Tumescent Solution Research Articles

Novel Forehead Augmentation Strategy: Forehead Depression Categorization and Calcium-Hydroxyapatite Filler Delivery after Tumescent Injection

The minimally invasive delivery of soft-tissue calcium hydroxyapatite fillers can ameliorate the appearance of forehead depressions and wrinkles. Forehead augmentations using fillers lead to fewer adverse events and to a faster recovery time than those using surgical procedures. However, many physicians avoid using them due to the risk of pain, intravascular injections, and embolisms that can cause skin necrosis and blindness. Strategy to address these issues includes pain reduction through tumescent solution before filler injection considering the vascular pathway. In addition, the strategy is also safer from embolism. The author presents a forehead augmentation technique involving the injection of a tumescent solution for tissue hydrodissection. Not only does this create a pocket of space (TS) for filler placement, it also allows the physician to detect bleeding and prevent vessel compromise It is better to minimize the number of entry-points where no vessel exists. By minimizing the number of entry-points and physical proximity to vessels and nerves during injection, this technique reduces the risks of embolization and bleeding. For optimal, patient-customized results, the author also classifies forehead depressions in 5 different categories, depending on the severity, shape, contour, slope, and quantity of volume deficiency observed. The author treated 218 patients using the author's forehead augmentations (using one central entry-site after TS test injection). The method was easy to perform and safe from adverse effects such as vascular problem, irregularity, infection, and prolonged swelling. Using this simple technique, I demonstrate how calcium hydroxyapatite fillers can be injected with little force or dilution, thus preserving its original properties while increasing procedural safety, minimizing pain, restoring convexity, and creating ideal curvatures.

Abstract: The Impact of N-Acetylcysteine on Autologous Fat Graft - First-in-Human Pilot Study

The aim of this pilot study was to determine whether N-acetylcysteine (NAC) administered at the fat graft donor site during the harvest procedure reduces oxidative stress and thus, improves graft survivability. The study included 15 women with mean age of 31.8 years (range, 23–39 years). A 200-ml adipose tissue graft was harvested from each thigh in each study subject. The procedure of graft harvesting from one thigh, considered as the control (n=15), included infiltration with a standard tumescent fluid. During harvesting the graft from the other thigh, a tumescent fluid containing NAC (Sandoz, Holzkirchen, Germany) was used (NAC group, n=15). Plastic surgeon who conducted the procedure was blinded to the type of administered fluid. All patients were followed-up for 6-months for potential adverse events associated with administration of the modified tumescent fluid. A 65-ml adipose tissue sample from each graft was subjected to immediate and postponed biochemical analysis, flow cytometric assay and Quantitative Real-Time Reverse Transcription Polymerase Chain Reaction (qRT-PCR). The rest of the graft was used for correction of breast asymmetry, to determine the degree of fat resorption based on the comparison of pre- and postoperative MRI findings (separate study). During biochemical tests, the severity of oxidative stress was determined based on the levels of reactive oxygen species (ROS) and nitric oxide (NO), along with the concentration and activity of superoxide dismutase (SOD). qRT-PCR analysis included targets linked with oxidative stress (GPX-3, hsCAT, hsSOD, iNOS, HO-1), angiogenesis (VEGF, ANG-2) and adipogenesis (PPAR-γ, C/EBP β). Normal distribution of the study variables was verified with Kolmogorov-Smirnov test. Intragroup comparisons were carried out with Wilcoxon signed-rank test. All calculations were conducted with Statistica 10 (StatSoft, Tulsa, OK, USA), with the threshold of statistical significance set at p<0.05. Neither local nor systemic postoperative complications were observed in the study subjects during a 6-month follow-up. Concentration of SOD in the NAC group turned out to be significantly higher than in the controls, in both fresh (p=0.041) and frozen samples (p=0.004). Also SOD activity in NAC group was significantly higher, both in fresh and frozen samples (p=0.023 and p=0.003, respectively). Interestingly, no statistically significant intergroup differences were observed in terms of ROS levels. The level of NO in frozen samples from the controls was significantly higher than in NAC group (p=0.009). The only qRT-PCR target showing significant intergroup differences was iNOS (encoding inducible NO synthase), with higher transcription levels observed in the controls (p=0.027). The results of this study imply that addition of NAC to tumescent solution may counteract oxidative stress the cells of autologous fat graft are exposed to during the harvesting procedure. This may contribute to lesser volume of the graft that undergoes resorption over time (the study is still ongoing). The lack of adverse events after the infiltration of the fat graft donor site with NAC-enriched solution suggests that this technique is safe. If addition of NAC was shown to improve the retention of the graft, this technique might become a routine adjunct method used during this type of procedures.

Sub-muscular Breast Augmentation Using Tumescent Local Anesthesia.

Tumescent local anesthesia (TLA) consists of infiltration of saline solution with lidocaine and epinephrine into the tissues to obtain regional anesthesia and vasoconstriction. The use of TLA in augmentation mammoplasty has been described for sub-glandular positioning. We describe a modified TLA technique for primary sub-muscular breast augmentation reporting our experience during the past 7years. From 2010 to 2017, 300 patients underwent bilateral primary sub-muscular breast augmentation under TLA and conscious sedation. The tumescent solution was prepared with 25mL of 2% lidocaine, 8mEq of sodium bicarbonate, and 1mL of epinephrine (1mg/1mL) in 1000mL of 0.9% saline solution. Firstly, the solution was infiltrated between the pectoral fascia and the mammary gland, secondarily, during surgery, under the pectoralis major muscle. The average amount of tumescent solution infiltrated while performing TLA was 740mL per breast. No signs of adrenaline or lidocaine toxicity were reported and conversion to general anesthesia was never required. In all patients, no pain nor discomfort was reported during the pre-operating infiltration and surgical procedure. We reported a major complication rate of 3.3% (4 hematomas and 6 seromas) and a minor complication rate of 6.0% (8 implant dislocation and 10 dystrophic scars formation). TLA represents a safe and efficacious technique for performing breast augmentation surgery with sub-muscular implant positioning. This technique guarantees good pain control during and after surgery and has low incidence of postoperative side effects. Patients subjected to sub-muscular breast augmentation with TLA were satisfied. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evaluation of Postoperative Residual Analgesia of Two Solutions Used for Local Anesthesia By Tumescence In Bitches who Underwent a Unilateral Mastectomy

Background: Breast tumors are common and require surgical treatment. A mastectomy causes edema, inflammation, and moderate to severe pain; therefore, analgesics should be used efficiently during the trans- and postoperative periods. Tumescence anesthesia has been studied in veterinary medicine; however, there is limited literature on the comparison of the constituents of the different solutions and the most suitable protocol. The objective of this study was to evaluate the residual postoperative analgesia of two solutions through the Melbourne, Modified Glasgow for dogs (EGM), and Visual Analogue (EVA) scales in bitches who underwent a unilateral mastectomy.Materials, Methods &amp; Results: Twelve bitches, weighing between 5 and 15 kilograms and aged between 5 and 13 years old, were included in the study. To determine if the animals were medically fit to undergo the procedure, they were evaluated by clinical examination, laboratory testing (complete blood count, serum biochemistry [urea, creatinine and alanine aminotransferase/ALT], and imaging (thorax x-ray and abdominal ultrasonography). Patients were randomly divided into two groups. One group received a lidocaine-containing tumescent solution (GTL) that consisted of 210 mL of lactated Ringer's solution (at a temperature between 8 and 12°C), 40 mL of 2% lidocaine hydrochloride without vasoconstrictor, and 0.5 mL of adrenaline (1 mg/mL). The other group received ropivacaine (GTR) with 233.3 mL of lactated Ringer's solution (at the same temperature as the previous group’s), 16.7 mL of ropivacaine (7.5 mg/mL), and 0.5 mL of adrenaline (1 mg/mL). Both groups received a combination of acepromazine (0.04 mg/kg) and meperidine (2 mg/kg) as preanesthetic medication (MPA), followed by induction using propofol (to effect) and maintenance using isoflurane. The solutions were infused subcutaneously (SC) 5 min after stabilization of the anesthetic plane. For the mastectomy, the solutions were distributed throughout the mammary chain to be withdrawn, starting at the thoracic and abdominal regions and ending in the inguinal region. In the postoperative period, the animals were evaluated using three different scales (Melbourne, Glasgow modified for dogs [EGM], and Visual Analogue [EVA] scales), at six time points: one, two, four, eight, 12 and 24 h after extubation, or until the time of analgesic rescue when the animal presented with a score higher than 3.33 on the EGM scale. There were no statistical differences between the groups (P &gt; 0.05) in any of the scales evaluated; however, most of the animals demonstrated analgesic rescue in the first hour of evaluation. GTR showed an additional rescue compared to GTL.Discussion: Analgesic rescue occurred in the first hour of the postoperative period. This differs from other studies that used morphine in MPA and observed higher analgesia. This occurred because meperidine, the drug used in the study, has a shorter duration and is a less potent analgesic than morphine. We opted for this opioid because of its minimal interaction with the drug used in MPA and to better identify the residual effect of the administered solution. In addition, it does not interact with the other drugs used in the anesthetic protocol. It is known that the tumescence technique prolongs the analgesic effect of MPA because of subcutaneous absorption of a portion of the injected solution adjacent to the area being operated on. However, this was not observed as 50% of the animals in each group were rescued during the first hour of the evaluation. From this study, it was concluded that the tumescent solutions used in the trans-operative period should not be expected to have analgesic effects during the postoperative period of mastectomies because of the short duration of action.

Anesthesia in outpatient phlebology practice

Tumescent and/or conductive anaesthesia is the most frequently performed procedure to anesthetize the thermal types of surgical interventions, mini-phlebectomy and stripping of subcutaneous veins in outpatient settings. These interventions have become a common outpatient procedure almost everywhere, which made the issue of local anaesthesia more sensitive over the past 5 years in Russia. The aim is to compare the efficacy, safety and comfort when injecting various anaesthetic solutions to relieve pain during endovenous laser obliteration/radio frequency catheter ablation, stripping of the subcutaneous veins and mini-phlebectomy. Searching method. We searched for original articles in PubMed, in the archives of «Phlebology» and «Angiology and Vascular Surgery» journals issued for the period between 2001 and November 2018 and the search for official instructions in the state register of medicinal products. Selection criteria. We included all comparative studies: randomized and non-randomized, in which pain was assessed both during injection of a tumescent solution before EVLO and/or mini-phlebectomy and during surgery, as well as systematic reviews and monographs. Data analysis. In total, we identified 9 studies: 7 randomized and 2 non-randomized, one systematic review and two monographs. The advantage of a buffered solution over unbuffered one in terms of reducing pain during injection is revealed in three randomized, one simple comparative study and on the basis of systematic review data. A great efficacy of combining tumescent anaesthesia with a femoral nerve blockade, which was equivalent to spinal anaesthesia, was found in 4 randomized trials, two of which were double-blind, and one non-randomized. In addition, a smaller degree of motor block was reported after blocking the femoral nerve in comparison with spinal anaesthesia. In one randomized trial in which pain was assessed using cold and warm solutions, no significant differences in pain were observed either during or after surgery. In order to prepare a tumescent solution, lidocaine, prilocaine and mepivacaine were used at concentrations ranging from 0.028% to 0.2%; the advantages of higher concentrations over the lower ones have not been revealed. No adverse reactions and complications of anaesthesia have been reported in the studies, except for one where methaemoglobinemia of mild degree was detected in a small number of patients when using 0.2% prilocaine. The conclusion. Local anaesthesia, namely, conductive and tumescent anaesthesia, is an effective and safe anaesthesia method in outpatient surgery. Even very low concentrations of anaesthetic solutions are effective for tumescent anaesthesia. The use of buffered solutions increases significantly patient comfort during the injection. The combination of tumescent anaesthesia and femoral nerve block increases the effectiveness of anaesthesia. The femoral nerve block has significant advantages in comparison with spinal anaesthesia in terms of safety.

Modified Tumescent Solution for Creating Working Space During Endoscopic Thyroidectomy.

To study the feasibility of gas-liquid mixing tumescent solution for creating a working space (WS) in endoscopic thyroidectomy (ET). A prospective study was performed on 186 patients with thyroid tumor who had undergone ET via chest and breast approach. Patients were randomly divided into 2 groups to receive traditional tumescent solution as group A and modified tumescent solution (gas-liquid mixing tumescent solution) as group B. This study compares the following surgical outcome parameters between the 2 groups, including changes of blood pressure, heart rate, and oxygen saturation before and after creating a WS, time for creating a WS, operative time, hemorrhage volume for creating a WS, overall hemorrhage volume, overall postoperative drainage volume, postoperative pain score, postoperative hospitalization, number of retrieved lymph nodes, total serum calcium, serum parathyroid hormone, and cases of transient and permanent recurrent laryngeal nerve palsy. No postoperative bleeding, permanent recurrent laryngeal nerve palsy, incision and surgical site infection, air embolism, flap injury occurred in both groups. The mean time for creating a WS and the whole operation in group B was significantly shorter than that in group A ( P < .05). There were no statistically significant differences in both groups in terms of other observation index ( P > .05). The clinical application of gas-liquid mixing tumescent solution can effectively reduce the time for creating a WS and whole operative time, and worthy of being widely used in ET as a safe and effective technique.

Volume of 4% sodium bicarbonate required to remove pain in tumescent anaesthesia for endovenous laser ablation of saphenous veins: a randomized, double-blind, controlled trial

Background: Sodium bicarbonate in tumescent anaesthesia for endovenous laser ablation (EVLA) of saphenous varicose veins is underused. Objective: To find the volume of 4% sodium bicarbonate required to significantly reduce intraprocedural pain. Methods: Tumescent solution ingredients were determined by recalculating concentrations based on the Klein solution and was titrated to a slightly alkaline pH by buffering with 4% sodium bicarbonate. The outcome variable was the level of intraprocedural pain measured with a visual analogue scale. Results: In total, 74 patients undergoing EVLA were randomized to receive either buffered solution at pH 7.1 (group A) or buffered solution at pH 6.63 (group B). Median pain scores (interquartile range) were significantly lower in patient group A than in group B (0.65 (0.2-1.38) versus 1.65 (0.87-3.5), p<0.01). Conclusions: These results show that tumescent anesthesia for EVLA of saphenous veins is less painful if the local anesthetic is buffered prior to its infiltration. Nonetheless, the buffering may be inadequate. We advise adding 143 mL of 4% sodium bicarbonate to 1000 mL 0.08% lidocaine so that the pH of the solution is increased to 7.1 and the intraprocedural pain is reduced significantly.

Treating pain on skin graft donor sites: Review and clinical recommendations.

Split-thickness skin grafting is the most common reconstructive procedure in managing burn injuries. Harvesting split-thickness skin creates a new partial thickness wound referred to as the donor site. Pain at the donor site is reported to be one of the most distressing symptoms during the early postoperative period. Here, we (a) identify strategies for managing donor site pain, (b) assess the quality of individual studies, and (c) formulate evidence-based recommendations based on the amount and consistency of evidence. Our analysis revealed five distinct approaches to minimize donor site pain. These include: continuous subcutaneous local anesthetic infusion (three studies), subcutaneous anesthetic injection (five studies), topical agents (six studies), nonpharmacological interventions (three studies), and wound dressings (18 studies). Available randomized control trials typically evaluated pain on standardized scales (i.e. Visual Analog Scale, Numerical Rating Scale), and compared the experimental group with standard care. Recommended treatments include: (a) subcutaneous anesthetic injection of adrenaline-lidocaine; (b) ice application; (c) topical agents, such as lidocaine and bupivacaine; and (d) hydrocolloid- and polyurethane-based wound dressings accompanied with fibrin sealant. Methodologically sound randomized control trials examining the efficacy of modified tumescent solution, ropivacaine, plasma therapy, noncontact ultrasound, and morphine gels are lacking and should be a priority for future research.

Effects of Tumescent Solution on Fat Survival.

AbstractAutologous fat transfer is a commonly used procedure in plastic surgery practice. The long-term survival rate of fat grafts is the most important issue for satisfactory results. The presented study includes the effects of different tumescent solutions on long-term fat graft survival. A total of 24 rats were divided into four groups: sham, lidocaine, adrenaline, and lidocaine + adrenaline groups. In all groups except the sham group, right inguinal fat pad was harvested 10 minutes after injecting 5 cc of the appropriate tumescent solution. The fat pad was trimmed and reimplanted to the interscapular area. After 3 months, fat pad was reharvested and sent for histopathologic evaluation. The harvested fat grafts were weighted in both surgical sessions. A significant difference was observed in comparison of fat grafts weights between the initial operation and the postoperative third month (p = 0.002). By intergroup comparisons, a significant difference was observed between sham and adrenaline groups (p = 0.002) and between sham and lidocaine + adrenaline groups (p = 0.007). No statistical difference was observed by the comparison of TUNNEL results (p = 0.663). The histopathologic evaluation of the specimens revealed similar results between groups. The injection of tumescent solutions containing only lidocaine before fat harvesting yields similar long-term fat graft survival rates in comparison to the conduction of surgical procedure without injecting any tumescent fluid. However, the injection of solutions containing adrenaline with or without lidocaine may decrease the long-term survival rates of fat autografts.

A refined surgical treatment modality for bromhidrosis: Subcutaneous scissor with micropore.

Axillary bromhidrosis has a strong negative effect on one's social life. A high success rate and few complications are criteria for a surgical treatment. The objective of this study was to evaluate a new surgical treatment modality for bromhidrosis: subcutaneous scissor with micropore. Twenty patients with bromhidrosis were treated. Patients were placed in a supine position with their treated arms abducted to 110°. After injection of 60 mL of tumescent solution into each axilla, one small incision was made at the middle axillary of the hair-bearing area. The whole hair-bearing skin was undermined at the level of the superficial fat to obtain adequate skin eversion. The flaps were everted to offer full exposure of the apocrine glands, and meticulous excision of each gland was performed. Both sides were punctured with scalpel. The micropore was used for drainage, and whose width was just 3 mm. Finally, the incisions were re-approximated, and bulky compressive dressings were applied to the area for 72 hours. Of the 40 axillae (20 patients), 34 (85.0%) showed excellent results, and six (15.0%) had good results. Malodor was significantly decreased. There were no serious complications. This technique can produce excellent results with a lower complication rate than most other surgical modalities and can be performed without costly equipment.

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

BackgroundThe 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).MethodsNine 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.ResultsThe measurements taken after elevation of the flap were not significantly different than measurements taken after the liposuction procedures.ConclusionsThe 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.

Low osmolality and shear stress during liposuction impair cell viability in autologous fat grafting

Liposuction and subsequent autologous fat grafting have become essential techniques for fat augmentation in plastic surgery. However, standard harvesting techniques that ensure the survival of adipocytes and stromal vascular fraction (SVF) cells and thus preserve the transplanted fat volume are lacking. In particular, the effect of different parameters of the tumescent solution has not been studied in this context. We hypothesized that the osmolality of the tumescent solution could have a significant effect on the survival of adipocytes and SVF cells. We developed two distinct invitro models based on freshly harvested excision fat from patients undergoing surgical treatment. First, we investigated the effect of osmolality by incubating excision fat in different tumescent solutions and analyzed the total cell survival and the differentiation potential of SVF cells. Vital whole-mount staining, isolation yield of SVF cells, clonogenicity, and osteogenic and adipogenic differentiation capacities were analyzed. Second, we addressed the additional effect of mechanical stress by simulating a liposuction on pieces of excision fat after incubation with the tumescent solutions. Osmolality of the tumescent solution by itself did not have a significant effect on adipocyte and SVF viability or SVF differentiation. However, when osmolality was combined with liposuction, a significant trend toward lower viability and more lipid droplets with lower osmolality was observed. Especially, SVF viability was significantly lower after liposuction with a hypotonic (150mOsm/kg) solution. This study demonstrates the considerable effect of osmolality during liposuction and may lead to the development of "cell-protective" tumescent solutions.

Immediate liposuction could shorten the time for endoscopic axillary lymphadenectomy in breast cancer patients

BackgroundEndoscopic axillary lymphadenectomy (EALND) was introduced to clinical work to reduce side effects of conventional axillary lymphadenectomy, while the lipolysis and liposuction of EALND made the process consume more time. The aim of the study was to determine whether immediate liposuction after tumescent solution injection to the axilla could shorten the total time of EALND.MethodsFifty-nine patients were enrolled in the study, 30 of them received EALND with traditional liposuction method (TLM), and the rest 29 patients received EALND with immediate liposuction method (ILM). The operation time, cosmetic result, drainage amount, and hospitalization time of the two groups were compared.ResultsThe median EALND operation time of TLM group and ILM group were 68 and 46 min, respectively, the difference was significant (P < 0.05); the median cosmetic results of the two groups were 6.6 and 6.4, respectively; the median drainage amount of the two groups were 366 and 385 ml, respectively; the hospitalization time of the two groups were 15 and 16 days, respectively. For the last three measures, no significant difference was confirmed (P > 0.05).ConclusionsOur work suggests immediate liposuction could shorten the endoscopic axillary lymphadenectomy process, and this method would not compromise the operation results. However, due to the limitations of the research, more work needs to be done to prove the availability and feasibility of immediate liposuction.

Commentary on: Exposure to Tumescent Solution Significantly Increases Phosphorylation of Perilipin in Adipocytes

Commentary on: Exposure to Tumescent Solution Significantly Increases Phosphorylation of Perilipin in Adipocytes

Blunt Blade Subcision: An Evolution in the Treatment of Atrophic Acne Scars.

Subcision is the mainstay of atrophic acne scar treatment but the efficacy and safety of the procedure is controversial. To improve the efficacy of the subcision procedure, a blunt subcision blade was designed and evaluated. Eighteen patients with bilateral atrophic acne scars considered eligible for subcision were enrolled. Before subcision, a tumescent solution was injected subdermally to anesthetize the treatment area and aid the dissection of the dermal-subcutaneous tissue. Patients underwent treatment using the blunt subcision blade, a long metal blade with gradually narrowing edges, and a rounded blunt tip. Early postoperative complications, overall aesthetic improvement and persistent discoloration, or lumpiness were assessed 7 days after subcision and at a 6-month follow-up visit. Moderate to marked improvement of atrophic scars was observed in 15 cases (83.3%). Mild to moderate tenderness, periorbital ecchymoses, and swelling were reported by some patients, but resolved completely within 1 week after the procedure. No cases of persistent discoloration or lumpiness were observed at the final visit. The blunt blade subcision procedure is suggested as an effective method for the treatment of atrophic acne scars.

Symptomatology and Surgical Perspective of Scar Endometriosis: A Case Series of 16 Women.

The prevalence of scar endometriosis is increasing with the increasing caesarean deliveries and laparoscopic procedures done for pelvic endometriosis. To analyse the symptomatology and surgical perspective of scar endometriosis. Retrospective review of 16 women who underwent surgery for scar endometriosis in the period of 4years in Amrita institute of medical sciences. Mean age of the patients is 35.19years. Mean interval from the index surgery to the presentation is 4.56years. Mean size of the swelling is 2.84cm. In 68.8% of the patients, caesarean section was the inciting surgery. 18.7% had port site endometriosis. Cyclical pain and swelling at the scar site was present in 93.8% of the women. 18.9% had concurrent pelvic endometriosis. All women had involvement of the subcutaneous tissue followed by 11 women with the involvement of rectus sheath. There was no recurrence of the lesion in the operated patients in the mean follow-up period of 11.91months. In all women presenting with cyclical scar site pain and swelling, scar endometriosis should be considered. It commonly follows caesarean section and laparoscopic surgeries done for endometriosis. Wide local excision with or without reconstruction is the method of choice for this condition. Role of tumescent solution during surgery and postoperative medical management to reduce recurrence needs further prospective studies.

Commentary on: Exposure to Tumescent Solution Significantly Increases Phosphorylation of Perilipin in Adipocytes.

The article “Exposure to Tumescent Solution Significantly Increases Phosphorylation of Perilipin in Adipocytes” indicates that the significant increase in this phosphyrylation process may have an effect on fat graft survival.1 This particular topic surfaces from time to time, and in the present report the authors showed that adipocytes collected before tumescent infiltration demonstrated that 10% of total perilipin was phosphorylated versus nearly 31% when tumescent solution was used. Since phosphorylation of perilipin renders the adipocyte more vulnerable to lipolysis, the authors recommended that the lowest possible concentrations of lidocaine and epinephrine be used. Why wouldn’t the explanation of these changes in phosphylation be increased because of …

Exposure to Tumescent Solution Significantly Increases Phosphorylation of Perilipin in Adipocytes.

Lidocaine and epinephrine could potentially decrease adipocyte viability, but these effects have not been substantiated. The phosphorylation status of perilipin in adipocytes may be predictive of cell viability. Perilipin coats lipid droplets and restricts access of lipases; phospho-perilipin lacks this protective function. The authors investigated the effects of tumescent solution containing lidocaine and epinephrine on the phosphorylation status of perilipin in adipocytes. In this in vitro study, lipoaspirates were collected before and after tumescence from 15 women who underwent abdominoplasty. Fat samples were fixed, sectioned, and stained for histologic and immunohistochemical analyses. Relative phosphorylation of perilipin was inferred from pixel intensities of immunostained adipocytes observed with confocal microscopy. For adipocytes collected before tumescent infiltration, 10.08% of total perilipin was phosphorylated. In contrast, 30.62% of total perilipin was phosphorylated for adipocytes collected from tumescent tissue (P < .01). The tumescent technique increases the relative phosphorylation of perilipin in adipocytes, making these cells more vulnerable to lipolysis. Tumescent solution applied for analgesia or hemostasis of the donor site should contain the lowest possible concentrations of lidocaine and epinephrine. LEVEL OF EVIDENCE 5.

On Beyond Lidocaine: Reconsidering Local Anesthetics in Tumescent Liposuction-A Critical Review.

The use of tumescent solution in liposuction is now considered standard of care; however, much debate still exists regarding its ideal components, especially surrounding the inclusion of local anesthetics. This article reviews the discussion regarding the use of local anesthetics in tumescent liposuction and how it may evolve in the future. The need for local anesthetic additives in tumescent liposuction has been questioned, and the use of longer-acting agents discouraged; however, increasing number of reports in recent years have described the increasingly widespread use of tumescent anesthesia where a wetting solution is infiltrated to achieve anesthesia in an operative field for procedures other than liposuction. More high-level evidence, such as randomized controlled clinical trials, will be required; however, it should be possible to develop a useful standardized algorithm that can guide surgeons to optimize patient safety as well as patient experience.

Utilizing the Power of Fat Grafting to Obtain a Naturally-Appearing Muscular "6-Pack" Abdomen.

Liposuction of the male abdomen can be a very challenging. If undertreated, any of several techniques can leave a less than satisfying result showing little if any improvement. With more aggressive generalized suction of the area, the patient can be left with irregularities, loose residual lower, and excess infraumbilical soft tissue and skin. In the modern age of fitness, we find that patients are increasingly interested in a fitter, more sculpted look with greater definition to the abdominal musculature. Currently we are experiencing a “golden age” of plastic surgery body contouring with new innovations by thought leaders, including fat grafting, which are completely raising the bar of postoperative results that can now be delivered to the patients in terms of appearing youthful and sculpted yet natural.1 Previous techniques involving abdominal contour including selective fat reduction or “sculpting” have been limited in terms of inability to achieve muscular appearance in patients with very little muscular bulk to the rectus abdominis.2,3 Furthermore, abdominal muscle enhancement with silicone has been equally disappointing due visible incisions, an unnatural appearance, technical difficultly, lack of implant availability, and increased infection rate. Here we present the senior author's (D.S.S) technique for achieving superior results in abdominal contouring using selective lipo-contouring with fat grafting. The technique may be used with general anesthesia, local anesthesia with sedation, or simply local anesthesia. All markings are done with the patient standing prior to any sedative administration. Anatomic asymmetry is noted. The patient is brought in the operating room placed in the supine position after circumferential betadine prep. Stab incisions are made after injection of 2% lidocaine with epinephrine and tumescent solution (0.9% saline with lidocaine 0.1% and epinephrine 1:1,100,000) is introduced into the areas to be suctioned. Three stab incisions are made in the underwear line to …