Review of Insurance Coverage for Abdominal Contouring Procedures in the Postbariatric Population.

BACKGROUND: Following bariatric surgery, patients develop problems related to lax abdominal skin that may be addressed by contouring procedures. Third-party insurers have subjective requirements for coverage of these procedures that can limit patient access. The authors sought to determine how well third-party payers cover abdominal contouring procedures in this population. METHODS: The authors conducted a cross-sectional analysis of insurance policies for coverage of panniculectomy, lower back excision, and circumferential lipectomy. Abdominoplasty was evaluated as an alternative to panniculectomy. Insurance companies were selected based on their market share and state enrolment. A list of medical necessity criteria was abstracted from the policies that offered coverage. RESULTS: Of the 55 companies evaluated, 98 percent had a policy that covered panniculectomy versus 36 percent who would cover lower back excision (p < 0.0001), and one-third provided coverage for circumferential lipectomy. Of the insurers who covered panniculectomy, only 30 percent would also cover abdominoplasty. Documentation of secondary skin conditions was the most prevalent criterion in panniculectomy policies (100 percent), whereas impaired function and secondary skin conditions were most common for coverage of lower back excision (73 percent and 73 percent, respectively). Frequency of criteria for panniculectomy versus lower back excision differed most notably for (1) secondary skin conditions (100 percent versus 73 percent; p = 0.0030), (2) weight loss (45 percent versus 7 percent; p = 0.0106), and (3) duration of weight stability (82 percent versus 53 percent; p = 0.0415). CONCLUSIONS: For the postbariatric population, panniculectomy was covered more often and had more standardized criteria than lower back excision or circumferential lipectomy. However, all have vast intracompany and interpolicy variations in coverage criteria that may reduce access to procedures, even among patients with established indications.

New Insights on Lipedema: The Enigmatic Disease of the Peripheral Fat.

BACKGROUND: Although a large number of adult women worldwide are affected by lipedema, the physiologic conditions triggering onset and progression of this chronic disease remain enigmatic. In the present study, a descriptive epidemiologic situation of postoperative lipedema patients is presented. METHODS: The authors developed an online survey questionnaire for lipedema patients in Germany. The survey was conducted on 209 female patients who had been diagnosed with lipedema and had undergone tumescent liposuction. RESULTS: Most of the participants (average age, 38.5 years) had noticed a first manifestation of the disease at the age of 16. It took a mean of 15 years to accomplish diagnosis. Liposuction led to a significant reduction of pain, swelling, tenderness, and easy bruising as confirmed by the majority of patients. Hypothyroidism [n = 75 (35.9 percent) and depression [n = 48 (23.0 percent)] occurred at a frequency far beyond the average prevalence in the German population. The prevalence of diabetes type 1 [n = 3 (1.4 percent)], and diabetes type 2 [n = 2 (1 percent)] was particularly low among the respondents. Forty-seven of the lipedema patients (approximately 22.5 percent) suffered from a diagnosed migraine. Following liposuction, the frequency and/or intensity of migraine attacks became markedly reduced, as stated by 32 patients (68.1 percent). CONCLUSIONS: Quality of life increases significantly after surgery with a reduction of pain and swelling and decreased tendency to easy bruising. The high prevalence of hypothyroidism in lipedema patients could be related to the frequently observed lipedema-associated obesity. The low prevalence of diabetes, dyslipidemia, and hypertension appears to be a specific characteristic distinguishing lipedema from lifestyle-induced obesity.

Abdominoplasty in the Obese Patient: Risk versus Reward.

BACKGROUND: The incidence of obesity is on the rise worldwide. Many surgeons elect not to perform abdominoplasty on patients with a high body mass index, fearing an increased risk of perioperative complications. In this study, the authors compare the outcomes of obese and nonobese patients who underwent abdominoplasty. METHODS: A retrospective chart analysis was performed on all patients who underwent abdominoplasty by a single surgeon from 2009 to 2016. Complication rates were compared in obese and nonobese patients. Patients were excluded if they did not undergo a full abdominoplasty, underwent a combined surgical procedure, or underwent liposuction in an area outside of the abdomen or flanks at the time of the abdominoplasty. RESULTS: A total of 83 patients were included: 62 nonobese and 21 obese patients. The obese group had a higher average body mass index (34. 9 kg/m versus 25.1 kg/m; p < 0.001). Follow-up time was similar (310 days versus 265 days; p = 0.468). No significant differences were seen with regard to perioperative seroma formation (14.2 percent versus 22.5 percent; p = 0.419)), wound dehiscence (9.5 percent versus 11.29 percent; p = 0.822), hematoma formation (4.7 percent versus 1.6 percent; p = 0.438), or surgical-site infection (9.5 percent versus 8.0 percent; p = 0.835). No instances of venous thromboembolism were observed. CONCLUSIONS: Abdominoplasty, with or without concurrent liposuction, in obese patients, is a safe and effective procedure with similar perioperative complication rates as the nonobese patient population. No significant differences were observed in perioperative complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Advanced Age Is a Risk Factor for Complications Following Abdominal Panniculectomy.

BACKGROUND: Widespread adoption of bariatric surgery in the treatment of obesity has led to greater numbers of patients seeking panniculectomy, including aged patients, who represent a rapidly growing proportion of the U.S population. Although the quality of life and functional benefits of abdominal panniculectomy have been established, its safety in patients 65 years and older has not been evaluated. METHODS: The American College of Surgeons National Surgical Quality Improvements (ACS-NSQIP) database was used to identify patients undergoing panniculectomy between 2010 and 2015. Age 65 years and older was the risk factor of interest, and primary outcomes included 30-day wound complications, overall complications, reoperation, readmission, and mortality. Multivariate regression was performed to control for confounders. RESULTS: Review of the database identified 7030 patients who underwent abdominal panniculectomy. When stratified by age, 6455 (91.8%) of patients were younger than 65, and 575 (8.2%) were 65 or older. Multivariate regression analysis demonstrated that age over 65 was a significant independent risk factor for wound complications (OR = 1.81; 95% CI 1.35-2.42; p < 0.001) and all complications (OR = 1.46; 95% CI 1.15-1.87; p = 0.002). BMI, smoking, diabetes, and partial or total dependence were also identified as significant independent risk factors for wound and all complications. CONCLUSION: Our analysis demonstrates that advanced age is an independent risk factor for wound and overall complications following abdominal panniculectomy. These results highlight the importance of preoperative evaluation and optimization of modifiable preoperative risk factors as well as close postoperative follow-up for safe outcomes in patients 65 and older.

Condutas em lipoaspiraçã o entre cirurgiões brasileiros / Liposuction Practices among Brazilian Surgeons

Introdução: Desde a década de 1980, com Illouz, a lipoaspiração ganhou popularidade e representa hoje um dos procedimentos mais realizados no mundo. Algumas de suas complicações são graves e potencialmente letais. Não existe, contudo, uma uniformidade em sua prática ou no seu ensino. A avaliação das técnicas empregadas por cirurgiões plásticos pode ser o início de uma padronização. Métodos: Foi aplicado um questionário sobre lipoaspiração no 52º Congresso Brasileiro de Cirurgia Plástica para cirurgiões plásticos de diferentes faixas etárias e regiões do Brasil, presentes no evento. Resultados: Foram contabilizados 243 questionários preenchidos (n = 243). O número médio de incisões foi de 9 (2 - 16). Duzentos e quarenta e um cirurgiões (99%) realizam incisões na linha mediana/ paramediana anteriormente e 236 (97%) incisam na linha mediana/paramediana na região posterior. Aproximadamente metade dos questionados utilizam a anestesia geral. Duzentos e nove cirurgiões (86%) posicionam o paciente em decúbito ventral durante o procedimento. A lipoaspiração superficial é realizada por 146 (60%) entrevistados, sendo que 22 (9%) fazem a aspiração apenas desta camada adiposa. Oitenta e cinco (35%) participantes relatam controlar a pressão do aparelho durante o procedimento. Conclusão: A lipoaspiração realizada no Brasil apresenta grande variação técnica. Essa constatação nos faz refletir sobre a necessidade de uma uniformização de sua prática e ensino a fim de aumentar o controle e a segurança do procedimento.

Introduction: Since the 1980s, with Illouz, liposuction has gained popularity and represents one of the most commonly performed procedures in the world today. Some of the complications are serious and potentially lethal. Nevertheless, uniformity in its practice or the manner in which it is taught does not exist. Evaluating techniques employed by plastic surgeons may be the start toward standardization. Methods: A questionnaire on liposuction was given to plastic surgeons of different age groups and from regions of Brazil who were present at the 52nd Brazilian Conference for Plastic Surgery. Results: Two hundred forty-three questionnaires were filled out (n = 243). The average number of incisions was 9 (2­16). Two hundred fortyone surgeons (99%) made incisions along the anterior median/ paramedian line, and 236 (97%) made incisions on the posterior median/paramedian line. Approximately half of those surveyed utilized general anesthesia. Two hundred nine surgeons (86%) placed the patient in the prone position during the procedure. One hundred forty-six (60%) interviewees performed superficial liposuction, with 22 (9%) performing liposuction only on this adipose layer. Eighty-five (35%) participants reported controlling the apparatus's pressure during the procedure. Conclusion: Liposuction procedures performed in Brazil have significant technical variations. This finding encourages us to reflect on the need to standardize liposuction practice and the manner in which it is taught so as to increase control over the procedure and its safety.

Evaluation of 389 patients following free-flap lower extremity reconstruction with respect to secondary refinement procedures.

INTRODUCTION: Primary functional and aesthetic results after free-flap salvage of lower extremities are occasionally suboptimal. The objective of this study was to identify predictors for secondary refinement procedures such as liposuction, dermolipectomy, or direct excision. In addition, patient-reported long-term satisfaction with the final reconstructive result was analyzed. PATIENTS AND METHODS: All patients undergoing free-flap lower extremity salvage between January 2011 and July 2015 were included in a comparative study. The patients of cohort 1 had no secondary refinement procedures, while those of cohort 2 had one or more procedures. The patient data, intraoperative characteristics, and postoperative course were reviewed. To assess the level of satisfaction, the patients were surveyed. RESULTS: Of the 389 patients included, 54 (13.9%) were identified with 1-3 secondary refinement procedures with an uneventful postoperative course. The most common procedure was surgical debulking (56.8%). The comparison of both cohorts revealed a statistical significance for patient's age (P < .01), gender (P = .02), ASA-score (P < .01), and localization (P < .01). Predictors for secondary refinement procedures were young age (<50 years), female gender, absence of comorbidities, and defects located at the feet or ankle. Overall patient satisfaction was negatively correlated with the number of secondary procedures performed. Patient-reported satisfaction with the overall (P < .01) and cosmetic (P = .02) result increased significantly with age. CONCLUSION: Secondary refinement procedures after successful free-flap lower extremity reconstruction are safe and not uncommon. Detailed information about the likelihood of secondary operations and the various techniques available should be part of the patient education to increase patient satisfaction and form realistic expectations.

Utilization of Body Contouring Procedures Following Weight Loss Surgery: A Study of 37,806 Patients.

BACKGROUND: Bariatric surgery has substantial health benefits; however, some patients desire body contouring (BC) procedures following rapid weight loss. There is a paucity of data regarding the true rate of BC following bariatric procedures. The purpose of our study is to examine the utilization of two common procedures, abdominoplasty, and panniculectomy, following bariatric surgery in New York State. METHODS: The SPARCS longitudinal administrative database was used to identify bariatric procedures by using ICD-9 and CPT codes between 2004 and 2010. Procedures included sleeve gastrectomy, Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding. Using a unique patient identifier, we tracked those patients who subsequently underwent either abdominoplasty or panniculectomy with at least a 4-year follow-up (until 2014). Multivariable Cox proportional hazard model was used to evaluate predictors of follow-up BC surgery. RESULTS: 37,806 patients underwent bariatric surgery between 2004 and 2010. Only 5.58% (n = 2112) of these patients subsequently had a BC procedure, with 143 of them (6.8%) having ≥1 plastic surgery. The average time to plastic surgery after band, bypass, or sleeve was 1134.83 ± 671.09, 984.70 ± 570.53, and 903.02 ± 497.31 days, respectively (P < 0.0001). Following the multivariable Cox proportional hazard model, a female, SG patients, patients with Medicare or Medicaid, and patients in either <20 or >80%ile in yearly income were more likely to have plastic surgery after adjusting for age, race/ethnicity, comorbidities and complications (P values < 0.0001). CONCLUSIONS: This study shows that plastic surgery is completed by only 6% of patients following bariatric procedures. As insurance and income are associated with pursuing surgery, improved access may increase the number of patients who are able to undergo these reconstructive procedures.

Temas controversos em Lipoaspiração: pesquisa de opinião nacional de membros da Sociedade Brasileira de Cirurgia Plástica (Update Liposuction Survey / SBCP) / Controversial themes in liposuction: national opinion survey of members of the Brazilian Society of Plastic Surgery (Update Liposuction Survey)

Introdução: A lipoaspiração é o segundo procedimento cirúrgico estético mais realizado no mundo. Entretanto, muitas condutas envolvendo a lipoaspiração permanecem controversas. As pesquisas de opinião com especialistas podem elucidar quais áreas encontram-se sem consenso. O objetivo é realizar uma pesquisa de opinião com cirurgiões plásticos membros da Sociedade Brasileira de Cirurgia Plástica, o Update Liposuction Survey (ULS/SBCP), a fim de esclarecer suas condutas em temas controversos em lipoaspiração. Métodos: Um link para um questionário contendo 11 perguntas envolvendo a lipoaspiração (ULS/SBCP) foi enviado eletronicamente a todos os membros da SBCP. O e-mail foi enviado em três momentos e com a oferta de incentivos para promover maior taxa de resposta. Resultados: Dos 4957 cirurgiões plásticos contatados, 917 responderam, resultando em uma taxa de resposta de 18,5%. Os resultados estão sendo analisados para posterior publicação na íntegra.

Introduction: Liposuction is the second most commonly performed surgical procedure worldwide. However, many liposuction procedures are controversial. In this context, expert opinion surveys may help elucidate topics lacking consensus. The objective of this survey was to interview plastic surgeons who are members of the Brazilian Society of Plastic Surgery (Sociedade Brasileira de Cirurgia Plástica [SBCP]), the Update Liposuction Survey (ULS/SBCP), to assess their opinions about controversial topics in liposuction. Methods: A link to a questionnaire containing 11 questions involving liposuction (ULS/SBCP) was sent electronically to all SBCP members. The email was sent in three instances and with the provision of incentives to promote a higher response rate. Results: Of the 4,957 contacted plastic surgeons, 917 responded (response rate, 18.5%). The results are being analyzed for publication in full.

A review of general cosmetic surgery training in fellowship programs offered by the American Academy of Cosmetic Surgery.

PURPOSE: We sought, first, to evaluate the operative experience of surgeons who have completed postresidency fellowships offered by the American Academy of Cosmetic Surgery (AACS), and second, to compare this cosmetic surgery training to other surgical residency and fellowship programs in the United States. Finally, we suggest how new and existing oral and maxillofacial surgeons can use these programs. MATERIALS AND METHODS: We reviewed the completed case logs from AACS-accredited fellowships. The logs were data mined for 7 of the most common cosmetic operations, including the median total number of operations. We then compared the cosmetic case requirements from the different residencies and fellowships. RESULTS: Thirty-nine case logs were reviewed from the 1-year general cosmetic surgery fellowships offered by the AACS from 2007 to 2012. The fellows completed a median of 687 total procedures. The median number of the most common cosmetic procedures performed was 14 rhinoplasties, 31 blepharoplasties, 21 facelifts, 24 abdominoplasties, 28 breast mastopexies, 103 breast augmentations, and 189 liposuctions. The data obtained were compared with the minimum cosmetic surgical requirements in residency and fellowship programs. The minimum residency requirements were as follows: no minimum listed for plastic surgery, 35 for otolaryngology, 20 for oral and maxillofacial surgery, 28 for ophthalmology, 0 for obstetrics and gynecology, and 20 for dermatology. The minimum fellowship requirements were as follows: 300 for the AACS cosmetic surgery fellowship, no minimum listed for facial plastic surgery and reconstruction, no minimum listed for aesthetic surgery, 133 for oculoplastic and reconstructive surgery, and 0 for Mohs dermatology. CONCLUSION: Dedicating one's practice exclusively to cosmetic surgery requires additional postresidency training owing to the breadth of the field. The AACS created comprehensive fellowship programs to fill an essential part in the continuum of cosmetic surgeons' education, training, and experience. This builds on the foundation of their primary board residency program. The AACS fellowships are a valuable option for additional training for qualified surgeons seeking proficiency and competency in cosmetic surgery.

Lipoaspiração: atualização dos fatores de riscos metabólicos e sua importância clínico-cirúrgica / Liposuction: an actualization of the risk factors and their clinical and surgical relevance

A lipoaspiração permanece como um dos procedimentos mais realizados pelos cirurgiões plásticos (1-3). O aumento da segurança no ambiente cirúrgico, o refinamento da técnica e a satisfação das pacientes contribuem para a popularidade desta intervenção idealizada por Ilouz, em 1979 (4). Tem-se observado, ainda, tanto no ambiente médico quanto na mídia, uma crescente preocupação não apenas com a nova forma dos pacientes, mas também com a segurança. O tecido adiposo atua como um verdadeiro órgão endócrino e é o principal depósito de triglicerídeos, que têm uma relação clássica com doença aterosclerótica e resistência insulínica (6, 7). Estudos recentes ligaram ainda o metabolismo lipídico dos adipócitos à manutenção de um estado inflamatório sistêmico de baixo grau, através de vários mediadores (8-10). Há evidências científicas (11) que mostram o aumento do percentual de obesos em nosso país e uma importante taxa de pessoas, com sobrepeso. Este estudo também relaciona a prevalência de diabetes e de hipertensão. A clássica inter-relação entre a quantidade de gordura corporal e as chamadas doenças metabólicas tem suscitado a investigação dos elementos envolvidos neste processo e de tratamentos para o controle dos mesmos. A descoberta da leptina na década de 1990 (12) chamou a atenção para a propriedade reguladora do tecido adiposo. Estudos posteriores (5, 13) relacionaram ainda a síntese de outros fatores. Decidimos fazer uma revisão da literatura para esclarecer o estágio atual das pesquisas, tentando ordená-las de forma didática para melhor compreensão e auxílio para uma conduta mais segura e eficiente nos pacientes submetidos à lipoaspiração.

Liposuction is one of the most frequently performed procedures by plastic surgeons. The increased safety associated with the surgical settings, technical refinements, and level of patient satisfaction have contributed to the popularity gained by this intervention since it was first introduced by Ilouz in 1979 (4). Moreover, among medical communities and the media, concerns have risen regarding not only the drastic changes in patients' appearance but also the safety of the procedure. Fat tissue is known to act as a legitimate endocrine organ (5), being the primary depository for triglycerides, which classically relate to atherosclerosis and insulin resistance (6, 7). Recent work has linked lipid metabolism in adipocytes to the maintenance of low levels of systemic inflammation through a series of mediators (8-10). Scientific evidence (11) revealed an increase in the percentage of obese people in our country, as well as a considerable proportion of overweight people. This study also investigates the relationship between the prevalence of diabetes and hypertension. The classic association between body mass index and common metabolic diseases has led to investigations focused on several factors involved in this relationship, along with research work directed at the treatments available. The discovery of leptin in the 1990s (12) highlights the regulatory properties of the adipose tissue, whereas recent studies (5, 13) have established a link with the synthesis of other factors. In this study, we aimed to perform a review of literatures that discuss the current state-of-the-art of scientific research, in which we organized published works in a didactic manner in order to facilitate better understanding, and promote the safety and efficacy of liposuction.

The incidence and management of secondary abdominoplasty and secondary abdominal contour surgery.

BACKGROUND: Limited data exist in the literature regarding the general incidence of secondary abdominal contour procedures and secondary abdominoplasty (excluding revisions) or specific recommendations for surgical management of these patients. METHODS: The authors performed a retrospective chart review of 562 patients who underwent abdominal contouring procedures (liposuction and/or modified or full abdominoplasty) performed by a single surgeon (A.M.) from January of 2004 until October of 2012. Nonsurgical primary cases, secondary surgery that was revisional in nature, and massive weight loss patients were excluded. RESULTS: Seventy-three patients (13.0 percent) underwent secondary abdominal contouring procedures. Forty-six of 73 patients had charts available to be examined in greater detail. Thirty-four of these patients underwent secondary liposuction, whereas 12 of these patients had secondary full abdominoplasty procedures. Secondary operations occurred an average of 4.98 years after the primary procedure (range, 6 months to 15 years). Patients underwent secondary liposuction (n = 34) on average 3.16 years after their initial procedure, significantly sooner than patients who underwent secondary abdominoplasty (n = 12) 8.35 years after their initial procedure (p = 0.002). Patients with a body mass index less than 25 kg/m2 (n = 26) had both secondary liposuction (n = 16) and secondary abdominoplasty (n = 10), whereas all patients who had a body mass index of 25 kg/m2 or greater (n = 20) underwent only secondary liposuction. CONCLUSIONS: True secondary abdominal contouring procedures represented 13.0 percent of all abdominal contouring procedures. The most common indication for a secondary procedure was an umbilical-site closure scar. Specific recommendations for surgical management of five common scenarios for secondary abdominal procedures are discussed.

Complications in body contouring procedures: an analysis of 1797 patients from the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program databases.

BACKGROUND: The purpose of this study was to examine the incidence and predictors of surgical and medical morbidity following body contouring procedures. METHODS: The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2010 for all identifiable body contouring cases including Current Procedural Terminology codes for brachioplasty, medial thigh lift, abdominoplasty, and suction-assisted lipectomy. Independent predictors of morbidity were determined. RESULTS: A total of 1797 patients underwent body contouring during the study period, and most were female (n = 1600; 89.0 percent). The average body mass index was 31.6 kg/m, and 239 were morbidly obese (body mass index ≥ 40 kg/m). The most common area of intervention was the trunk region, with 1652 patients (91.9 percent) receiving abdominal contouring and/or contouring of the hips and buttocks. Minor wound complications occurred in 114 individuals (6.3 percent), 122 patients (6.8 percent) suffered a major surgical morbidity, and 40 (2.2 percent) experienced a medical complication. Multiple comorbidities (OR, 15.87; p = 0.014), presence of bleeding disorder (OR, 20.31; p = 0.026), preoperative albumin level (OR, 0.14; p = 0.003), and malnutrition (OR, 0.19; p = 0.065) were associated with an increased odds of minor wound complications. Inpatient procedures (OR, 4.64; p = 0.06) and functional status (OR, 9.71; p = 0.011) were associated with an increased odds of major surgical morbidity. CONCLUSIONS: This study characterizes the 30-day morbidity rates in patients undergoing body contouring procedures using a large, prospective, validated national data set, highlighting the critical importance of careful preoperative patient evaluation and underscoring the need for detailed preoperative counseling and risk stratification. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Broad overview of a clinical and commercial experience with CoolSculpting.

BACKGROUND: Cryolipolysis has been shown to be a safe and effective noninvasive procedure for the reduction of localized subcutaneous fat. OBJECTIVES: The authors examine the safety, efficacy, and procedural growth of cryolipolysis (via the CoolSculpting device; Zeltiq, Pleasanton, California) in a single plastic surgery practice. METHODS: A retrospective chart review was conducted for 528 consecutive patients who underwent cryolipolysis treatment from January 2010 to December 2012. The number of patients, the number of treatment cycles, the average number of cycles per patient, all treatment areas, and all procedural complications were recorded and analyzed. Overall practice growth with the device was also analyzed. RESULTS: Over the study period, 1785 anatomic sites were treated with 2729 cycles, primarily in the lower abdomen (28%, n = 490 cycles), upper abdomen (11%, n = 189), left flank (19%, n = 333), right flank (19%, n = 333), inner thigh (6%, n = 111), outer thigh (5%, n = 87), and back (6%, n = 99). The age distribution for men and women was similar (46.6 ± 12.8 years for women and 46.5 ± 12.3 years for men; overall range, 18-79 years). Only 3 cases of mild or moderate pain/neuralgia were reported and resolved in 4 or fewer days. No adverse events were reported. Procedure volume showed consistent growth, with treatment cycles increasing by 823% by 2012. CONCLUSIONS: Based on the results in this single plastic surgery practice, cryolipolysis is a safe and effective nonsurgical body contouring method associated with high patient satisfaction that can generate steady, significant business growth.

Prospective study of lidocaine, bupivacaine, and epinephrine levels and blood loss in patients undergoing liposuction and abdominoplasty.

BACKGROUND: Bupivacaine levels have not been measured in cosmetic surgery patients to establish safety. Blood loss has been underestimated using the small volumes present in the aspirate. The proportion of wetting solution removed by liposuction has not been reliably ascertained. METHODS: To remedy these deficiencies, a prospective study was undertaken among 322 consecutive patients presenting for superwet ultrasonic liposuction and/or abdominoplasty, and other combined procedures, using infusions containing 0.05% lidocaine (liposuction) and/or 0.025% bupivacaine (abdominoplasty) with 1:500,000 epinephrine. Plasma levels of lidocaine, bupivacaine, and epinephrine were studied in a subset of 76 consecutive patients, including hourly intraoperative samples in 39 consecutive patients. Anesthetic levels were also measured in 12 consecutive patients during the 24-hour period after infusion. RESULTS: The maximum lidocaine dose was 3243 mg and the maximum level was 2.10 µg/ml. The maximum bupivacaine dose was 550 mg and the maximum level was 0.81 µg/ml. No clinical toxicity was encountered. Estimated blood loss from liposuction was 217.5 cc + 187 cc/liter of aspirate (r = 0.65). Abdominoplasty added 290 cc of blood loss, on average. The mean proportion of wetting solution removed by liposuction was 9.8 percent. CONCLUSIONS: Bupivacaine may be safely used in cosmetic surgery. A concentration of 1:500,000 epinephrine is safe and effective when administered as part of a wetting solution that is limited to less than 5 liters. Estimated blood loss is higher than previous estimates based on lipocrits. Combination procedures are safe.

Regional differences in subcutaneous adipose tissue gene expression.

Adipose tissue (AT) located in the viscera is considered to be functionally and metabolically different from that found in the subcutaneous depot. However, subcutaneous AT (SAT) in generalized regions is considered to be homogeneous in nature. Affymetrix GeneChip Human Exon 1.0 ST Arrays were used to determine differential gene expression in four subcutaneous adipose depots (upper abdomen, lower abdomen, flank and hip) in normal weight women. A total of 2,890/24,409 transcripts were differentially expressed between all sites. When comparing the hip and flank to the lower abdomen, 248 and 83 genes were differentially expressed, respectively. When comparing the hip and flank to the upper abdomen, 2,480 and 79 genes were differentially expressed, respectively. No genes were significantly different when the lower abdomen was compared to the upper abdomen and the hip to the flank. Genes involved in the complement and coagulation cascades and immune responses showed increased expression in the lower abdomen compared to the flank. In addition, two genes involved in the complement and coagulation cascade, CR1 and C7, were expressed more highly in the lower abdomen compared to the hip. Genes involved in basic biochemical metabolism including insulin signaling, the urea cycle, glutamate metabolism, arginine and proline metabolism and aminosugar metabolism had higher expression in the lower abdomen compared to the hip. These results in normal weight healthy women provide a new perspective on regional differences in SAT biology that may have pathophysiologic implications when adiposity increases.

1,000 consecutive cases of laser-assisted liposuction and suction-assisted lipectomy managed with local anesthesia.

BACKGROUND: Advances in suction-assisted lipectomy (SAL) include improved instrumentation, better understanding of fluid dynamics, and an improved concept of appropriate indications. The tumescent technique uses subcutaneous injection of isotonic fluid containing vasoconstrictive and analgesic agents and is proved to be safe, with low morbidity and mortality rates. Laser-assisted liposuction (LAL) using local infiltration of an anesthetic and no general anesthesia or sedation has been developed, with claims of fat destruction and skin tightening. This study aimed to review 1,000 consecutive cases of LAL and SAL performed with the patient under local anesthesia and to determine whether this represents a safe technique with few complications. METHODS: During a period of 22 months, 581 consecutive patients (486 females and 95 males) underwent 1,000 LAL/SAL operations, 545 of whom had multiple procedures performed. None of the patients had a body mass index (BMI) higher than 30 kg/m2. The patients ranged in age from 18 to 62 years. The fat aspirate ranged from 50 to 1,400 ml. Patients were given an oral sedative, an antibiotic, and an analgesic. Ringer's lactate solution containing lidocaine and epinephrine was injected into the subcutaneous space. The 1,064-nm and/or 1,320-nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser was used for laser lipolysis followed by SAL using standard and/or power-assisted liposuction (PAL) cannulas. The treated areas included the neck, triceps, male breast, midback, flanks, axilla, abdomen, mons pubis, thighs, presacrum, and knees. No patient was administered intravenous sedation or general anesthesia. RESULTS: The average number of areas treated was 1.8, and no major complications or mortalities were observed. There were three burns, two infections, one hematoma, and one seroma. A total of 73 secondary procedures were performed (7.3%). No tertiary procedures were required. CONCLUSION: For appropriately selected patients, comparable results can be obtained with an excellent safety profile and short recovery period using LAL and SAL with the patient under local anesthesia. The awake patient is able to participate in body positioning and to provide physiologic monitoring. No major complications occurred in this series. The burn and hematoma complications occurred in the first 25 cases and may have been related to a learning curve. One case of cellulitis occurred in the triceps region, and a second infection occurred in the abdomen. Both responded to antibiotics. Altogether, 73 touch-up procedures (7.3%) were performed. The amounts of fat removal were comparable with the volumes obtained using traditional liposuction. In conclusion, this series demonstrated that LAL/SAL using local anesthesia is a safe procedure for selected patients, with acceptably low morbidity and revision rates. 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 at www.springer.com/00266.