Tumescent simply means to place fluid and specific substances or medications within the fatty cells, which will help to hydrate and help to remove the fat in a uniform and consistent pattern.  The technique and tumescent liposuction usually includes using three components:  1) the wetting solution, either lactated ring or normal saline solution.  This solution can be infiltrated with a Kline needle infiltrator hooked up to a pressurized bag which will then allow once again for a uniform removal of fat in the deep fat deposit areas.  The fat should usually be removed from the deeper fat layer, staying away from the subdermic which could increase risk of contour irregularities and deformities of the skin.  The second component is Lidocaine.  One percent Lidocaine, 40 cc, is often placed with the tumescent liter per liter of fluid and this helps to relieve pain up to 24 hours or more.  The third component is epinephrine.  Epinephrine is simply a vasoconstrictive agent which causes blood vessels to constrict thereby reducing bruising and bleeding.  Epinephrine is often used 1 cc per 1:1000 part per 1 liter of normal saline or lactated ringer.

We have used the tumescent liposuction technique over the last 13 years without complications.  It is an extraordinarily safe approach.  We do not usually place more than 3.5 to 4 liters at any time of wetting solution in our patients.  Dr. Linder prefers to stage large body sculpting techniques rather than to take the risk of using high amounts of epinephrine, lidocaine or excessive amounts of wetting solution fluids.  We perform our liposuction technique using the tumescent technique under general anesthesia.  By placing the patient under general, they are completely immobilized, intubated on a respirator and the plastic surgeon can do his or her work without consideration of patient movement.  Movement on the abdominal wall can be very severe which could lead to perforation of the abdominal wall with intestinal perforations. 

Liposuction technique using the tumescent approach is safe and certainly the gold standard in the United States.

Below is the extremely interesting case of a patient who is now four weeks postoperative for augmentation mammoplasty as well as abdominal contouring as well as thigh liposculpture at six months of age undergoing radiation therapy for neuroblastoma of the gastric or stomach region.  The patient on preoperative photograph has loss of fatty tissue and some muscle development along the left lateral wall.  The umbilicus is shifted to the left.  She was very disturbed in her clothes through the years of the extra fat along the iliac crest roll or hip lower flank area as well as the periumbilical lower abdomen and epigastric area which rolled up upon her pants.  She also is very unhappy with the gynoid appearance of her lower third showing severe lipodystrophy of both the inner and outer thigh in a pear-like figure.  The patient underwent abdominal CT scan showing no fascial defects or hernias on the abdominal wall along the right side of the umbilicus and therefore she was safe to undergo tumescent liposuction of the epigastric right area and the hip as well as of course to sculp the thighs. 

The patient underwent augmentation mammoplasty procedure with a 210 cc saline implant through the subpectoral periareolar approach as well as tumescent liposuction removing over 1.2 liters of fat of the periumbilical, right hip, lower flank and contouring of the inner and outer thighs. 

The patient is ecstatic with her results.  Most importantly, when she wears her clothes and pants, the fat no longer rolls up above the jean line.  She underwent the Linder Bi-directional Flank Liposuction Technique, both in the vertical and oblique plane on the right hip and smoothed out the lower epigastric area.  The thighs are beautifully contoured and she cannot be happier.

This is an extremely interesting case as a young six-month old with a very rare tumor of a stomach.  She had undergone cobalt and radiation therapy which caused necrosis and complete atrophy of the left abdominal wall.  It is always a challenge, but it is very pleasing to be able to help patients not only with cosmetic appearance, but certainly the functional impairments that they have throughout their everyday lives.

Recently played both on the East and West Coast, was a special segment on Cellulite and Celebrities with Cellulite. Dr. Linder acts as a consultant for Entertainment Tonight. He discussed issues on cellulite with patients and celebrities and specifically that there really are no surgical corrections for cellulite, including liposuctioning or non-invasive procedures. Diet and exercise may be helpful, but prevention and maintaining a healthy lifestyle is most important.

The segment on Entertainment Tonight included Linder Bi-Directional Liposuction Technique using both 4 and 3 mm triple lumen Mercedes cannulas and localized deep fat deposit areas of the upper iliac crest roll in order to remove the gene roll fat in both the vertical and oblique planes by using the 4 mm deep and the 3 mm triple lumen Mercedes tip cannula around the superficial in both the transverse, vertical and oblique fashion to contour the hips nicely and reduce the upper bulkiness above the gene line. The video on the media page is up for your review. Hope you find it entertaining as well as interesting, as this has been a successful procedure that Dr. Linder performs weekly on his patients.

Dr. Linder describes a technique that he uses which includes bi-directional liposuctioning and a vertical and oblique plane in the iliac crest roll/hip areas.  He has found this approach using 3 mm small cannulas under tumescent technique, under general anesthesia, suctioning in two levels of Camper’s and Scarpa’s fascia with a 4 mm cannula in the deeper Scarpa’s fascia both in an oblique and vertical manner and then with a smaller 3 mm cannula in the superficial fat layer as well in a vertical and oblique bi-directional pattern.  This has reduced that muffin top above the jean line and allowed women to have a more elegant, softer contour of the lower flank hip region and less bulkiness above the jeans and the jean riding area.  This will be showcased on Entertainment Tonight/CBS at 7:00 p.m. on May 13, 2010.  Dr. Linder is proud to work with Entertainment Tonight as a correspondent on issues and techniques in body sculpting procedures for women.

The upper pole compression band is another form of a garment that helps to reduce upper pole fullness.  It also allows the implants to be inferiorly displaced, reducing upper pole fullness that is unnatural, and is useful for lowering of the implant immediately postsurgically. 

Abdominal binders are used on abdominoplasty and tumescent lipectomy lipo-sculpted patients.  These are worn for at least six weeks, if not longer.  This allows for reduced swelling and edema.  It also helps to reduce pain and discomfort.  When contouring the thighs, girdles are usually worn that can be from the hip area or above the hip area, if the upper abdominal area is suctioned, down to the mid-thigh region or down to the knee, as necessary. 

These compression garments may also be used on mastectomy patients of course, which helps to provide support and maximum compression after recovery.  The material should be soft, often combinations of Spandex as well as cotton.  This will reduce irritation and abrasion.  Normally, the compression garments are worn continuously for a prolonged period of time in order to maintain shape of the implants postoperatively and prevent malposition of the implants.

This patient is a 60-year-old healthy female who desired to have liposuction of her midriff area, abdominal area, hips, flanks, as well as her inner and outer thighs.  She is an excellent candidate.  She underwent tumescent liposuction procedure under general anesthesia with approximately 2.2 liters of aspirate fat removed with a 3 mm triple lumen Mercedes cannula.  She has worn an abdominal binder and girdle for six weeks for compression therapy and now has an excellent result.  Please note her testimonial below.  Also, review her before and after photographs showing good skin retraction after surgery, even at the age of 60.

Dear Dr. Linder,

You Made a difference.

I sincerely would like to thank you for taking care of my liposuction needs. I am on top of the world with happiness and a renewed self-confidence.

Sincerely,

J. M.

Los Angeles, California

COMBINATION PLASTIC SURGICAL PROCEDURES

INDICATIONS

Patients present to us for body sculpting procedures every week.  Some patients are excellent candidates for combination surgical procedures, including breast surgery as well as abdominoplasty and/or liposuction as well as lipo contouring of the thighs.  Initially, we must make sure the patient is in good health, that there are no significant systemic diseases, including high blood pressure, diabetes, asthma or anemia.  The patient having multiple procedures over the age of 40 should be cleared with a history and physical from a general internist, as well as receive a 12-lead EKG and a full set of labs.  Labs should include coagulation panel in order to check for clotting, a CBC which will include white count and hematocrit as well as a beta HCG may be performed in order to check for pregnancy and an HIV test.  If the patient is medically stable and healthy, she may undergo combination procedures.   

The example here shows a breast augmentation with a mini abdominoplasty and lipo contouring of the hips.  Surgery time is approximately two hours performed under general anesthesia with a Board Certified Anesthesiologist.  The patient is now two months postoperative.  The implants have settled nicely and the contour of her lower abdomen is excellent. 

Other factors important when considering combination procedures include length of time in surgery (in general, Dr. Linder performs surgery in less than five hours) and the amount of anticipated blood loss.  Patients who are healthy certainly can undergo combination surgical procedures with safe, predictable and excellent results.

TOTAL BODY MAKEOVER AFTER GASTRIC BYPASS SURGERY
BEVERLY HILLS

One of the most exciting challenges of plastic surgery for Dr. Linder is reconstructing the entire mid torso, breasts and abdominal area after patients have had massive weight loss.  The above patient flew in from Idaho, having had a gastric sleeve surgical procedure over one year ago performed.  She at the time weighed approximately 300 pounds, has lost over 180 pounds and is now 120 pounds with massive amounts of skin on the breasts and abdominal area.  She was an excellent candidate for a combination of formal mastopexy using the inferior pedicle Wise-pattern technique and abdominoplasty or panniculectomy.  She also had lipo contouring of her thighs.  The photographs show the patient now at three weeks postoperative.  Her before pictures show the nipple areolar complex with grade III ptosis way below the inframammary fold, but notice that she has a tremendous amount of tissue.  Although there is a lot of skin, she has good volume and therefore an implant was not placed.  Rather, a formal inferior pedicle Wise-pattern technique breast lift was performed using the so-call “anchor scar.”  The abdominoplasty was performed with an extensive tummy tuck, dissecting all the way up to the ribcage, removing all the extra skin both above and below the umbilicus.  Three-week postoperative results are shown and sutures have now been removed. 

The challenge of post-bariatric surgery patients for breast reconstruction and paniculectomies is quite amazing and the results are often quite spectacular.

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Tumescent liposuction requires installation of fluid into the area to be sculpted.  Three components of fluid are 1) lactated ringer or sodium chloride wetting solution; 2) epinephrine to reduce bleeding causing vasoconstriction of blood vessels; and 3) an anesthetic such as local 1% Lidocaine, which will allow for numbing up to 24 hours.

Post liposuction, we always use compressive garments.  For the abdomen, we use abdominal binders.  For the thighs, we use girdles, which will allow for compression for 6 to 8 weeks and allow for a smoother postoperative contour with reduction of swelling and edema.

Tumescent liposuction performed by Board Certified Plastic Surgeons in an accredited ambulatory center under general anesthesia on patients who are good candidates with good skin tone in the specific designated areas will achieve an exceptional result.