**2.5 Liposculpting**

Historically, early liposuction was little more than large bore tubes used to remove conduits of fat. Because tumescent anesthesia had not been discovered yet, some of those patients exsanguinated from blood loss, had significant contour irregularities and skin sloughs. While these are all possible risks of modern liposculpting, they are very rare because of the techniques and technologies currently employed.

LipoSculpting is both an art and a science. After the tumescent anesthesia has taken effect, and lack of sensation to painful stimuli removed, it is helpful to establish a surgical plane through the fat for suction cannula passage using a cannula without suction or a multi-holed, non-suction, fat shifting/emulsifying cannula (Blugerman or cheese grater style). This 3-5 mm blunt tipped cannula should be introduced through the same insertion sites and pushed parallel to the skin surface. The "dumb" hand pushes and pulls the cannula through the compartment. It should travel easily through the fatty layers and not pushed with enough force to penetrate through the skin or fascia. The "smart" hand feels and directs the cannula through the tissue and monitors the thinning of the fat compartment. A thumb slot in a cannula handle indicates that the majority of openings at the tip are on the other side. This helps orient the cannula so as to not overly rasp the undersurface of the skin and cause unnecessary scaring, slough or erythema ab igne.

Cannulas come in every configuration and size desired. They are generally attached via a disposable suction tube, to glass or disposable canister which is attached to a vacuum pump that generates 15-25 mm Hg vacuum. There are both manual cannulas and power assisted oscillating, rotary or vibrating cannulas. Decreasing the cannula size, number of openings in the tip and decreasing the suction, all decrease effect and vice versa. Once the treatment areas are tunneled and a surgical plane designed, suction cannula(s) are used to sculpt the underlying fat to reveal the desired anatomic contours available. The aspirate should generally be yellow to orange, indicating that there is hemostasis in that area. Presuming one has stayed in the plane of subdermal adiposity, excessive aspirated blood noted would be a reason to stop rasping that area, potentially infuse more tumescent fluid into the area to help with hemostasis and discomfort and hold direct pressure on the area briefly to assure hemostasis ensues.

Viewing the sculpted form from the head and feet, overhead, at table level and sitting or standing the patient up to see how the tissue contours due to gravity is helpful to assure desired contours and symmetry.

Once sculpting is completed, the patient is cleaned and dried, any overly traumatized insertion sites are loosely closed (leaving some open to drain by gravity or any drains placed).

A compression garment of 10-20 mm Hg that covers both the sculpted and immediately adjacent areas to help blend their contours rather than tourniquet or indent the treated tissue is applied. It has an opening that can be pulled forward or back in the crotch area for hygiene, rather than grommets to release and has side zippers to allow easy changing or the absorbent pads applied over the insertion sites without taking the garment fully off or down. The garment is left in place and supports the patients blood pressure by preventing rapid third spacing until the tissues start to reattach in the first few days. Thereafter, the garment can be worn primarily when the patient is awake and removed during sleep for 4–6 weeks, at which point the tissues should have reattached well, softened and seromas resolved or drained early on (sometimes with ultrasound guidance and sometimes just by palpation when the patient is standing). The patient is offered fluids, and they are observed until they meet discharge criteria-alert enough to cooperate, minimal nausea, good hemostasis, no orthostatic vital signs and an adult to drive them home and supervise them as any sedation wears off. Contact information and instructions including medication use and pad changes are verified and follow up visit time and date is reviewed with the responsible person who is picking the patient up and staying with them that night. A call in a few hours to verify patient comfort and review instructions and medications is helpful. Many physicians put patients on broad spectrum anti-biotics starting 1–3 days pre-op and continuing for 5–10 days post op. Others give just a gram of Ancef or similar at the start of the case. Lipo-sculpting is at best a clean, rather than sterile procedure because of all the movements the patient makes during the procedure. That said, the use of oral antibiotics, anti-microbial soap use at home for several days pre-op, surgical prep of the treatment areas, use of bacteriostatic tumescent fluid, sterile instruments etc., and dedicated OR or procedure rooms, make infection quite rare. An inexpensive single (parting) dose of Gentamicin 5 mg/kg IM in an ASA 1–2 patient with normal kidney and ear function is performed by some physicians as well [3–5].

## **2.6 Drains**

Drains are not usually required in straight lipo cases but may be utilized when combined with skin excision or abdominoplasty cases, even small Penrose drains that only stay in for a few days may decrease the risk of seromas and the resulting "woody" areas of healing.

### **2.7 Ancillary procedures**
