Enhancing Safety in Tumescent Liposuction: Managing Sedation-Related Respiratory Issues and Serious Complications Under Deep Sedation with the Propofol-Ketamine Protocol.

BACKGROUND: Over the past 4 years, aesthetic surgery, notably liposuction, has substantially increased. Tumescent liposuction, a popular technique, has two variants-true tumescent liposuction (TTL) and semi-tumescent liposuction. While TTL reduces risks, it has limitations. There is no literature reported on semi-tumescent liposuction under deep sedation using the propofol-ketamine protocol, which is proposed as a potentially safe alternative. METHODS: The retrospective analysis covered 8 years and included 3094 patients performed for tumescent liposuction under deep sedation, utilizing the propofol-ketamine protocol. The evaluation of patient safety involved an examination of potential adverse events with a specific focus on respiratory issues related to sedation, including instances of mask ventilation. RESULTS: Among the 3094 cases, no fatalities were recorded. Noteworthy events included 43 mask ventilation instances, primarily occurring in the initial 10 min. Twelve cases experienced surgery cancellation due to various factors, including respiratory issues. Three patients were transferred to upper-level hospitals, while another three required blood transfusions. Vigilant management prevented significant complications, and other adverse events like venous thromboembolism (VTE), fat embolism, severe lidocaine toxicity, and so on were not observed. CONCLUSIONS: The analysis of 3094 tumescent liposuction cases highlighted the overall safety profile of the propofol-ketamine protocol under deep sedation. The scarcity of severe complications underscores its viability. The study emphasizes the significance of thorough preoperative assessments, careful patient selection, and awareness of potential complications. Prompt interventions, particularly in addressing sedation-related respiratory issues, further contribute to positive outcomes for patients. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Development and Implementation of an Evidence-Based Tumescent Liposuction Protocol, Online Educational Course for Perioperative Staff, and Discharge Instructions: A Quality Improvement Project.

PURPOSE: The purpose of this quality improvement project was to improve perioperative management of patients undergoing tumescent liposuction (TL) through the development and implementation of a perioperative evidence-based protocol, educational course for perioperative staff, and patient discharge instructions. DESIGN: The TL protocol was validated using the modified Delphi process. The educational course and discharge instructions used a pre and postimplementation design. METHODS: An evidence-based protocol, an educational course for perioperative staff, and readable discharge instructions for patients undergoing TL were developed in accordance with best practice guidelines. The protocol was validated by subject matter experts at the facility and submitted for adoption. The evidence-based educational course was implemented, and the effectiveness of the course was evaluated for improving providers' knowledge and self-confidence. The evidence-based discharge instructions were implemented and evaluated for patient satisfaction and readability. FINDINGS: Three items were removed from the protocol, 2 items were modified, and 25 items were accepted with no change from modified Delphi analysis. Provider knowledge scores improved from 85.7% ± 16.18 to 97.1% ± 4.88; however, this was not statistically significant (P = .066). There was a trend toward improved confidence scores (P = .180). Overall patient satisfaction scores slightly improved postimplementation; results were not statistically significant (P > .05). CONCLUSIONS: All three phases of perioperative care in patients receiving TL were evaluated, reflecting best practice guidelines and successful adoption. There was no statistically significant improvement in provider knowledge, provider self-confidence, or patient satisfaction. A small sample size was a significant limiting factor.

Extracellular vesicles derived from lipoaspirate fluid promote fat graft survival.

Extracellular vesicles (EVs) are specific subcellular vesicles released by cells under various environmental conditions. Tumescent liposuction is a commonly used procedure in plastic surgery practice. In the present study, we aimed to extract EVs derived from lipoaspirate fluid (LF-EVs) and characterize them using transmission electron microscopy, nanoparticle tracking analysis, and western blotting. The global profiles of proteins and microRNAs from LF-EVs were identified, strongly suggesting a potential regulatory function of LF-EVs. In addition, we investigated the effects and mechanisms of LF-EVs on fat graft survival. Cell functional tests showed that LF-EVs promoted the proliferation, migration, and tube structure formation of human umbilical vein endothelial cells. LF-EVs also promoted the adipogenic differentiation of adipose tissue-derived stem cells. The results of animal experiments showed that the average weights of fat grafts in the LF-EVs-treated group were significantly higher than those in the control group. Histologically, there was less fibrosis, fewer cysts, and increased fat tissue survival in the LF-EVs group. Further investigations of angiogenic and adipogenic factors revealed that LF-EVs also promoted angiogenesis and exerted a pro-adipogenic effect in vivo. Our findings will help to elucidate the functions of LF-EVs and provide a reference dataset for future translational studies.

Cause and management of lipedema-associated pain.

Lipedema is a painful, underdiagnosed adipose tissue disorder, characterized by symmetrical swelling of the extremities due to subcutaneous fat deposition in the buttocks, thighs, legs, and arms, sparing the most distal part of the extremities. Although etiology and pathogenesis of lipedema is unclear, possible role of hormonal and genetic factors have been proposed previously. Patients with lipedema suffer from pain, easy bruising, tenderness, and disfigurement. Pain is the leading symptom in lipedema. Since the pain is associated with depression and impaired quality of life, reduction of pain is the major therapeutic approach. Pain in lipedema is attributed to allodynia, exaggerated sympathetic signaling, and estrogens. Although the mechanism of pain in lipedema is uncertain, effective treatment of lipedema should provide a satisfactory pain reduction. Efficacy of the conservative treatment is a matter of debate. Microcannular tumescent liposuction is the most effective therapeutic option for lipedema. There is a large body of evidence that this procedure significantly reduces pain in patients with lipedema.

Differentiation potential and mRNA profiles of human dedifferentiated adipose cells and adipose­derived stem cells from young donors.

Dedifferentiated adipose cells (DAs) and adipose­derived stem cells (ADSCs) are two of the primary types of stem cells derived from adipose tissue, which have been reported to possess similar characteristics, but also exhibit unique phenotypic and functional advantages. However, several reports have described inconsistent results regarding their differences in multilineage differentiation function. Moreover, to the best of our knowledge, there are no studies assessing their myogenic ability, or the differences in the transcriptome between the two cell types derived from lipoaspirates via tumescent liposuction from the same donors. The aim of the present study was to compare the properties and expression profiles of these cell types. Subcutaneous adipose tissue of three female patients (aged 23­30 years) with a physiological BMI (19.1­23.9 kg/m2) were obtained during tumescent liposuction of the abdomen or the thigh. The stromal vascular fraction and mature adipocytes were obtained via collagenase digestion, and ADSCs and DAs were cultured successively. To determine the differences between DAs and ADSCs after 6­7 passages, cell proliferation assays, phenotypic assessment, differentiation assays and high­throughput RNA sequencing (seq) were used. Similar cell morphologies, proliferation dynamics, surface markers and transcriptome expression profiles were observed between the DAs and ADSCs. Whilst there were notable individual differences in the osteogenic, lipogenic, chondrogenic and myogenic abilities of the DAs and ADSCs, it was difficult to determine their differentiation potential based only on the cell source. Interestingly, the myogenic ability was relatively stronger in cells with relatively weaker lipogenic ability. Only 186 differentially expressed genes between the two groups were identified using RNAseq. Several of these genes were involved in biological functions such as transcription regulation, protein translation regulation, cytokine interactions and energy metabolism regulation. The results of the present study suggested a similar functional potential of DAs and ADSCs from young donors undergoing tumescent liposuction operation in regeneration areas and the balance of the differentiative ability of the same cell populations. These data may provide a foundation for further clinical administration of stem cells derived from adipose tissues in therapy.

Overcoming the Achilles' heel of orthostatic hypotension during interactive standing liposculpture.

BACKGROUND: Orthostatic hypotension (OH) is a major obstacle to standing liposculpture. AIMS: To investigate the feasibility of a novel "interactive standing liposculpture" procedure under local anesthesia to avoid possible general anesthesia-related complications and overcome standing-associated OH. METHODS: A total of 68 subjects undergoing IsLipo were divided into three groups: Individuals with normal body weight (18 ≤ BMI < 23, n = 21, Group 1), overweight or mildly obese subjects (23 ≤ BMI < 30, n = 29, Group 2), and those with moderate-to-severe obesity (BMI ≥ 30, n = 18, Group 3). A 4-area liposculpture technique was adopted with alternate change in position from recumbent to standing for each area. Subjects with symptoms of OH (ie, dizziness or/and nausea) were allowed to rest in a supine position before resuming the procedure. Incidence of OH and duration of liposculpture for each area were recorded and analyzed. RESULTS: The incidence of OH was 15 (four subjects experienced two episodes during the same procedure). All OH episodes occurred in Group 3 subjects. The total liposuction time significantly increased from Group 1 to Group 3 (all P < .001). The IsLipo time in Group 3 was also substantially longer than that in Group 1 and Group 2 (P < .001). Mean arterial blood pressure dropped and heart rate increased significantly in all subjects experiencing OH without fluctuation in arterial oxygen saturation. All subjects with OH recovered after a 10-minute rest and resumed the IsLipo procedure. Successful liposculpture were performed in all subjects. CONCLUSION: Orthostatic hypotension associated with interactive standing liposculpture, which predominantly occurred in subjects with moderate-to-severe obesity, could be resolved with an intraoperative resting strategy.

Tumescent Anesthesia for Dermatosurgical Procedures Other Than Liposuction.

CONTEXT: Tumescent local anesthesia is a form of local anesthesia, which is a technique in which a dilute local anesthetic solution is injected into the subcutaneous tissue until it becomes firm and tense. Originally developed to facilitate liposuction, the use of tumescent anesthesia has expanded to other dermatological and plastic surgery procedures, as well as to other disciplines, including endocrine and vascular surgeries. For infiltration local anesthesia, the conventional dosage of lidocaine is up to 4.5 mg/kg, and that with adrenaline is up to 7 mg/kg; however, in liposuction using tumescent anesthesia, the recommended maximum dose of lidocaine with adrenaline is up to 55 mg/kg. There are several important pharmacological, pharmacokinetic, and pharmacodynamic factors that need to be considered in the administration of tumescent anesthesia leading to considerable interdisciplinary differences of opinion with respect to the maximum dose of local anesthetic permissible. Although several studies and publications have studied these issues in liposuction extensively, the role of tumescent anesthesia in other indications has not been reviewed adequately. AIMS AND OBJECTIVES: The aim of this study was to discuss the science behind tumescent anesthesia, its applications, and safety considerations in different dermatosurgical procedures other than liposuction. MATERIALS AND METHODS: For this review, a systematic literature search in PubMed, Embase, Web of Science, Cochrane Library, Central, Emcare, Academic Search Premier, and ScienceDirect was conducted for safety studies on tumescent anesthesia. CONCLUSION: Tumescent anesthesia is generally very well accepted by patients and is relatively safe at the recommended doses. Nonetheless, one must be vigilant about the signs and symptoms of LAST, as they may not manifest until several hours after the procedure. Lipid emulsion therapy should be readily available and could prove life-saving in such situations.

Anatomical, imaging and histological observations of the circumferential full-length of superficial fascia structure of the upper limb / 中华整形外科杂志

Objective@#To describe the general and histological features of the full-length superficial fascia of the circumferential upper limb.@*Methods@#Fresh frozen arm specimens were dissected, and then MRI imaging in vivo, enhanced CT angiography and HE histological staining were used to describe the characteristics of the full-length superficial fascia of the circumferential arm and its relationship with important blood vessels.@*Results@#The four typical structures of the superficial fascia of the arm were divided into subcutaneous superficial fat, membrane-like substance, deep fat and deep fascia from superficial to deep. The thickness and stratification, fusion degree and histological characteristics of the superficial fascia of these four layers were obviously different in different levels and regions of the arm. MRI confirmed that the total thickness of superficial fascia gradually decreased from shoulder to wrist. Venography showed that the cephalic vein ran below the second layer of superficial fascia and above the deep fascia. The basilic vein originated from the dorsal vein network of the hand and always lied below the second layer of membranous material until the basilic vein penetrates below the deep fascia of the upper arm.@*Conclusions@#The deep understanding of the circumferential full-length of superficial fascia structure of the upper limb provides an important theoretical basis for improving the surgical safety and fine operation for the Dynamic Arm Circumferential Liposuction.

Application of liposuction in treating the primary end-stage lymphedema of lower extremities / 中华整形外科杂志

Objective@#To investigate outcome and clinical value of liposuction in primary lymphedema of lower extremities.@*Methods@#Thirty patients with primary lymphedema in unilateral lower extremity were recruited in this study from July 2016 to August 2017 in Beijing Shijitan Hospital. There were 13 male and 17 female patients, with the average age of (36±16.3) years. All the patients were underwent liposuction. The volume of hemorrhage and lipid, operation time and the volume changes of affected extremity were recorded. The subjective evaluation of the patients were also proceed. The patients were divided into different groups according to gender, stage and erysipelas history.@*Results@#Total lipid volume is 900-3 900 ml. The hemorrhage volume is 160-1 100 ml during liposuction. The ipsilateral-contralateral percent volume of lower extremity was decreased immediately after surgery (6.6%±10.0%, t=7.050, P=0.000), and 3 months postoperatively (12.2%±10.7%, t=5.365, P=0.000), when compared with preoperative (31.4%±16.4%). However, the percent volume was increased 3 months after surgery, compared to immediately postoperative measurements (t=-2.088, P=0.041). Female patients had more lipid volume and higher liposuction rate than males, whereas male patients show more affected extremities volume before, after and in 3-month follow-up. The hemorrhage volume was also higher in male than female patients. Patients with erysipelas had higher volume of hemorrhage, with lower lipid volume and liposuction rate. Stage Ⅱpatients show higher lipid volume and liposuction rate than stage Ⅲ patients in operation, with lower hemorrhage and affected extremity volume changes in before, after and 3-month follow-up. In subjective assessment, the experienced heaviness and fatigue was alleviated in all patients, while the pain and tightness was increased.@*Conclusions@#Liposuction is an effective therapy for primary lymphedema in lower extremity. It is necessary to combine with other therapies to improve lymph circulation. Patients′ gender, stage and the history of erysipelas are the main influencing factors of operation difficulty and prognosis.

Lipoedema is not lymphoedema: A review of current literature.

Lipoedema is a rare painful disorder of the adipose tissue. It essentially affects females and is often misdiagnosed as lymphoedema or obesity. It is globally misdiagnosed or underdiagnosed, and the literature is lacking appropriate guidance to assist clinicians towards this diagnosis. However, the need to recognise this disorder as a unique entity has important implications to establish proper treatment and, therefore, its tremendous effect on patients. Early diagnosis and treatment can turn these patients' lives upside down. The aim of this review is to focus on the clinical guidance, differential diagnosis, and management strategies. In addition, other aspects of lipoedema, including epidemiology and pathogenesis, are also being discussed here. Lipoedema is distinct from obesity and distinct from lymphoedema, although it might progress to involve the venous and lymphatic system (venolipedema or lympholipedema or both). Late diagnosis can leave the patient debilitated. Management of lipoedema includes weight loss, control of oedema, complex decongestive physiotherapy, liposuction, and laser-assisted lipolysis. However; there are increasing reports on tumescent liposuction as the preferred surgical option with long-lasting results. The role of more randomised controlled studies to further explore the management of this clinical entity remains promising.

[Liposuction]. / Liposuktion.

Liposuction began in the 1920s when the Parisian surgeon Charles Dujarier became interested in body shaping and fat removal. Today, it is estimated that 1,453,000 liposuctions are annually performed worldwide. In Germany, 45,000 liposuctions are performed annually. The majority of liposuctions are performed as self-pay services. The aim of this article is to outline the development of liposuction, to explain the various liposuction procedures and methods, to clarify the indications for treatment, and point out the complications and pitfalls described in the literature.

Madelung's Disease - Case Series and Treatment by Tumescent Liposuction or Lipectomy.

Madelung disease is a disfiguring disorder belonging to the heterogeneous group of lipomatosis. The aetiology is not well understood, but alcohol consumption has been regarded as of importance. The reported incidence is about 1 in 25,000 inhabitants. We reviewed our files of the last ten years and identified eight adult patients with an equal gender distribution. Their age was between 60 and 85 years of life. Comorbidities are frequent. Clinical presentation may vary. Surgical treatment is reported and discussed. Both cold steel surgery and tumescent liposuction have their place in treatment.

Debulking surgery for elephantiasis nostras with large ectatic podoplanin-negative lymphatic vessels in patients with lipo-lymphedema.

OBJECTIVE: Elephantiasis nostras is a rare complication in advanced lipo-lymphedema. While lipedema can be treated by liposuction and lymphedema by decongestive lymphatic therapy, elephantiasis nostras may need debulking surgery. METHODS: We present 2 cases of advanced lipo-lymphedema complicated by elephantiasis nostras. After tumescent microcannular laser-assisted liposuction both patients underwent a debulking surgery with a modification of Auchincloss-Kim's technique. Histologic examination of the tissue specimen was performed. RESULTS: The surgical treatment was well tolerated and primary healing was uneventful. After primary wound healing and ambulation of the patients, a delayed ulceration with lymphorrhea developed. It was treated by surgical necrectomy and vacuum-assisted closure leading to complete healing. Mobility of the leg was much improved. Histologic examination revealed massive ectatic lymphatic vessels nonreactive for podoplanin. CONCLUSIONS: Debulking surgery can be an adjuvant technique for elephantiasis nostras in advanced lipo-lymphedema. Although delayed postoperative wound healing problems were observed, necrectomy and vacuum-assisted closure achieved a complete healing. Histologic data suggest that the ectatic lymphatic vessels in these patients resemble finding in podoplanin knockout mice. The findings would explain the limitations of decongestive lymphatic therapy and tumescent liposuction in such patients and their predisposition to relapsing erysipelas.

Tumescent liposuction.

The evolution of liposuction has been multidisciplinary. The tumescent variant was developed using dilute local lidocaine and epinephrine and was meant to specifically exclude additional intravenous sedation, regional or general anesthesia, and intravenous fluids. Clinical pharmacology, pathophysiology, and safety studies are reviewed in this article. Tumescent formulations for varied anatomic sites are discussed, as well as other indications for tumescent anesthesia.

Gynecomastia Treated with Tumescent Liposuction and the Pull-Through Technique / 대한피부과학회지

Gynecomastia is the most common condition affecting the male breast due to enlargement of both ductal and stromal tissue. Growth of the male breast can be manifested at any age, but 40% of cases present in adolescent boys. The condition depends mainly on the balance between serum estrogens and androgens. Gynecomastia represents a source of embarrassment, and optimal correction is difficult to achieve. Numerous methods of gynecomastia repair are available. Our method is a combination of liposuction and the pull-through technique. The purpose of this treatment is to resect excess tissue and restore the normal chest contour with minimal scarring. We report a case of gynecomastia treated with a combination of tumescent liposuction and the pull-through technique.

Comparative Analysis of Tumescent Liposuction according to the Dermal Curettage Level for the Treatment for Axillary Osmidrosis / 대한피부과학회지

BACKGROUND: The efficacy of tumescent liposuction in the treatment of axillary osmidrosis has been widely established. But there have been few studies that have conducted a comparative analysis according to the level of dermal curettage with respect to the efficacy and safety. OBJECTIVE: The aim of this study was to evaluate the clinical efficacy and complications of tumescent liposuction according to the degree of dermal curettage. METHODS: From September 2004 through August 2009, a total of 33 patients with axillary osmidrosis (66 axillae) were included in this study. Twelve patients (24 axillae) were treated by tumescent liposuction with dermal curettage at the level of the mid-dermis (the classical technique group), and the other 21 patients (42 axillae) were treated by tumescent liposuction with dermal curettage at the level of the dermo-subcutis junction (the modified technique group). The preoperative and postoperative disease severity was measured as 0, 1, 2 and 3. The improvement of symptoms was graded by the patient as excellent, good, fair and poor. We also evaluated the postoperative complications, including skin necrosis, scar, hematoma, sensory disturbance and infection. Biopsies of the axillary skin were performed in 7 patients to confirm the level of dermal curettage and the reduction of apocrine glands after treatment. RESULTS: The follow-up ranged from 6 to 60 months. Six months after treatment, 95.8% (23/24) of the axillae in the classical technique group and 95.2% (40/42) of the axillae in the modified technique group had reduced disease severity below 1. Among the 12 patients treated with the classical technique, 11 (91.7%) had excellent to good results, while 95.2% (20/21) of the patients treated with the modified technique had excellent to good results by the patients' own grading. The complications included skin necrosis, scar and hematoma. In the classical technique group and the modified technique group, the incidence of skin necrosis was 12.5% (3/24) and 2.4% (1/42), respectively, the incidence of scar formation was 4.2% (1/24) and 0%, respectively, and the incidence of hematoma was 8.3% (2/24) and 0%, respectively. The postoperative histologic examinations confirmed that the dermal curettage level was at the mid-dermis in the classical technique and at the dermo-subcutis junction in the modified technique. Interestingly, the histologic examination from the classical technique group revealed vacuolar alteration of keratinocytes and partial separation of the dermo-epidermal junction. CONCLUSION: The efficacy of the modified technique is compatible with that of the classical technique, but the modified technique offers fewer complications. So, the modified technique may improve the cosmetic outcome without reducing the treatment efficacy for the patient with axillary osmidrosis.

Treatment of Axillary Hyperhidrosis; Manual Subdermal Excision Combined with the Tumescent Liposuction and Subcutaneous Tissue Shaver

BACKGROUND: Axillary osmidrosis is a distressing problem characterized by unpleasant odor, profuse sweating, and occasional wetting of clothes that may handicap those affected both socially and psychologically. A variety of surgical methods have been developed for the treatment of axillary osmidrosis. OBJECTIVE: To introduce the manual subdermal excision combined with the tumescent liposuction and subcutaneous tissue shaver for axillary osmidrosis. METHODS: Twenty-five patients with axillary osmidrosis were treated by the manual subdermal excision combined with the tumescent liposuction and subcutaneous tissue shaver. RESULTS: Twenty-one(84%) patients had good results, four(16%) fair, and none had a poor result or recurrence. Complications included one case of hematoma, two cases of partial skin necrosis. The wound complication rate was 6.0%(3/50) for the axilla and 12%(3/25) for patients. CONCLUSION: The manual subdermal excision combined with the tumescent liposuction and subcutaneous tissue shaver is effective surgical procedure for the treatment of axillary osmidrosis with a low complication rate and recurrence.