1. Introduction
Today self-image is largely influenced by self-perception; a small waist diameter has become a matter of concern to both women and men such that many people with various concerns including aesthetic and functional bodily issues are increasingly seeking surgical intervention (Achauer et al., 2000). As a consequence, new techniques have been implemented in the aesthetic field of plastic surgery and have increasingly improved the long-term post-operative results, providing greater patient satisfaction.
Body contouring is defined as a procedure(s) that involves the removal of excess subcutaneous fat and skin; it mainly consists of liposuction with or without an open surgical method to correct body deformities. In addition, filler injections, implants and autologous fat grafting (Appendix 1) into areas which require volume enhancement are evolving constituents of body contouring and have been carried out for the purpose of liposculpture.
The population of weight loss patients has risen as a result of current progress in bariatric surgery (Appendix 1) (Thorne, 2006). This has subsequently increased the number of people seeking aesthetic body contouring procedures following massive weight loss to reach their desired figure. This in itself has encouraged researchers to develop more advanced techniques to overcome many of the body dysmorphic complications faced by overweight patients after gastric banding and gastric by-pass operations.
(This section is authored by: Zain Bukamal & Ash Mosahebi)
2. History of liposculpture
Liposculpture was originally introduced and successfully carried out at the onset of the twentieth century; however, a French surgeon, Dr Yves-Gerard Illouz, was the first to perform a safe, modern liposuction procedure (Sterodimas et al., 2012) in 1982, alongside his fellow French surgeons Dr Pierre Fournier and Dr Francis Otteni (Thorne, 2006).
For the past century, abdominoplasty has been described by many surgeons, using various surgical techniques aimed to improve outcomes and lessen complication rates. Limited dermolipectomy (i.e. excision of excess adipose tissue and skin, mainly in the abdomen) was first reported in France by two French surgeons in 1890: Demars and Marx (Shiffman and Mirrafati, 2010).
In 1899, a gynaecologist, Kelly, reported performing the same procedure in the USA for the first time in John Hopkins Hospital, Baltimore (Shiffman and Mirrafati, 2010).
3. Patient selection
The appropriate selection of patients for liposuction and body contouring is a vital factor in achieving a favourable aesthetic outcome. The patient’s target outcome of a desired procedure(s) should be assessed by the surgeon; thereupon, an explanation of which procedure is possible to carry out and which is not should be given to the patient (Thorne, 2006).
After assessment, some patients will require liposuction alone while others may also require an open surgical intervention as a consequence of differing body fat proportions and differing amounts of excess subcutaneous tissue and residual skin.
When it comes to determining whether a patient is suitable for body contouring, particularly those who have experienced massive weight loss, it is crucial to assess the patient’s past history. Major weight fluctuation in the period prior to body contouring is a risk factor for regaining weight following the procedure (Thorne, 2006). Smoking, too, is an important consideration in body contouring because of the resultant compromised blood supply at operative sites. Smoking patients are at an increased risk of tissue necrosis; they are therefore asked to abstain from smoking for at least 2 weeks pre-operatively and 2 weeks post-operatively in order to prevent vascular compromise.
Patients who are considered poor candidates for body contouring surgery (Table 19.1) include ‘idealists’ with undetectable body deformities, those with eating disorders who present with severe depression and, finally, those who are extremely overweight and have consistently failed to reduce their weight.
Ideal patients for a good aesthetic outcome (Table 19.1), on the other hand, are those who have maintained a stable weight for at least 6–12 months, those following an effective diet and exercise routine, and those within 20% of their ideal weight or above chart weight by up to 50 lb (22.7 kg) (Thorne, 2006). The patient’s general health status should be considered an integral part of the overall pre-operative assessment to determine whether the patient is sufficiently fit for anaesthesia. Body contouring procedures, particularly for patients who have experienced massive weight loss, are usually performed under general anaesthesia when more than one body part is targeted.
Therefore, the patient’s co-morbidities are addressed and managed prior to surgery in order to avoid concurrent post-operative complications.
A stable pre-operative weight has, again, been shown to reduce the risk of complications after body contouring surgery compared with variable and unstable body weights (van der Beek et al., 2011). This concept is more applicable to massive weight loss patients who have been previously overweight or obese; however, stable weight maintenance before body contouring is a key consideration for all patient groups in general.
Table 19.1. Patient selection: descriptions of an ideal patient and a poor candidate for body contouring.
| Ideal candidate | Poor candidate |
| Stable weight for at least 6–12 months | ‘Perfectionists’ with undetectable body deformities |
| Following an effective diet and exercise routine | Eating disorder problems with severe depression |
| Within 20% of his/her ideal weight | Extremely overweight, unable to lose excess weight |
| Above chart weight by 50 lbs (22.7 kg) |
4. Pre-operative marking
Pre-operative measurement of excess skin in the area being prepared for surgery and incision markings on skin should be carefully undertaken prior to body contouring surgery to ensure a better surgical outcome. Measurement of the excess tissue is estimated by pinching, and later by marking, the lines to be used for resection to indicate where the lines can be re-connected after excision of the excess skin and tissue.
The use of a permanent marker pen by the surgeon to mark the operative areas is an integral part of almost every pre-operative anaesthesia plan. Anatomical landmarks are often used to plan the marking of incisions because they provide accurate measurements of the area to be excised and can also predict the width of the post-operative scar. The markings are usually done with the patient positioned standing with the aim of creating surgical scars at the lowest level possible so that they can eventually be hidden by underwear (in the cases of abdominoplasty and circumferential body lift) (Vico et al., 2010a).
5. Tumescent anaesthesia
Anaesthetic practice in plastic surgery has evolved over time since the introduction of the tumescent technique in 1987 (Dhami and Agarwal, 2006) to yield a number of intra- and post-operative advantages over traditional anaesthesia. Initially, it was indicated as a means of anaesthesia for liposuction procedures; however, its popularity has expanded into other surgical fields including breast, vascular, and ear, nose and throat surgery (Conroy and O’Rourke, 2013).
Tumescent anaesthesia, also known as the ‘wet technique’, describes the local infiltration of an extensive amount of solution containing a low concentration of local anaesthetic, adrenaline and sodium bicarbonate (Conroy and O’Rourke, 2013).
Adrenaline provides the vasoconstriction required to reduce bleeding at the operative site, while sodium bicarbonate is added to neutralise the acidity of the local anaesthetic, mainly lidocaine, therefore reducing pain at the injection site. This type of local anaesthesia has the advantage of covering a large area of subcutaneous adipose tissue.
As previously stated, the tumescent technique has proven main advantages, including:
- Considerable reduction in intra- and post-operative bleeding rates.
- Easy tissue dissection (Davila and Garcia-Doval, 2012).
- Avoidance of risks associated with general anaesthesia.
- Decreased systemic uptake of the employed anaesthetic due to a higher local concentration at the operating site (Thorne, 2006).
Additionally, this technique has exhibited minor tissue oedema during the course of post-operative healing (Dhami and Agarwal, 2006).
