Non-Surgical Alternative to Facial Liposuction
Anesthesia may be divided into four broad categories local anesthesia, local anesthesia combined with sedation, regional anesthesia and general anesthesia. The ultimate decision to select the type of anesthesia depends on the type and extent of the surgery planned, the patient's underlying health condition and the psychological disposition of the patient. For example, a limited liposuction of less than 500 ml of fat from a small area in a healthy patient, with limited anxiety, could certainly be performed using strictly local anesthesia without sedation. As the scope of the surgery broadens, or the patient's anxiety level increases, the local anesthesia may be supplemented with oral or par-enteral analgesic or anxiolytic medication.
Each of these choices has distinct advantages and disadvantages. While convenient and economical, office based surgery is associated with three times the mortality of surgeries performed at other types of facilities 11 . Ultimately, patient safety should be the paramount factor in the final decision. Patients with a risk of ASA III undergoing major liposuction or large abdominoplasty should preferentially be treated at hospital-based or hospital-associated surgical units rather than office-based operating rooms 12-14 .
Candidates include patients who fail qualification for implants due to prior chest-wall irradiation or implant anxiety or who have abdominal scars precluding TRAM reconstruction. Such scars may have resulted from laparotomies, enterotomies, previous abdominoplas-ties, liposuction, or TRAM harvests. This flap may represent the only autogenous option in thin patients who lack sufficient abdominal or lateral thigh tissue for unilateral or bilateral reconstruction.
Studies correlating the amount of fat aspirate during liposuction or the amount of tissue removed during abdominoplasty with perioperative morbidity and mortality have not been performed, it would not be unreasonable to extrapolate conclusions from the previous studies and apply them to abdominoplasty and lipo-suction. Liposuction surgeries with less than 1,500 ml fat aspirate are generally considered less invasive procedures, while liposuctions aspirating more than 3,000 ml are considered major surgical procedures 19 . As blood loss exceeds 500 cc 59 , or the duration of surgery exceeds 2 h, morbidity and mortality increase 48, 60 .
According to the National Commission on Sleep Disorders Research, approximately 18 million Americans suffer with obstructive sleep apnea (OSA). Unfortunately, the majority of patients with OSA remain undiagnosed 123 . The incidence of sleep apnea increases among obese patients 124 . Since the target population for major liposuction and abdominoplasty includes patients with morbid obesity, concern about OSA becomes more germane.
Fat distribution abnormalities result in a wasting appearance ( slim disease ) and abnormal fat accumulation in localized areas ( protease pouch, buffalo hump, and crix belly ) (205-220). Some studies have shown that saquinavir, ritonavir, and nelfinavir all reduce the development of fat cells from stem cells in vitro. In addition, they increase the metabolic destruction of fat in existing fat cells. It is postulated that loss of deposited fat in the body could lead to high levels of LDL, cholesterol, and triglycerides. An alternative mechanism could involve retinoids (221). When retinoids are combined with PIs, complex reactions occur in certain genes. It is postulated that indinavir may cause some effects resembling lipodystrophy by changing retinoid signaling. Therefore, patients taking PIs may be advised to avoid vitamin A supplements. Still another hypothesis suggests that PIs, which show approximately 60 homology with lipoprotein receptor-related protein...
While some authors attribute the majority of complications occurring during and after liposuction to the administration of systemic anesthesia 148, 206 , others consider sedation and general anesthesia safe and appropriate alternatives in indicated cases 19, 158, 207, 208 . In fact, Klein correctly acknowledges that most of the complications attributed to midazolam and narcotic combinations occurred as a result of inadequate monitoring 148 . Although significant advances have been made in the administration of local anesthetics and supplemental medications, the use of general anesthesia may still be the anesthesia technique of choice for many patients. General anesthesia is especially appropriate when working with patients suffering extreme anxiety, high tolerance to narcotic or sedative medications, or if the surgery is particularly complex. The goals of a general anesthetic are a smooth induction, a prompt recovery, and minimal side effects, such as nausea, vomiting, or sore throat....
The current prevalence of obesity in the USA is estimated to be 55 of the population 76 . It is reasonable to assume that patients undergoing major liposuction or abdominoplasty have a greater incidence of obesity. The most widely accepted method of quantifying the level of obesity is the body mass index (BMI), which is determined by weight (kg) height (m)2. Patients with a
The estimation of perioperative blood and fluid loss during liposuction and abdominoplasty surgeries is not a trivial task. Observers in the same room frequently have wide discrepancies in the estimated blood loss. In the case of the abdominoplasty, unrecognized blood loss occurs. Substantial amounts of blood typically seep around and under the patient, unnoticed by the surgeon, only to be discovered later as the nurses apply the dressing. Because of subcutaneous hematoma formation and the difficulty of measuring the blood content in the aspirate, estimating the EBL during liposuction may be a particularly daunting task. Fortunately, the development of tumescent technique has dramatically reduced perioperative blood loss during liposuc-tion surgeries 24, 293 . The blood content in the aspirate after tumescent li-posuction has varied between less than 1 288, 293 and 8 290 . To underscore the difficulty of estimating the EBL, the range of the determined blood loss in one study was...
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