The trauma of suction-assisted lipectomy cannula on flap circulation in rats

Perfusion Dynamics during Secondary Flap Debulking with Liposuction

BACKGROUND

 Lower extremity trauma often necessitates reconstruction with flap transfer. One of the reconstructive goals is a thin soft tissue coverage with appropriate contour. Therefore, a secondary debulking of the flap is usually performed.

METHODS

 Debulking through conventional lipectomy is compared with liposuction followed by excision of the defatted flap excess. Demographic data, surgical details, and postoperative outcomes are compared and analyzed. The perfusion dynamics of the flaps undergoing liposuction debulking are studied by means of perioperative indocyanine green fluorescence angiography, as well as postoperative laser Doppler imaging.

RESULTS

 Patients undergoing lipectomy (n = 69; 57.5%) or liposuction (n = 51; 42.5%) debulking had a similar rate of postoperative complications. Partial necrosis was observed in 7.2% (lipectomy) versus 7.8% (liposuction) of flaps. Fluorescence angiography showed a substantial decrease in flap perfusion following the infiltration with an epinephrine-containing tumescent solution (74.3% ± 8.2% prior to infiltration versus 16.8% ± 7.1% after infiltration; p < 0.001), resulting in a dark flap appearance. Laser Doppler imaging confirmed the hypoperfusion on postoperative day 1.

CONCLUSION

 Secondary debulking of a lower extremity flap can be safely and efficiently performed through liposuction combined with peripheral excision of the defatted flap in a single stage. Perfusion studies may show a misleading hypoperfusion of the defatted flap, which does not accurately predict subsequent necrosis or complications.

Assessment of Tissue Perfusion Following Conventional Liposuction of Perforator-Based Abdominal Flaps

Background

The effect of liposuction on the perforators of the lower abdominal wall has been investigated in several studies. There are controversial results in the literature that have primarily demonstrated the number and patency of the perforators. The aim of this study was to determine the effect of liposuction on the perfusion of perforator-based abdominal flaps using a combined laser–Doppler spectrophotometer (O2C, Oxygen to See, LEA Medizintechnik).

Methods

Nine female patients undergoing classical abdominoplasty were included in the study. Perforators and the perfusion zones of the deep inferior epigastric artery flap were marked on the patient's abdominal wall. Flap perfusion was quantitatively assessed by measuring blood flow, velocity, capillary oxygen saturation, and relative amount of hemoglobin for each zone preoperatively, after tumescent solution infiltration, following elevation of the flap on a single perforator, and after deep and superficial liposuction, respectively.

Results

The measurements taken after elevation of the flap were not significantly different than measurements taken after the liposuction procedures.

Conclusions

The liposuction procedure does not significantly alter the perfusion of perforator-based abdominal flaps in the early period. The abdominal tissue discarded in a classic abdominoplasty operation can be raised as a perforator flap and has been demonstrated to be a unique model for clinical research.

Efficacy of Liposuction as a Delay Method for Improving Flap Survival

BACKGROUND

Flaps are often used in repairing tissue defects and partial or full flap loss is still an important morbidity cause. Several techniques have been tried to increase flap circulation but none of these could replace the delay technique. Our goal in this study is to show the efficacy of liposuction in delay of dorsal rat cutaneous flaps and improvement in flap survival.

METHODS

Twenty-four Wistar rats were used. The rats in group 1 received 9 × 3-sized caudally-based random pattern skin flaps. In group 2, liposuction was done under the tissue island spotted as the flap and after 14 days, standard flap surgery was done. In group 3, surgical delay was done and after 14 days, standard flap surgery was done. In group 4, liposuction was done under the tissue island spotted as the flap and standard flap surgery was done right after the liposuction.

RESULTS

The rate of necrotic tissue in group 3 (surgical delay; mean % 13.7) was less than the rate in group 2 (liposuction delay; mean % 15.1), although the difference was not statistically significant. The necrosis rates in group 3 (surgical delay) and group 2 (liposuction delay) were less than the rates in both group 1 (only flap; mean % 41.5) and group 4 (liposuction flap; mean % 40.0) and this difference was statistically significant (p < 0.0001).

CONCLUSION

Liposuction can be an alternative to surgical delay as a less invasive method in the clinic.

NO LEVEL ASSIGNED

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Free DIEAP and SGAP flap breast reconstruction after abdominal/gluteal liposuction

Perforator flaps are widely used in our unit for breast reconstruction. They provide ample tissue with minimal donor site morbidity together with long lasting aesthetic results. Increasing number of patients may have liposuction procedure which may jeopardise areas such as the abdomen and the buttock which are the donor sites for perforator-free flaps in breast reconstruction. Therefore, liposuction has been considered as a relative contraindication of raising perforator flaps. Six patients who had previous liposuction of the donor sites underwent autologous breast reconstruction with perforator-free flaps. Colour Duplex imaging was obtained in all cases preoperatively in order to evaluate the blood supply to the flap and to map the perforators. There were five deep inferior epigastric artery flaps (DIEP) and one superior gluteal artery perforator (SGAP) flap used. Total flap survival was obtained in all cases. Postoperative course was uneventful. Our results showed that raising perforator flaps after liposuction of the donor sites is possible. Preoperative radiological evaluation of the perforators is mandatory for such difficult cases.

Liposuctioned rectus abdominis myocutaneous flap to cover a vulval skin defect

A woman with genital Paget disease had a reconstruction with a rectus abdominis myocutaneous flap after primary liposuction during operation. The patient recovered satisfactorily.

TRAM Flap Breast Reconstruction After Abdominal Liposuction

The transverse rectus abdominis musculocutaneous (TRAM) flap has become the gold standard of autologous breast reconstruction. It is typically a low-risk procedure with few surgical contraindications. A relative contraindication, however, is prior liposuction of the abdomen. The contention has been that the trauma of the liposuction procedure can damage or destroy the musculocutaneous perforators that supply circulation to the TRAM flap skin paddle. The authors present 2 patients who previously underwent suction-assisted abdominal lipectomy and, after mastectomies, successfully underwent unilateral breast reconstruction using single-pedicle TRAM flaps. They also examine the literature that supports the feasibility of this procedure.

Conventional Liposuction-Assisted Debulking of Muscle Perforator Flaps

Late recontouring of the usual bulky cutaneous flap via conventional liposuction is an accepted practice and usually without fear of tissue necrosis. Muscle perforator flaps, on the other hand, initially depend only on often fragile, minuscule vessels that could readily be traumatized by any form of suction-assisted lipectomy. Single-staged muscle perforator flap debulking was thus performed with some trepidation for 8 flaps in 7 patients. All flaps ultimately remained successful, but in 2 cases obvious tissue ischemia delayed healing. It can only then be assumed that this adjunctive technique places all perforators at jeopardy for injury. Survival of the given flap may then depend solely on neovascularization from the recipient site, and that must be protected to retain pedicle independence, or otherwise flap necrosis would ensue. Thus, the timing of muscle perforator flap debulking could then be critical. Although that averaged 9.1 months (range, 3-15 months) after flap transfer in this series, the observed ischemia occurred at both ends of this spectrum.

Suction lipectomy during flap reconstruction provides immediate and safe debulking of the skin island

Immediate suction lipectomy combined with flap reconstruction has not been reported to date. Concern of skin island compromise has swayed clinicians from attempting synchronous debulking of generous skin island tissue during primary flap reconstruction. To date, several reports have documented the safe use of liposuction during mobilization of skin flaps as a minimally invasive, undermining tool in the cervical neck area. Additionally, liposuction has been used safely as an adjunct to rhytidectomy procedures over areas containing vital structures. The authors report 2 patients in whom generous skin island tissue prevented primary closure after transposition of the flap into its recipient site. Aspiration of subcutaneous tissue in a transverse rectus abdominis musculocutaneous flap and gluteus musculocutaneous rotational flap for breast and sacral ulcer reconstructions respectively resulted in appropriate debulking of the skin island without any flap skin compromise. The findings of this report may provide impetus for further clinical investigations establishing the utility of combined suction lipectomy and flap reconstruction.

The effect of ultrasound-assisted liposuction and conventional liposuction on the perforator vessels in the lower abdominal wall

Scientific reports of clinical in vivo research into the effects and side-effects of ultrasonic-assisted liposuction (UAL) are scarce. Advocates of UAL claim that the damage to vascular and nervous structures is limited and even less than with conventional and/or tumescent liposuction (CL). The effect of tumescent infiltration alone and combined with either CL or UAL was assessed by performing injection studies of the panniculus adiposus of the lower abdominal wall of 20 fresh cadavers and five abdominoplasty specimens. Besides the control and infiltration groups (n=5 in each), there was an additional group of ten cadaver flaps and five abdominoplasty flaps that underwent infiltration followed by UAL in the right half of the flap and infiltration followed by CL in the left half of the flap. Radiographs of these flaps were shown to a blinded panel of ten plastic surgeons, who were asked to evaluate and compare the damage on the basis of the number and magnitude of contrast-medium extravasations in the flap. Vascular damage to the perforating vessels was seen even after infiltration alone, although it was very limited. A variable amount of damage (ranging from little to extensive) was observed in the CL and UAL groups. Statistical analysis of the judgments of the observers could not show that either technique was less damaging than the other. UAL is, therefore, probably more beneficial to the surgeon than to the patient. The financial investment in the device is justified for surgeons with large liposuction practices, mainly, and probably solely, because of the reduced physical strain for the surgeon.

Superficial liposculpture of the face and neck

The capacity to benefit from scar tissue retraction beneath the intact skin has been demonstrated by a number of surgeons working in the superficial fat over the past decade. The efforts to achieve predictable skin retraction have largely overlooked the importance of the mechanism of removal of fat, focusing instead on the depth of the surgical plane and the vacuum pressure utilized. Recent experimental and clinical evidence has pointed out the role of mechanical dislodgment as a key factor in fat removal. A modification of an existing cannula design has been utilized to achieve predictable skin retraction in the face and neck in a series of 75 patients with follow-up from 3 months to 3 years. Facial and cervical flap elevation with this instrument (with or without deep tissue tightening and skin excision) has consistently enhanced results, improving skin tone and facial contours and at the same time diminishing both recovery and operative time. The combination of the technique described and existing techniques such as endoscopic and composite lift approaches may offer enhancement of achievable results.

Suction-assisted lipectomy does not increase the risk of random flap necrosis in a randomized study in pigs

Thirty-two dorsally based random flaps were raised in eight Yorkshire pigs (26-31 kg) after infiltration with 200 mL of dilute lidocaine (0.1%) with epinephrine (1:1,000,000) into each flap. Prior to elevation 16 of the flaps were treated with syringe-assisted liposuction, while the remaining flaps served as controls. One week postoperatively the viability of the flaps was assessed with computer-assisted planimetry of the necrotic area and by measurement of capillary blood flow using radioactive microspheres. The mean area of necrosis was nearly identical in the flaps treated with liposuction and in the control flaps, and there was no statistically significant difference in blood flow between the groups. The results show that liposuction performed with the "super-wet" or "tumescent" technique can be done prior to elevation of flaps in pigs without increasing the risk of flap necrosis.

Circulation of blood and viability after blunt suction lipectomy in pig buttock flaps

Bilateral buttock flaps were raised in 13 Yorkshire pigs, and the viability and superficial blood flow were assessed by injection of fluorescein and laser Doppler flowmetry. One flap was then chosen at random from each pig to be defatted by blunt suction lipectomy. The opposite flap served as the control. Five and 30 minutes after lipectomy, the experimental flaps showed a 31% and 37% decrease in laser Doppler values (p < 0.05 and p < 0.01, respectively), measured 6 cm proximal to the margin of the fluorescein dye. There was no reduction in the values in the controls. One week after liposuction, the median area of flap necrosis in treated flaps was 4,615 mm2 (range 735-6,748) and in controls 4,104 mm (1,576-5,879). This difference was not significant (p = 0.24). Blunt suction lipectomy of the skin flaps did not significantly decrease the viability. The decreased skin circulation shown by laser Doppler soon after lipectomy may be a minor or temporary phenomenon.