INTRODUCTION
Lipoplasty techniques have evolved over the
last century passing through several points of
transmission and advancement from the different
primitive curetting techniques to the recent highdefinition
sculpting [1].
This long path has based mainly on the accurate
knowledge of human anatomy, symmetry, proportions,
different landmarks, and good understanding
of how those landmarks display themselves and
their appearance change with motion [2]; the other
roles which were played by the advent of the
tumescent technique and the development of new
technologies have aided in lipoplasty transmission
from a traditional primitive unrefined fat debulking,
to a form of artistic sculpting [3].
In the recent years, high-definition lipoplasty
has provided the aesthetic surgery an innovative
solution to face the continuous escalated demands
for the toned athletic appearance which can be
achieved via exemplifying in a perfect and a harmonious
manner the balanced anatomical definitions
of the human body [4]; this solution has betted
on the ability of revealing, modifying and creating
controlled deformities [5].
To achieve those abilities and take the superiority
over the traditional lipoplasty; high-definition
lipoplasty was in a need to find a modern chisel
giving the advantage of working in all the subcutaneous
planes not only to debulk unrefined body
contours but also to highlight the superficial musculature
in a safe way to avoid the possibility of
the final aesthetic compromise [6].
In pursuit of finding this modern surgical tool,
Ultrasound-Assisted Lipoplasty (UAL) was advanced
as a less traumatic procedure than the
traditional suction-assisted methods; however the
early reports have declared several complications
related to burns, scarring, unintended contour
deformities and regressed aesthetic results [7].
Third-generation ultrasound lipoplasty device:
VASER (Vibration Amplification of Sound Energy
at Resonance) has taken the place as the enabling
technology to address the superficial and deep fat
layers in an efficient and a safe manner through
cavitation, expanding the clinical application of
the differential lipoplasty in different body regions
with fewer complications [8].
In 2003, a new concept of body contouring has
been introduced and termed as “High Definition
Liposculpture” (HDL) referring to an advanced
sculpting approach that creates a slim athletic
figure and selectively delineate the surface anatomy
of the human body by proportional superficial and
deep fat removal to highlight muscle groups [9].
HDL has been combined with the technological
advancement of VASER which is currently considered
as the gold standard for Liposculpting to
overcome the technical challenge of superficial
sculpting, facilitating refined contouring in delicate
tissues, and achieving advanced three dimensional
aesthetic results with minimal complication rate
[10].
Recent studies have mentioned many advantages
of VASER Assisted HDL (VAHDL) including
shorter operative time than standard liposuction,
less surgeon effort, more advantageous for tight,
fibrous areas where increased blood loss would be
expected, smaller incisions to access different
zones, and selective disruption of relatively weak
adipose tissue with sparing of the surroundings
which can be translated to less bleeding, less bruising,
and rapid recovery [11].
Those advanced aesthetic results of VAHDL
cannot be realized without high level of training,
experience, accurate knowledge and deep understanding
of aesthetic ideals, how the superficial
anatomy influences the external appearance and
the aesthetic contributions made to the human body
by the superficial and deep fat layers [12].
On the other hand, HDL as an advanced surgical
technique which demands superficial plane sculpting
to get the targeted aesthetic results and sometimes
necessitates removal of large amounts of
fats, has been surrounded by a many types of
avoidable complications [13]; acute fluid collection
due to the traumatic irritation of the tissues is one
90 Vol. 44, No. 1 / Appraisal of Closed Active Surgical Drainage
of those common complications which can occur
especially with torso liposculpting and should be
prevented to preserve sculpting results [14].
Hence, the agreed value of surgical drainage
as one of the acute fluid collection preventing
measures which guards the HDL results comes;
however drainage system type remains an issue of
dispute that is still subjected to literature evaluation
[15].
MATERIAL AND METHODS
From April 2016 to March 2019, a prospective
case series study was carried out on 120 VAHDL
patients presented with limited torso areas of fat
accumulation.
Our inclusion criteria has been meshed with
the sculpting purpose by selecting those who presented
with good muscle tone, BMI less than 35,
and without excessive skin laxity.
Besides deep discussion and clear understanding
of patients' wishes; pre-operative assessment of
extra-abdominal torso fat distribution, contribution
made by intra-abdominal one, muscular mass, tone,
skin laxity, and waist contour was done.
Informed consent was obtained from all patients
of the study who were good candidates for VAHDL
according to their expectations and the physical
examination and routine pre-operative laboratory
tests were done.
Pre-operative framing of muscles and anatomical
landmarks, marking of extra fat areas, determination
of negative spaces and transition zones
were done using different colour markers while
the patient in the standing position Fig. (1).
All patients were operated under general anaesthesia
starting with superficial and deep layers
infiltration using the standard solution of 1,000cc
normal saline, 1:100,000 epinephrine and lidocaine
20cc of 1% solution; half of the volume was infiltrated
first into the deep layer followed by the
other half into the superficial one.
Proceeding to the next step of emulsification
after 10 minutes allows the vasoconstrictive effect
to take place, starting with the superficial layer to
be fully treated followed by the deep one rubbing
our 2.9mm or 3.7 probe against muscular layer
with smooth probe movement and turned VASER
system to the continuous mode at the power of 70-
80%; loss of resistance was our clinical endpoint
Egypt, J. Plast. Reconstr. Surg., January 2020 91
and 1 minute per each 100mL of infiltration was
the duration limit of VASER use (30 minutes for
3 litters of solution).
Deep extraction from the deep fatty layer was
done using 3.5mm or 4mm cannula, starting from
the infraumbilical area proceeding to the flanks
and supraumbilical region including the pectoral
area in patients suffering from gynecomastia leaving
a flap of 10mm thickness in the anterior abdomen
and 5mm in the flanks.
By pinching the skin over a 3mm cannula,
superficial framing was done from different access
incision sites Fig. (2) to frame the anterior abdominal
wall anatomical landmarks in varied degrees
taking into consideration patients gender and wishes;
thin flaps were created exactly below the preoperative
framing and following the real muscular
curvatures to sculpt realistic and natural ridges or
indentations.
In males, special attention was given for the
need to define both recti and linea alba more prominently;
three well defined horizontal inscriptions
were done over the tendinous intersections of both
recti in a direct manner sculpting from several
access points using curved cannulas treating the
superficial layer and later proceeding more deeply.
Criss-crossing from different access sites was done
to produce a natural tonal progression from the
grooves to the convex surfaces.
VASER pulsed mode was used after suction
at the power of 40-60% using a 2.9mm probe to
treat the delicate regions and other areas of skin
laxity.
Superior and umbilical incisions were closed
using subdermal sutures and closed suction drains
(Surgivac) were left in the lower dependent incisions
for 2 to 5 days (amount less than 50cc per
day) together with the use of mild-compression
garment for at least 4 weeks. Post-operative followup
was scheduled at 1, 4, 8, 12 and 24 weeks for
all patients.
RESULTS
The age of the patients ranged from 21 to 45
years; with female predominance (75 cases) representing
62.5% and BMI from 25 to 35. Overall
satisfactory result has been achieved in 105 patients
representing 87.5% with higher satisfactory rate
among male patients. Complication rate was 25.8%
(31 cases) with unequal distribution among variety
of possible lipoplasty complications (Table 1).
Fig. (1): Pre-operative farming and marking using different
colour markers.
Fig. (2): Access incision sites.
Table (1): Post-operative complications.
Complication
Seroma
Edema & induration
Pigmentation
Port-site burn
Distant burn
Sensory change
Contour irregularity
Skin laxity
Under correction
Overcorrection
Infection
Bleeding
Skin necrosis
Chronic edema
Male
1
–
1
–
1
2
2
1
3
1
–
–
–
–
Female
1
2
2
1
–
3
4
3
2
1
–
–
–
–
Total
2
2
3
1
1
5
6
4
5
2
–
–
–
–
92 Vol. 44, No. 1 / Appraisal of Closed Active Surgical Drainage
Fig. (3): (A) Pre-operative frontal view of male patient 37 years old, (B) Post-operative frontal view of the same
patient after torso VAHDL, (C and D) Pre-operative and post-operative lateral views of the same patient.
Fig. (4): (A,C) Pre-operative frontal and lateral views of female patient 35 years old, (B,D) Post-operative frontal
and lateral views of the same patient after torso VAHDL and augmentation mammoplasty.
Egypt, J. Plast. Reconstr. Surg., January 2020 93
Fig. (5): (A) Pre-operative frontal view of female patient 32 years old, (B) Post-operative
frontal view of the same patient after torso VAHDL and buttocks fat injection,
(C,D) Pre-operative and post-operative lateral views of the same patient.
Fig. (6): (A) Pre-operative frontal view of male patient 40 years old, (B) Post-operative
frontal view of the same patient after torso VAHDL, (C,D) Pre-operative and postoperative
lateral views of the same patient.
94 Vol. 44, No. 1 / Appraisal of Closed Active Surgical Drainage
Closed drains have enabled the current study
to accurately record both the range and average
values of the drainage volumes over the first postoperative
5 days (Table 2), Chart (1) and the timing
of drain removal among the patients (Table 3).
experience by the good planning, attention to
details, skillful execution and well oriented postoperative
care which optimizes the results of the
work and helps to get the desired outcomes [18].
Seroma with its classic definition of postoperative
inflammatory exudate collection in the
subcutaneous tissues at the operative bed due to
tissue trauma, burn, irritation or lymphatics breakdown
represents one of the most encountered hindrances
for good sculpting results [19]; absolutely
this complication has an elevated rate with the
obese patients, large amounts of fat debulking and
extensive subcutaneous sculpting [20].
VAHDL has achieved high sculpting results
and a dropped rate of seroma formation referring
to the adopted lower BMI of the HDL which means
less amounts of fat debulking and the valuable role
of the VASER technology which reduces blood
loss, tissue edema and promotes skin retraction
[21].
There is a wide consensus about the important
role of the surgical drainage and the continuous
compression as effective methods that minimize
the rate of this complication [22].
Most of the previous studies have depended on
the dependent open drainage with wide variations
in the reported rate of seroma formation; many
regards were mentioned about the need for frequent
dressing change with this type of surgical drainage
[23]. Current study has betted on the closed active
drainage (Surgivac) for the patients who have
developed seroma at a rate of 1.6% (2 cases).
This complication was detected by the 5th to
the 7th post-operative day usually in the lower
abdomen and outer aspects of the thighs. Diagnosis
was done by the clinical examination and all were
managed successfully within 2 to 3 weeks by the
repeated needle aspirations under sterile precautions
followed by adequate compression; there are no
resistant or chronic cases.
Many advantages, closed active drainage has
achieved in the current study; it eliminates the
dead space, prevents fluid accumulation, enables
accurate volume recording, eliminates the need for
frequent dressing change, achieved less postoperative
pain, ecchymosis, time needed for wearing
compression garments and gives more advanced
results than the other studies that adopt open drainage
regarding seroma formation and rapid recovery
of post-operative edema and unmasking of sculpting
aesthetics.
Table (2): Range and average drainage volumes.
1st day
2nd day
3rd day
4th day
5th day
Highest Vol
450cc
180cc
130cc
95cc
60cc
Mean Vol
310±36cc
110±21cc
65±16cc
50±12cc
35±5cc
Lowest Vol
220cc
50cc
40cc
30cc
25cc
Chart (1): Range and average drainage volumes.
500
450
400
350
300
250
200
150
100
50
0
Drainage volume in CC
1st day 2nd day 3rd day 4th day 5th day
Highest Lowest Mean
Table (3): Timing of drain removal among patients.
2nd day
3rd day
4th day
5th day
Timing of removal Patients percentage
15%
45%
30%
10%
Discussion
High definition liposculpting employs advanced
surgical techniques and a highly demanding step
of extensive superficial sculpting which greatly
affect the final aesthetic outcome [16]; these important
points make HDL not a suitable procedure to
be done by the inexperienced surgeons and should
be done only by the surgeons who have prolific
work in conventional lipoplasty [10].
HDL aesthetic outcome depends mainly on the
well defining of the muscle groups and creating
blended controlled irregularities which can be
compromised by a variety of intraoperative and
postoperative complications [17]; those complications
can be avoided next to the surgeon high
Egypt, J. Plast. Reconstr. Surg., January 2020 95
On the otherhand the problem of the clogged
drains in few numbers of the patients has faced
and the risk of tissue injury from the suction force
remains a theoretical possibility.
Edema, induration and ecchymosis can be anticipated
as transient reactions of the human tissues
to the trauma produced by the cannula which usually
respond to the conservative measures within
4 to 8 weeks with complete return to the normal
appearance after 12 weeks [24].
In the current study, two patients representing
1.6% have developed post-operative edema and
induration within the first week that were managed
successfully with optimum compression.
A thorough pre-operative evaluation of the
coagulation profile, liver and platelets functions,
pre-operative stoppage of the antiplatelet medications,
usage of adrenaline in the tumescent solution,
blunt tipped small cannulae together with the postoperative
adequate compression have prevented
hematoma development in the patients as one of
the possible post-operative complications.
Many authors have reported infection rate less
than 1% that usually occurs as a direct consequence
of the secondary bacterial infection of the postoperative
hematoma or uncontrolled diabetes [24].
This study has adopted besides the basic principles
of infection control and sterilization, routine
pre-operative blood sugar measurement for all
patients, strict perioperative glycemic control for
diabetic patients, perioperative smoking stoppage,
and post-operative prophylactic antibiotics; those
measures have nullify the infection rate in our
patients.
The complication of the skin hyperpigmentation
has been reported in several studies with wide
variation in the incidence due to the hemosiderin
deposition from ecchymosis [25]; three cases in the
study representing 2.5% have developed this complication,
they have been managed successfully
with conservative measures.
Skin necrosis is another possible complication
that occurs as a direct consequence of the subdermal
vascular plexus damage which has an increased
incidence in chronic smokers, with sharp cannulae
usage and with aggressive liposuction [19]; this
type of complication has not occurred in our patients.
Five patients representing 4.1% have suffered
from transient hypoesthesia which represents one
of the very common neurologic sequels of liposuction
and liposculpture operations.
Other complications are the port-site and distant
burns; both types were superficial and have faced
us in two patients which have been managed conservatively.
Secondary procedures were required
for 3 patients to correct contour irregularities,
residual skin laxity and localized residual fat deposits.
Conclusion:
High definition liposculpting is a highly demanding
aesthetic surgery that can achieve advanced
results only by the highly experienced
surgeons.
It has provided the aesthetic surgery an innovative
solution to face the continuous escalated
demands for the toned athletic appearance.
It has been combined with the technological
advancement of VASER to overcome the technical
challenge of superficial sculpting with minimal
complication rate.
One of those avoidable common complications
that surround Torso HDL is the acute fluid collection;
it should be prevented to preserve sculpting
results.
There is an agreed value about the role of the
surgical drainage in preventing the acute fluid
collection and preserving the sculpting results.
Most of the previous studies have depended on
the dependent open drainage with many regards
about the need for frequent dressing change with
this type of surgical drainage.
Current study has done an appraisal on the
closed active drainage as a more convenient substitute
for torso HDL patients.
Closed active drainage in spite of the problem
of the clogged drain, still has the ability to achieve
many advantages regarding effective prevention
of seroma formation, elimination of the frequent
need for dressing change, enables accurate drainage
volume recording, less postoperative pain, ecchymosis,
time needed for wearing compression garments,
rapid recovery of post-operative edema and
unmasking of sculpting aesthetics.
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