DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON

BODY CONTOURING

ST LOUIS, MISSOURI

314-984-8331

                                                                         

 

BEFORE TUMMY TUCK, LIPOSUCTION BY DR KOO

AFTER TUMMY TUCK, LIPOSUCTION BY DR KOO

                                                                                                                                                                                                         

Lipodystrophy is the term used to describe locations of fat that tend to accumulate in certain areas.  The areas on our body that tend to accumulate fat are genetically determined and is a source of frustration for most people.  No matter how much we exercise and diet, there are areas of our body that will accumulate fat disproportionately. 

We all accumulate fat in specific areas determined by our genetics. Women then to accumulate fat in the hips, thighs, abdomen and buttocks. Men tend to accumulate fat in the abdomen and midriff.  Fat, however can be located in all of the following areas: abdomen, flanks, thighs, arms, neck, knees, back, buttocks, and breasts.

Dr Michele Koo, St Louis, MO will give you a careful physical examination to detail all of the areas that bother you that can be remedied with liposuction. Liposuction is a very safe procedure which can often be achieved as an outpatient procedure.

Men who present for abdominal liposuction often times have intraabdominal fat, which is not addressed by liposuction. In men interested in body contouring of the anterior chest, in other words, gynecomastia, Dr Koo will direct the method of surgical treatment. Ultrasound-assisted liposuction or direct excision of skin and breast tissue may be necessary in those with additional fibrous tissue.

Other anatomical areas that require special attention if liposuction is to be performed are the legs and ankles. Patient satisfaction is not as high with liposuction in these areas. Pain can be a prolonged problem and complications are more frequent than with liposuction of most other areas. It is important to understand the patterns of fat distribution and how they relate to the anatomy of the area.

Dr Michele Koo, MD, pays special attention to the preoperative markings, with careful attention to the suction area, and her office renders close postoperative follow-up to achieve the utmost optimal results that are possible with liposuction and tummy tucks (abdominoplasty).

Skin evaluation is pertinent in the evaluation of any patient seeking body-contouring procedures. For those seeking liposuction, adequate skin elasticity should be present to allow for skin retraction after surgery. Particular attention should be given to associated wrinkles, laxity, and surface irregularities, including dimpling.  Previous abdominal scars and stretch marks can often be removed with the tummy tuck (abdominoplasty) procedure. Men also do well with the tummy tuck procedure if they want to remove the over hang of skin in the belly area.

Cellulite is a term that is used to describe the lipomatous deposits under the skin that outwardly give the skin a lumpy or orange peel-like appearance. Cellulite is often noted in areas such as the hips, buttocks, or thighs. Cellulite is predetermined by genetics, so even thin women can develop the appearance. Factors such as hormones, pregnancy, and aging may all attribute to the appearance of cellulite. Patients should be aware that liposuction procedures do not address cellulite and may in fact worsen its appearance. In contrast, dimpling is usually considered to be a more isolated area of concavity that may be secondary to underlying scar or fascial attachments and may be improved by the liposuction process.

Dr Koo makes a special effort to correct any dimpling or asymmetry intraoperatively; however, this is frequently difficult to achieve. The patient should be aware of possible persistent asymmetry, depressions, and dimpling after the liposuction procedure.

The tumescent technique was introduced in 1985. It uses the largest volume of infiltrate and involves infusing 3 to 4 ml of the infiltrate solution for each planned milliliter of aspirate. Drug concentrations in the tumescent infiltrate solution vary, but typically they consist of a range of 0.025% to 0.1% lidocaine and epinephrine 1:1,000,000 in a lactated Ringer’s or normal saline solution. Estimated blood loss with the tumescent technique is approximately 1 percent of the aspirate, comparable to the superwet technique.

Since the advent of epinephrine-containing wetting solutions and sophisticated fluid management techniques, increasingly larger volumes of liposuction aspiration have been reported. Large-volume liposuction, defined as a total aspirate of 5000 ml or greater, can be a safe and effective procedure when patients are carefully selected and when anesthetic and surgical techniques are properly performed. Meticulous fluid balance calculations are necessary to avoid volume abnormalities, as metabolic alterations and fluid shifts result from medication effect, hypodermoclysis, and surgical technique. General practice guidelines recommend overnight observation postoperatively for patients undergoing large-volume liposuction.

Dr Michele Koo is very experienced in tumescent and large volume liposuction to achieve the most amazing results safely. She will advise you as to what procedures can be done at one time and will stage your entire body makeover to achieve the flat tummy and thin thighs and buttocks that you are looking for. 

Ultrasound-assisted lipoplasty. Introduced in the late 1980s, ultrasound-assisted liposuction uses a cannula or probe to deliver fat-liquefying ultrasound subcutaneously. This technique permits the removal of fat from fibrous areas such as the upper abdomen, back, and flanks with greater ease, especially during secondary procedures. To prevent thermal injuries while performing ultrasound-assisted liposuction, two technique rules are of critical importance. First, the ultrasound probe or cannula must be kept in motion. Second, the infiltrate solution is a required component of ultrasound-assisted liposuction because it plays a crucial role in the process of fat emulsification and cooling the heat generated in the process. The dry technique should never be used in ultrasound-assisted liposuction, regardless of the planned volume of aspirate.

Modern abdominoplasty techniques were developed during the last 40 years of the last century. Standard abdominoplasties include a transverse lower abdominal incision, wide undermining of the skin and subcutaneous tissue to the costal margins, tightening of the abdominal musculature with correction of rectus muscle diastasis, resection of redundant abdominal skin and subcutaneous tissue, umbilical repositioning, and skin closure. The introduction of liposuction has revolutionized the treatment of aesthetic deformities of the trunk and the extremities, but it only deals with the element of excess subcutaneous adipose tissue and does not confront the laxity of the skin or the irregularities of contour. Concentrating on aesthetic deformities of the trunk without considering their circumferential aspects (and those of the lower extremities) may lead to asymmetry and imbalance of the body aesthetic unit. Therefore, it is necessary to consider lateral and posterior truncal deformities and the deformities of the buttocks, hips, and thighs to obtain a successful result from body contour surgery.

DR KOO will take an accurate assessment of your entire trunk deformities and DR KOO’S technical expertise are essential components of successful body contour surgery. DR KOO takes into consideration all aspects of the your medical history to determine the ideal course of treatment. Most patients requesting body contour improvement will be women who have given birth and are multiparous. Knowledge of the number of children and whether the woman has a history of caesarean section is important. The effects of smoking cigarettes on wound healing are well known.  Patients should abstain from smoking for a significant period before and after surgery. Significant medical problems that may affect the outcome of surgery include a history of hypertension, coronary artery disease, chronic obstructive pulmonary disease, diabetes mellitus, hepatitis C, and human immunodeficiency virus. A history of abdominal hernia and a thorough gastrointestinal history, such as irritable bowel syndrome or inflammatory bowel disease, is  covered. The female patient who has had more than one pregnancy is certainly more likely to have developed rectus muscle diastasis. Any woman requesting surgery is questioned regarding her desire for future pregnancies. Most surgeons advise their patients to wait until their family has been completed before proceeding with definitive abdominal body contour improvement. An additional factor that is of significance is a history of intraabdominal operations. The location of scars is important in determining the plan of correction. In addition, a tall, lean individual will undoubtedly have an easier postoperative course and a different appearance than an obese, short individual, who may require more procedures than an abdominoplasty for body contour improvement.

It is extremely important that the physician knows about a personal and/or family history of deep vein thrombophlebitis, in addition to any other hemostatic problem. Knowledge of the intake of medications, whether prescribed or over-the-counter, and the ingestion of herbs and other products that may adversely affect the coagulation mechanism is important so that the patient may be instructed to discontinue them for an appropriate period before undergoing surgery.

The patient’s general appearance-especially the appearance of the abdomen, including the location of scars-is documented, measured, and photographed. Although most infraumbilical scars are removed during abdominoplasty, supraumbilical scars can present certain problems, such as impaired blood supply of the superior flap, difficult dissection in the scar area, or patient dissatisfaction with the scar still visible postoperatively. The most common complication is fat necrosis under the scar, and possibly skin necrosis, dehiscence, or infection.  Adhesions of the skin at the level of the waist are not uncommon, and these bands can essentially divide the abdominal excess skin into superior and inferior segments. There is a significant risk of ischemia of the abdominal flap if extensive release of these adhesions is attempted; discontinuous undermining is preferable. 

If any herniae are present, their concurrent repair is essential for aesthetic improvement. This can be accomplished by either the operating surgeon or another surgical consultant. Large herniae, such as ventral, umbilical, or incisional, may require complex repair before the performance of an abdominoplasty for aesthetic improvement, which would then subsequently be performed at a later date. Diastasis of the rectus abdominis muscles, whether mild, moderate, or severe, is usually corrected at the time of the abdominoplasty. All patients are concerned with stretch marks, most of which occur during one or more pregnancies and are located in the lower half of the abdomen, extending laterally to the flanks. Many of these will be removed along with the skin and subcutaneous tissue flap. There are some physicians who feel that they can be removed with external lasers, but the efficacy of that procedure has yet to be proven. The flaccidity and laxity of skin of the abdomen above the umbilicus is treated by redraping of the abdominal flap, although in severe cases, it may require a staged reverse abdominoplasty. Below the umbilicus, it is treated by redraping with excision of the excess skin and soft tissue along the inferior margin. Laxity of the adjacent areas of the flanks and thighs can be treated with liposuction, but in more severe cases, high-lateral-tension abdominoplasty procedures along with extension of the incision laterally should be considered.

An abdominoplasty, with or without suction-assisted lipectomy, is considered a major surgical procedure and must be approached systematically to avoid complications. Before surgery, the anesthesiologist will assign an aesthetic risk scale to the patient, but the surgeon should be aware of the guidelines that determine the American Society of Anesthesiologists classification of physical status. The scale is divided into four categories, depending on severity, as follows: American Society of Anesthesiologists class I, no risk factors; class II, minor risk factors; class III, serious risk factors; and class IV, life-threatening risk factors. A local anesthetic and/or local anesthetic with simple intravenous sedation is usually not satisfactory for the performance of an abdominoplasty. It is advisable to have the procedure performed under general anesthesia with an anesthesiologist in attendance to ensure patient comfort and safety. Use of wetting solution containing local anesthetics and epinephrine injected into the subcutaneous adipose tissue has significantly decreased blood loss and provided a more pain-free postoperative environment.

Muscle relaxation during the procedure is essential if musculofascial tightening procedures are to be performed. All forms of anesthesia are associated with a relatively low incidence of complications, but the surgeon must be aware of all of them. The best prevention of complications is for the physician to be informed of the patient’s medical history, especially regarding drug allergies and experience with anesthetics. Postoperative nausea and vomiting is the most common complication after general anesthesia, which can be extremely debilitating for the patient and may have an adverse effect on fascial sutures if extreme vomiting occurs. In addition to routine antiemetics, propofol and dexamethasone have antiemetic properties that may be beneficial. Clinicians must be prepared with monitors, emergency drugs, and airway supplies to facilitate treatment of laryngospasm, intraoperative hypotension or hypertension, oxygen desaturation, bradycardia or other cardiac arrhythmias, seizures, and cardiac standstill to reduce the risk of long-term sequelae should a severe or toxic reaction occur during or after surgery.

Abdominoplasties can be performed on an inpatient or an outpatient basis. If performed in an outpatient facility, that facility should be accredited by the Joint Commission on Accreditation of Healthcare Organizations or the American Association for Accreditation of Ambulatory Surgical Facilities. Patients should be admitted for postoperative care to an accredited facility for observation, monitoring of vital signs, and pain control.

The time it takes to perform the operation depends on the extent of the procedure, including the performance of ancillary suction-assisted lipectomy and the treatment of other areas in addition to the trunk. There are no data to support a definite time limit in surgery; however, 6 to 7 hours appears to be the maximum surgical time for any one operation.

Proper preoperative planning is essential to avoid intraoperative and postoperative complications. Hypothermia is not an uncommon problem, especially when liposuction is performed in conjunction with abdominoplasty. The vasodilatation associated with general anesthesia, the large skin surface area, and the infiltration of cold solutions can all contribute to hypothermia. Care should be taken to warm the operating room and intravenous and wetting solutions and to use forced warmed air devices liberally. It is of paramount importance to address venous thromboembolism, a term referring to a spectrum of diseases that includes deep venous thrombosis and pulmonary embolism, in these patients. Unfortunately, the patient’s first symptom is often fatal; therefore, prevention is the key to reducing the incidence of deep venous thrombosis and pulmonary embolism. Demographic risk factors include the following: a previous history of deep venous thrombosis or pulmonary embolism, history of malignancy, inherited or acquired thrombophilia disorders, obesity, heart failure, use of oral contraceptives, history of spontaneous miscarriages, pregnancy within the past 3 months, age older than 40 years, presence of varicose veins in the lower extremities, and recent surgery with use of general anesthesia.

DR KOO thinks it is important to educate the patient and provides informed consent about the risk of deep venous thrombosis and pulmonary embolism. Multiple methods have been studied and recommended for venous thromboembolism prophylaxis. Early ambulation and proper patient positioning are perhaps the simplest and most logical measures. Studies have demonstrated techniques to position the patient in such a way as to maximize venous flow through the legs and avoid external pressure.  Aspirin has been used in the past; however, it has been felt that because of lower efficacy and high-risk profile (gastrointestinal and wound-related bleeding), is should not be recommended for the prophylaxis of venous thromboembolism. Graded elastic compression stockings have been shown to reduce the incidence of deep venous thrombosis by increasing venous return as a result of the constant pressure to the lower extremities. Studies show that their efficacy is greatly improved when combined with other modalities, such as low-dose unfractionated heparin or intermittent pneumatic compression stockings, and therefore they are not currently recommended for monotherapy. The use of intermittent pneumatic compression stockings on the lower extremities is essential. These devices reduce stasis by increasing venous blood flow, improving valve function, and reducing the distention of the vein walls. They also have a poorly understood mechanism of reducing the level of plasminogen activator-1, which in turn increases fibrinolytic activity.

Studies of general surgical procedures have demonstrated a 50 to 60 percent reduction in deep venous thrombosis with their use. The devices should be applied to all patients undergoing general anesthesia or procedures longer than 1 hour in duration. It is important to apply them 30 to 60 minutes before induction of anesthesia (because general anesthesia itself is associated with higher rates of venous thromboembolism) and should be continued postoperatively until the patient is fully ambulatory. Low-molecular-weight heparin and low doses of unfractionated heparin have been shown to reduce 65 percent of deep venous thrombosis and 50 percent of pulmonary embolism in abdominal surgery. Both forms work through inactivating two factors in the coagulation cascade-factor Xa and factor IIa (thrombin). The advantage of low-molecular-weight heparin is that it is dosed once daily, does not require coagulation monitoring, and has a lower rate of bleeding complications. In addition, because it does not bind to platelets, it is less likely to create heparin-induced thrombocytopenia.  It is important to begin therapy 2 hours before or 12 hours after surgery to reduce the risk of bleeding complications. Several studies have shown that administering low-molecular-weight heparin preoperatively provides a protective effect during surgery and in the immediate postoperative period.  There is a slightly higher risk of bleeding with preoperative dosing; therefore, the decision on when to give the first dose should be based on the patient’s individual risk-to-benefit ratio. Therapy is usually continued for at least a few days after active ambulation. Warfarin sodium (Coumadin; Bristol-Myers Squibb, Princeton, N.J.) is only recommended for patients with the highest risk factors. It is seldom used in plastic surgical patients because of its several drawbacks, which include a delayed onset of action, multiple drug interactions, and an increased bleeding and hematoma rate. The American College of Chest Physicians has devised a classification scheme that divides patients into one of four risk categories based on age, clinical setting, and known risk factors. Davidson et al. combined these recommendations with the risk assessment model of Caprini et al. to create an algorithm for venous thromboembolic prevention in plastic surgery patients.

Musculofascial repair is performed in almost all types of abdominoplasty techniques. Although the incidence of true diastasis recti has been reported to be quite low, most women have laxity secondary to prior pregnancies. Plication of the fascia is typically in a midline fashion; however, a combination of vertical, horizontal, and/or oblique plication has been advocated based on the musculoaponeurotic deformity.

Most surgeons place subcutaneous suction drains during abdominoplasties to prevent the formation of seromata. Most prefer to place at least two drains, with their orientation and exit points varying, depending on surgeon preference. The drains are usually removed when there is less than 30 cc of aspirate collected in each drain over a 24-hour period.

Routine wound dressings vary from the placement of Steri-Strips (3M, St. Paul, Minn.), gauze over the incision, and a bolus and stent over the umbilicus, to circumferential compression by an elastic abdominal binder or an appropriately sized elastic compression girdle (with lower extremity extensions if additional contour procedures have been performed). Some feel that the use of compression garments does not affect long-term outcome but believe they produce beneficial effects in the immediate postoperative period. Care must be taken to not place abdominal binders too tight, because they can compromise perfusion to the skin flap and/or increase intraabdominal pressure.

Pain management is important to consider in the body contour patient. The use of a postoperative anesthetic pump has become increasingly popular and has been shown to offer benefit to some patients. Pain pumps may help decrease the need for postoperative narcotic analgesia, which has the benefit of decreasing the side effects associated with these medications. Although the pain pumps have been shown to be extremely effective, it is necessary to determine whether the cost and the inconvenience of wearing the pump is acceptable to the patient.

Liposuction in combination with abdominoplasty has long been a controversial topic. Combining both procedures has been reported to magnify the potential for thrombotic or fat embolic problems. It has also been associated with increased complications if performed in patients identified as having high-risk factors, such as obesity, smoking, and diabetes mellitus. If direct undermining is performed and the abdominal wall is liposuctioned, one risks further impingement of the vascular supply, with increased potential of skin or soft-tissue necrosis. For this reason, some advocate liposuction of the hips only and refrain from epigastric and saddlebag area suctioning. The blood supply of the abdominal wall is divided into three zones: zone I, in the midabdomen and supplied by the deep epigastric arcade; zone II, in the lower abdomen and supplied by the external iliac artery; and zone III, consisting of the flanks and lateral abdomen and supplied by intercostal, subcostal, and lumbar arteries. Abdominoplasty sacrifices the blood supply in zones I and II, leaving the flap perfused by perforators in zone III and from collateral flow from the superficial circumflex iliac artery in zone II. Safe zones for liposuction in combination with abdominoplasty on the basis of this blood supply have been described. Safe areas are considered lateral and superior, whereas the central medial flap should be suctioned with caution.  When liposuction is performed, it is recommended that the superficial fat compartment be avoided and that one stays below Scarpa’s fascia to limit vascular compromise and contour irregularities. The introduction of Lockwood’s high-lateral-tension technique, which limits direct undermining and preserves blood supply to the abdominal wall flap, has enabled surgeons to use liposuction more liberally in conjunction with abdominoplasty.

Immediate complications of surgery can be catastrophic and include the development of deep vein thrombosis, pulmonary emboli, fat emboli, and hematoma. Fat embolism syndrome is a rare occurrence that is manifested by the clinical triad of respiratory distress, cerebral dysfunction, and petechial rash. The syndrome usually manifests itself within the first 2 postoperative days and is treated supportively with corticosteroids. Information regarding the risks of developing venous thromboembolism in plastic surgery patients is limited; however, Grazer and Goldwyn reported a deep venous thrombosis incidence of 1.1 percent and a pulmonary embolism incidence of 0.8 percent in abdominoplasty patients. Hester’s group found that when abdominoplasty was combined with other surgical procedures, the incidence of pulmonary embolism was significantly greater. There have been studies documenting a higher incidence of thromboembolic phenomena when combining abdominoplasty with gynecologic surgical procedures and contrasting data showing no statistical difference in the frequency of these complications when the two types of procedures are combined.

Early complications include infection, skin necrosis, umbilical necrosis, seroma, and prolonged edema. The order of occurrence varies in the literature, but the most commonly reported complications are wound infection, dehiscence, hematoma/seroma, and skin loss. Not surprisingly, the incidence of these complications is higher in smokers, patients with diabetes or hypertension, and obese patients. Some have reported an alarmingly high incidence of injury to the lateral femoral cutaneous nerve. The frequency of most complications appears to be inversely related to the surgeon’s experience. Most surgeons place patients on prophylactic antibiotics, administered intravenously before and during the surgical procedure, and oral supplements during the immediate postoperative period. The high level of methicillin-resistant Staphylococcus aureus infections encountered in some surgical facilities indicates the need for prophylactic antibiotic administration in these locations. Skin necrosis occurs as a result of decreased blood supply caused by increased tension, excessive thinning of subcutaneous tissues, or the presence of obesity-related comorbidities. Seromata can best be prevented by the placement of postoperative drains. Some surgeons place quilting sutures, attaching the undersurface of the adipose tissue of the abdominal flap to the anterior surface of the underlying muscular fascia in an attempt to decrease the empty space.  Preserving a thin layer of adipose tissue on the fascia in an effort to preserve some lymphatic drainage has also been reported. Seromas can be treated with percutaneous aspirations, placement of a subsequent drain, or open surgical evacuation. Protocols for the use of medications, such as doxycycline, used to sclerose seromas has also been discussed.

Uneventful healing and a good cosmetic result is almost always the case, but occasionally reoperation to correct hypertrophic scarring, suprapubic deformity, umbilical deformity, excision of excess residual abdominal skin or subcutaneous adipose tissue, secondary correction of rectus diastasis, or additional lipoplasty to improve a contour irregularity of the abdominal wall may be necessary. It is useful to establish parameters of success and to discuss these with the patient before surgery. A realistic date for return to work and physical activities should be established and ideally agreed on before surgery. If the patient is satisfied with the result of surgery, the physician is almost always satisfied as well. However, self-evaluation for improvement by the physician should be considered if it is felt that a second operation is necessary to further manage and improve the patient’s residual deformities.

DR MICHELE KOO, MD, FACS, 314-984-8331, ST LOUIS, MISSOURI