Body Contouring Terms Mountain View
Abdominoplasty and Thigh Lift Terms
Abdominoplasty: when there is significant laxity of the buttocks and thighs, as in massive weight loss, the laxity involves the front of the abdomen as well. Abdominoplasty is frequently a component of a thighplasty and other body contouring procedures. The surgery is more extensive and is sometimes done as two separate procedures, the abdominoplasty first followed by the lateral thigh lift. Excess skin and fat is removed from the abdomen, with the incision going across the upper border of the pubic area and up toward the waist at an angle so that the final scar is concealed by underwear. The incision blends into the incision of the thighplasty at the waist.
Circumferential body lift: another name for thighplasty, usually implying that the abdomen is treated as well. The incision goes across the upper border of the pubic area, up and over the front of the pelvis, and around the waist to meet in the midline at the back. In other words, the scar extends all the way around the body. It should be designed so as not to be visible in underwear or a bathing suit.
Drains: thin, flexible silicone tubes placed after surgery to remove accumulated fluid under the skin. The drains exit small incisions in the pubis and lateral thigh and are connected to silicone bulbs that pull the fluid out of the body. It is necessary in abdominoplasty and thighplasty to remove this fluid during the healing process so the tissue will stick down to the abdominal wall and anterior thigh. If not, the fluid will stay there and form a fluid cavity, called a seroma (ser-om’-a) that may grow a lining and require another surgery to remove. The drains are in place for up to a week after abdominoplasty and thighplasty. Antibiotics are used during the period that the drains are in place.
Superficial fascia: think about the old Chinese finger trap puzzle. You put a finger in each end and pull, the trap tightens and you cannot remove your finger. Such a network of interlacing fibers, called the superficial fascia, exists under your skin. It is utilized in the closure of the thighplasty and abdominoplasty body contouring procedures to get long-lasting support of the tissues and put the least tension possible on the skin. Minimal skin tension is a favorable condition for minimal scarring
Venous or fat emboli: these are uncommon risks which can occur in the post-operative period. Blood clots which may form in the legs can travel to the heart and impair circulation. Small fat particles or metabolic products of fat called free-fatty acids are thought to damage cell membranes in the lungs, causing fluid to accumulate. While there is no specific prevention for these conditions, precautions such as calf-compression devices are usually worn during surgery. Warning symptoms can include shortness of breath, rapid heart rate, and chest discomfort. Treatment is medical, supportive, and directed at the underlying cause.
Liposculpture: This term was coined to denote the philosophy that removal of fat should be approached in a thoughtful way and done artistically and carefully. We are trying to create a pleasing form, so what is left behind is just as important as what is removed. Lipoplasty is not a treatment for obesity, and gross removal of fat is not the object. The techniques to achieve liposculpture take time and experience to refine.
Cannula: (can’-nu-la) A small, metal tube that removes the fat during the liposuction procedure, cannulas have been in a constant state of development and change during the past fifteen years. They generally have blunt tips and one or more openings at or near the tip. Different tip shapes and arrangements of the openings suit different purposes and surgeon preferences. Cannulas are hollow and are attached at the handle end to a suction source.
Suction: Pulling the fat through the cannula requires a source of suction, which is accomplished using either a vacuum pump connected to the cannula by tubing or a large syringe specially fitted so that when the plunger is withdrawn and locked in place, a suction is created. Both are equally effective and their use during the liposuction procedure is a matter of surgeon preference.
SAFE Liposuction: Separation and fat equalization. The need for refinement in lipoplasty was clear when the techniques of deep fat removal alone often resulted in waviness and depressions, particularly in the hip and thigh area. A thick skin and fat flap unsupported by the deep fat will droop. Folds and waviness of the contour can occur. The goal of SAFE liposuction is to refine the contour, not just remove deep fat. Using expanded basket cannulas without suction both below the skin surface and in the deeper layers first before starting liposuction, and then following the chosen method of liposuction, whether traditional, power-assisted, vaser ultrasonic or laser assisted, allows the skin to contract over the reduced surface. This technique leaves a smooth layer of fat on the under surface of the skin, and superior contouring results can be obtained, compared to suctioning deep fat only.
Skin contraction is best when the skin has retained some youthful elasticity, but the ability to achieve good results in patients whose skin has lost some elasticity makes it possible to recommend liposuction to some patients in their fifties and older.
When SAL was first developed, cannulas as wide as 6 mm were used. The risks of excess fat removal along the path of the cannula resulting in depressions or grooves was correspondingly large. With years of experience, Dr. Lowen has found it possible to use cannulas in the range of 2.5 to 3.7 mm for the majority of liposuction patients. Using highly efficient cannulas and lower than usual suction, a degree of control of the process can be obtained that justifies use of the term liposculpture.
Super-wet or Wet Liposuction: The instillation of a ration of salt solution and dilute adrenaline into the fat compared to the total amount of fat and fluid to be removed, prior to beginning suction. It is not necessary to add the anesthetic, lidocaine, but reasonable amounts based on body weight are usually added for post-operative comfort. The total blood loss is about 1 percent of aspirate. Most plastic surgeons perform liposuction under general anesthesia and do not depend on fluid instillation for anesthesia. Using lower fluid volumes results in the same minimal degree of blood loss as using larger fluid volumes. Using smaller volumes of fluid decreases the risk of fluid overload, and allows safe removal of fat in the range of 2500-5000 cc, which many patients require to obtain their desired result. Using smaller amounts of fluid does not distort the tissues, so final shaping of the contour is more predictable.
Tumescent Liposuction: It is possible to do liposuction in an office setting under local anesthesia by instilling large volumes of salt solution, combined with an anesthetic, lidocaine, and dilute adrenaline into the tissues in a ration of approximately 3:1. Three times as much fluid is instilled as the anticipated fat and fluid removal. Blood loss is about one percent of total aspirate. The amount of fluid instilled results in a swollen or “tumesced” contour of the area with a tense skin surface. Tumescent liposuction is a drug-delivery system for anesthesia, as opposed to the wet or super-wet techniques which were developed by plastic surgeons to minimize blood loss. The tumescent technique was developed by Dr. Klein, a dermatologist, and allows liposuction to be performed without general anesthesia. This is reasonable if it is done within sensible guidelines for volume removal, in a well-equipped surgical facility, and with care to ensure sterility.
Tummy Tuck Terms
Drains: fluid accumulates under the skin after tummy tuck surgery. This is true in many plastic surgery operations which elevate broad areas of tissue from underlying structures. It is necessary in abdominoplasty to have some way to remove this fluid during the healing process so the tissue will stick down to the abdominal wall. If not, the fluid will form a fluid cavity, called a seroma (se-rom’-a), that may grow a lining and require another surgery to remove. Drains are used to prevent this. The thin, flexible silicone tubes are placed under the abdominal flap and exit small incisions in the pubis. The drains are connected to silicone bulbs or reservoirs about the size of a pear. When the bulbs are squeezed and their stoppers plugged in, they create a suction that pulls fluid out of the body. They are left in for up to a week after abdominoplasty.
Fascia: the white, shiny, and tight, non-yielding fibrous tissue to which the thin sheets of abdominal muscle attach. The outer surface of the abdominal wall is fascia. Muscles in your arms and legs start by attachment to bone and end in tendons which also attach to bone. In the abdomen, the muscles may originate on the lower ribs, but have no bone to attach to, so they end up attached to the specialized anterior and lateral abdominal wall fascia. This joins in the midline as a tough midline structure.
Flap: a flap is the plastic surgery term for tissue which is raised from its bed on the body, but left attached so it has a blood supply to nourish it. The abdominal flap is the full thickness of skin and subcutaneous fat which is elevated from the abdominal wall. The incision is on the lower abdomen, so the flap is left attached to the upper and lateral abdomen. Blood supply is critical when creating the flap. Several sources of the blood supply of the abdominoplasty flap are interrupted by necessity during the elevation of the flap. The blood vessels which come out of the rectus muscle are cut, including the rich blood supply around the umbilicus. The remaining blood supply comes from the flanks and the area under the rib cage. Care in preserving more of this blood supply and placing tension on the flap, as described in the next section, makes the risk of skin loss lower.
High-lateral tension abdominoplasty: in this procedure, the location of the incision is very important because it determines both aesthetic satisfaction and the ability to wear bathing suits and underwear without having a visible scar. Older tummy tuck methods placed the scar right across the lower abdomen, and it was visible on the front of the thighs below the bathing suit line. As the fashions women wear get higher and higher in front of the thigh, no scar visibility is desired in this area.
The scar must go across the pubic area, but to hide it, it has to slant up at about a forty-five degree angle toward the waist. How long the scar is from the pubic area upwards is determined by how much excess skin and fat are present. Older abdominoplasty methods pulled the skin primarily in a downward direction. This puts all the tension at the pubic area. Tension on skin edges, if excessive, can compromise circulation, resulting in loss of skin or full-thickness loss of skin and fat at the pubic area. The technique of HLTA puts the tension on the upward slope of the incision. Minimal tension is placed at the pubic area. The tension is in an area with a more robust blood supply and the skin tension and removal is along a direction that leads to a more pleasing shape. The only minor disadvantage of this approach is that patients have increased swelling of the lower abdomen that lasts until the lymphatic drainage to the groin and umbilical areas regrows.
Liposuction: also suction-assisted lipoplasty, or SAL, for short, this procedure is performed to remove subcutaneous fat by inserting small metal tubes called cannulae (singular, cannula) through small skin incisions, passing these tubes, which have various kinds of openings at their blunt tips, back and forth in the fat, and removing the fat as it is broken up with a vacuum that pulls the fat out of the body. A cannula may be connected to a vacuum pump or hose, or to a special syringe which holds the vacuum. A wetting solution of dilute adrenaline and salt solution is always placed in the tissues before suction starts in order to minimize blood loss.
Rectus muscle: This is your main “sit-up” muscle. It is a vertical muscle, one on each side of the midline, that starts at the rib cage. It is reinforced by several horizontally-oriented fascial bands in the upper abdomen that are visible through the skin on someone with a “washboard” abdomen, and inserts at the pubic bone. It is enclosed in a fascial sheath, like a tube, going up and down.
Plicating: (pli’-cating) means to fold. The fascia of the abdominal wall is folded in with sutures to make it narrower in the desired dimension. Usually the rectus fascia is plicated to narrow the abdomen. The abdominoplasty sutures are placed in a vertical row from pubis to umbilicus and then to the upper abdomen if necessary. Although these sutures narrow the abdomen from side to side, and narrow the waist, the forward bulge is also reduced.
Superficial fascia: think about the old Chinese finger trap puzzle. You put a finger in each end and pull, the trap tightens and you cannot remove your finger. Such a network of interlacing fibers called the superficial fascia exists under your skin. It is utilized in the closure of the abdominoplasty to get long lasting support of the tissues and put the least tension possible on the skin. Minimal skin tension is a favorable condition for minimal scarring.
An incision is made in the skin around the umbilicus. The umbilicus is dissected free and left where it is, and the flap is elevated above it up to the rib cage. Care is taken to limit elevation of the flap to a narrow tunnel above the umbilicus to preserve as much of the blood supply in this area as possible. A tunnel is created to allow plication of the rectus muscle, and the excess skin is measured and removed. The excess fat in the lower abdomen is removed from the bottom of the flap and tapered to blend with the thinner, lower margin of the incision. After closure, the location of the umbilicus is confirmed, a vertical incision made, and the umbilicus retrieved and sutured.
If liposuction is necessary to enhance the tummy tuck results, it is usually done in the upper abdomen and to a limited extent in the flanks, keeping in mind that excess fat removal should not be done at the expense of blood supply. Sometimes a two stage procedure, with the liposuction done separately, is necessary or recommended for this reason.