumescent Local Anesthesia
If the skin surface shows softness, additional fluid infiltration is indicated to stabilize tissue during the liposuction surgery.
Alternatively, a well-trained assistant stabilizes the tissue manually by horizontal fixation.
It is important not to distort the tissue or change the correct anatomical conditions to prevent over-suctioning specific areas.
Tumescent Local Anesthesia
This situation is advantageous where there is little room for error, such as in medial thighs and jowls.
After withdrawing the cannula, a band-aid is placed to stem the fluid flow from the incision site.
Tumescent Local Anesthesia
I prefer to use tumescent local anesthesia alone (awake liposuction) for; minor cases, single sites, revisions, touch-ups, and fat extraction.
The result is complete fat removal with less traumatic injury to delicate structures of fatty tissue; this is crucial for both liposuction results (fat left) or the need for it later, whether for immediate contour correction or the next step in lipofilling.
Large Volume Liposuction
The AACS 2000 Guidelines for Liposuction Surgery state that the maximal volume extracted may rise to 5,000 ml of supernatant fat in the ideal patient with no comorbidities.
Currently, conservative guidelines limit the total volume of supernatant fat aspirate to less than or equal to 4 l in liposuction cases.
The guidelines also state that the recommended volumes aspirated should be modified by the number of body areas operated on, the percentage of body surface area worked on, and the percentage of body weight removed.
Large Volume Liposuction
The guidelines also state that the recommended volumes aspirated should be modified by the number of body areas operated on, the percentage of body surface area worked on, and the percentage of body weight removed.
The risk of perioperative morbidity and mortality increases with the increasing time and size of the procedure.
Large Volume Liposuction
Two options are available to decrease the risk of lidocaine toxicity in large-volume liposuction cases.
The first is to reduce the concentration of lidocaine in the wetting solution.
The second is to use smaller volumes of infiltrating by applying the superwet technique rather than the tumescent technique.
Large Volume Liposuction
Although lengthy operations are prone to complications, it is safer to Inject by section, i.e., one area is infiltrated and extracted while the other is injected.
Large Volume Liposuction
Alternatively, anesthetic solution is injected with two infusions.
Large Volume Liposuction
Alternatively, the extraction is performed using two suction machines simultaneously.
Large Volume Liposuction
The patient's body mass index and the potential physiologic consequences of tissue loss should be considered to ensure that the volume of aspirate removed is proportional to the patient's overall size and medical condition.
A urine catheter is placed for the expected liposuction volume greater than 4 liters.
Large Volume Liposuction
The following formula aids in fluid management for these patients.
Maintain fluid throughout the procedure and manage it based on vital signs and urine output.
Employ the superwet infiltration technique.
Administer crystalloid replacements, 0.25 mL for each milliliter of lipoaspirate over 5 L.
Large Volume Liposuction
For me, liposuction is "large" when it is over 5,000 mL.
I try not to extract over 10,000 mL per session.
I always stay below the 55 mg/kg body weight range regarding lidocaine.
Now the anesthesia has reached its peak.
The skin looks blanched and firm.
Adjunctive Anesthesia
Several adjunctive types of anesthesia are used during liposuction procedures, including
General anesthesia.
Epidural anesthesia.
Spinal anesthesia.
Sedation/analgesia.
Adjunctive Anesthesia
Many factors influence the usage of adjunctive anesthesia decision including:
Expected lipoaspirate.
Length and extent of the procedure.
Patient positioning.
Surgeon preference.
Anesthesiologist preference.
Overall health of the patient.