FAT AND THE SUBCUTANEOUS LAYER in .NET framework

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CHAPTER 3 FAT AND THE SUBCUTANEOUS LAYER
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LIPOSUCTION COMPLICATIONS While there have been reports of mortality with general anesthesia, there have been no reports of death with tumescent anesthesia alone When practitioners adhere to the AACS and ASDS guidelines, tumescent liposuction is a safe outpatient procedure Common complications are bruising, swelling, localized paresthesia, and irritated incision sites after liposuction Other complications include hematomas, seromas, and infection There are serious complications that the surgeon must be aware of, however, such as the development of a fat embolus,
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TABLE 3-3 Synopsis of 2006 ASDS Guidelines of Care for Tumescent Liposuction Indications Aesthetic body contouring: most common regions include thighs, abdomen, hips, arms, back, buttocks, neck, breasts, and calfs Other indications: treatment of lipomas, gynecomastia, lipodystrophy, axillary hyperhidrosis, axillary bromidrosis, and subcutaneous fat debulking during reconstructive procedures Preoperative evaluation History: diet patterns, exercise, unwanted regions, underlying disorders such as poor wound healing, bleeding abnormalities, diabetes mellitus, keloid formation, problems with past surgical procedures, personal or family history of thrombophlebitis, pulmonary emboli, and drugs that may interfere with blood coagulation or the metabolism of lidocaine Explanation: procedure, risk and bene ts, expected outcomes, needing a touch-up procedure Physical examination: assessment of both general physical health and speci c sites amenable to liposuction Laboratory studies: may or may not be necessary for a given patient depending on the type and extent of anticipated liposuction procedure Some surgeons may wish to obtain CBC, PT, PTT, LFT, UA, pregnancy test, screening for HIV, hepatitis B, and hepatitis C Technique Tumescent Anesthesia: consists of very dilute lidocaine and epinephrine solutions ranging from 005% 01% of lidocaine with epinephrine (around 1:1,000,000), sodium bicarbonate and / triamcinolone Volume removal Removal of more than 4 L of supranatant fat should be divided into more than one operative session Monitoring: pulse oximetry, cardiac monitoring, and intermittent monitoring of BP, HR, and RR Postoperative care Use compression garments for 1 to 4 wk
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visceral perforation, pneumothorax, deep vein thrombosis, congestive heart failure, and lidocaine toxicity Fortunately, these complications are very rare during tumescent liposuction The relative skills and experience level of the operating physician represent important contributing factors to the incidence of adverse events from liposuction Careful patient selection is the key to a successful outcome Younger patients, those with good skin tone, and those close to their ideal weight tend to be the best candidates Poor patient selection may lead to the development of rippling or poor skin contraction
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VOLUME LOSS
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Normal Aging
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The aging face shows characteristic changes, many of which were once solely attributed to the effects of gravity on skin, muscle, and fat It is for this reason that the main approach to the aging face was to lift and reposition ptotic tissue However, we now recognize that there are complex changes occurring in which volume loss is a significant contributor These changes include muscle atrophy, bone resorption, and fat atrophy There are some well-designed studies that look at the bony changes of the face and the change in the malar fat pad with time The results of these studies show that the lower midfacial skeleton becomes retrusive with age relative to the upper face34 Study authors speculate that the skeletal remodeling of the anterior maxillary wall allows soft tissues to be repositioned downward thereby accentuating the nasojugal fold and malar mound In a different study, some of the same authors describe the increasing incidence of a negative vector face as one ages35 A negative-vector patient is one in whom the bulk of the malar fat pads lies posterior to a line drawn straight down from the cornea to the orbital rim With this change, the lower eyelid fat pads appear more prominent but are not truly hypertrophied In a magnetic resonance imaging (MRI) study by Gosain et al the deepening appearance of the nasolabial fold with age seems to be a combination of ptosis and fat/skin hypertrophy 36 They found a difference in the redistribution of fat within the malar fat pad by age, with older women exhibiting a relatively increased thickness of the midportion of the malar fat pad and overlying skin compared to younger females More interestingly, they did
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not find an increase in the length or projection of the levator labii superioris muscle between young and old subjects A more recent cadaveric study considered the fat distribution of the face37 The authors found distinct facial fat compartments and subdivisions within these areas The malar fat pad is composed of three separate compartments: medial, middle, and lateral temporal cheek fat The nasolabial fold was uniformly a discrete unit with distinct anatomic boundaries and little variation in size from one cadaver to the next The forehead also consisted of three anatomic units: central, middle, and lateral temporal cheek fat Orbital fat is noted in three compartments determined by septal borders However, the superior orbital fat did not connect to the inferior orbital fat The jowl fat is the most inferior of the subcutaneous fat compartments and was found to be closely associated with the depressor anguli oris muscle One of the easiest ways for a cosmetic surgeon to begin to understand these changes in patients is by evaluating photographs of the patient both in youth and at the time of presentation for a consultation This can be seen in the works of surgeons that have performed a great deal of volume restoration surgeries over the years38,39
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variation in these techniques probably accounts for why some surgeons find success with this modality and others do not achieve long-lasting results42 Factors that influence survival of fat after injection include the anatomic sites of harvesting and placement, the degree of mobility in the recipient area, the vascularity of the recipient tissue, and the overall health and age of the patient43 We found that fat aspirated from the lateral thigh lasts longer than fat taken from the abdomen Even during harvesting, one will find a noticeable difference in the quality of the fat between the two areas The fat of the upper arms, inner thighs, and abdomen tends to be softer and contain less connective tissue Fat from the lateral thigh tends to be more dense and fibrous Furthermore, placement of the fat into the tissues is critical to ensure viability Adipocytes require a healthy and vascular bed in which to engraft For this reason, fat must be placed in small parcels and in multiple layers, including in and under muscles The less movement in the recipient site, the more that fat survives Therefore, the malar and infraorbital areas do well while the nasolabial folds and lips require touch-ups to achieve the desired effect
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