Marcaine

Vancouver, B.C. -- Performing lipoplasty with precision is the key to better clinical results, says Peter Fodor, M.D., who adds: "The best surgeons do more than remove fat. They sculpt."

Dr. Fodor, president of the American Society for Aesthetic Plastic Surgery (ASAPS), photographs patients prior to surgery and then takes Polaroid pictures after marking the patient for the procedure. He marks the patient the day before surgery, when practical, or in the operating room on the day of the procedure. The pictures are then discussed with the patient.

For buttock surgery, he asks the patient to contract the muscles, and draws a vertical line to demarcate the lateral end of the banana roll and the medial end of the trochanteric fat deposit. This is to define true, as opposed to pseudo, fat deposits.

If the buttocks are very large, they tend to push the trochanteric fat deposits laterally, making it easy to over-mark and over-resect, Dr. Fodor explains. He then uses the pinch test to estimate the thickness of the fat deposit. Although Dr. Fodor says he does not have an effective way to estimate the exact volume of the aspirate preoperatively, "it is amazing how accurate you can become with experience." he says.

The marking is carried out with the patient first standing, facing the wall, then supine.

In the operating room, the patient wears a foil cap to preserve the body's core temperature. Small crosses are used on the fat deposits and the estimated volume of fluid to be extracted is also noted on the skin sites. A dotted line is drawn on the patient's side to guide the lateral suction.

Dr. Fodor says he does not use multiple, circular, "topographic" markings because he does not believe they add any value and they increase the risk of tattooing.

Following marking, the patient is fitted with an elasticized garment then prepared for the procedure while standing. A sheet with a slippery surface is placed on the bed to facilitate turning the patient during surgery and the patient then lies on the bed wearing sterile booties. Next, general or epidural anesthesia is administered. Sterile sheets are then stapled to the skin.

The procedure is carried out sequentially in the targeted area in order to limit the amount of medication given at any one time.

For the super-wet technique, proposed by Dr. Fodor since 1986, an infusion of 1.0 cc to 1.5 cc per cc of the estimated aspirate is given. The infusate consists of 1000 cc of Ringer's lactate, 0.5 to 1 cc epinephrine 1/1000, and 25 cc of marcaine.

For small body regions such as the banana roll, Dr. Fodor infuses by hand. Skin protectors are used to protect the patient from friction burns. The protectors also prevent over-suctioning in the area immediately adjacent to the incision, Dr. Fodor says.

For larger areas, he uses a mechanical infusion pump. The pump's measurement of the rate of infusion is accurate to within 1 cc, and can be adjusted within a range of 50 cc to 600 cc per minute, Dr. Fodor says. The quantities of infusion are recorded on a data sheet, which becomes part of the patient's medical record.

For ultrasound-assisted lipoplasty (UAL), Dr. Fodor far prefers the VASER device (Sound Surgical Technologies). The machine is set at 80 percent of its maximum power in a pulsed mode.

Single groove probes are used for fibrous fat, and multiple groove probes are useful for softer fat, Dr. Fodor says. The probe is inserted into the fat tissue and moved slowly back and forth until it no longer encounters resistance.

An estimated 100 cc of subcutaneous fat can be emulsified per minute, he says. "As with any form of aspiration, the less experienced lipoplasty surgeon may be well served by using longitudinal markings in the shape of spokes of a wheel over the area to be suctioned and applying the cannulae a predetermined number of times," Dr. Fodor advises.

Small cannulae with 2 cc increments and larger cannulae with 10 cc increments are used.

Suctioning is easier if each area is as flat as possible, Dr. Fodor says. If this is not practical, the shaft of the cannulae can be bent to accommodate the angle.

Positioning the patient to best accommodate the area to be suctioned is important. For example, to suction the posterior aspect of the medial thigh, the patient is flexed at the hip and knee, with the operating table in the Trendelenburg position if necessary, and the incision is made at the gluteal fold.

Moistening the surface of the area being treated helps in determining the end point, Dr. Fodor says. A depression created on purpose in the upper lateral thigh when properly performed can be aesthetically pleasing. When sculpting of this area is not properly achieved, a deformity difficult to correct may result.

Antibiotic ointment is applied and protective foam sponges are placed over the suture sites. A compression garment is then placed on the patient. It is removed three to five days after surgery when he or she returns for the first time to the office. Then this is replaced with a smaller one, which the patient wears for three to five weeks. In addition, the sutures are removed three to five days after surgery. Patients begin walking on the day of surgery and resume a full exercise program from three to five weeks post-operatively.

Instant analysis

Performing lipoplasty with precision is the key to better clinical results. "The best surgeons do more than remove fat. They sculpt," says Peter Fodor, M.D. Dr. Fodor takes great care in marking, prepping and positioning a patient to best accommodate the area to be suctioned.

Disclosure: Dr. Fodor is a consultant of MicroAire Surgical Instruments, which partially funded a clinical study resulting in publication of the paper, Power Assisted Lipoplasty, Aesthetic Surg J; 2001; Vol. 21, 1; 90-92.

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