Fluid management in extensive liposuction: A retrospective review of 83 consecutive patients.

Tumescent anesthesia makes it feasible to perform liposuction in an office setting. There are often patients who desire extensive liposuction on approximately 30% of total body surface area, which means the potential of fluid overload. In this study, the charts of 83 patients undergoing extensive liposuction were retrospectively reviewed. The intra-operative fluid ratio was 1.66 for the extensive liposuction. There were no episodes of pulmonary edema, congestive heart failure exacerbation, or other major complications. The average urine output in the operating room, the recovery room, and while on the floors was 1.35, 2.3, and 1.4 mL/kg/hour respectively. Intravenous (IV) fluid administration during operation was minimized to approximately 300 to 500 mL. The total volume of IV injection was also reduced to less than 1500 mL when the patient was in the recovery room and on the hospital floor. Our fluid management strategy in extensive liposuction reflects minimal risk of volume overload. Foley catheters are not applied and patients could resume oral intake in usual, so they can discharge after 6 hours of recovery room stay in our daily practice.

Intralesional injection of adipose-derived stem cells reduces hypertrophic scarring in a rabbit ear model.

INTRODUCTION: Redundant collagen deposition at sites of healing dermal wounds results in hypertrophic scars. Adipose-derived stem cells (ADSCs) exhibit promise in a variety of anti-fibrosis applications by attenuating collagen deposition. The objective of this study was to explore the influence of an intralesional injection of ADSCs on hypertrophic scar formation by using an established rabbit ear model. METHODS: Twelve New Zealand albino rabbits were equally divided into three groups, and six identical punch defects were made on each ear. On postoperative day 14 when all wounds were completely re-epithelialized, the first group received an intralesional injection of ADSCs on their right ears and Dulbecco's modified Eagle's medium (DMEM) on their left ears as an internal control. Rabbits in the second group were injected with conditioned medium of the ADSCs (ADSCs-CM) on their right ears and DMEM on their left ears as an internal control. Right ears of the third group remained untreated, and left ears received DMEM. We quantified scar hypertrophy by measuring the scar elevation index (SEI) on postoperative days 14, 21, 28, and 35 with ultrasonography. Wounds were harvested 35 days later for histomorphometric and gene expression analysis. RESULTS: Intralesional injections of ADSCs or ADSCs-CM both led to scars with a far more normal appearance and significantly decreased SEI (44.04 % and 32.48 %, respectively, both P <0.01) in the rabbit ears compared with their internal controls. Furthermore, we confirmed that collagen was organized more regularly and that there was a decreased expression of alpha-smooth muscle actin (α-SMA) and collagen type Ι in the ADSC- and ADSCs-CM-injected scars according to histomorphometric and real-time quantitative polymerase chain reaction analysis. There was no difference between DMEM-injected and untreated scars. CONCLUSIONS: An intralesional injection of ADSCs reduces the formation of rabbit ear hypertrophic scars by decreasing the α-SMA and collagen type Ι gene expression and ameliorating collagen deposition and this may result in an effective and innovative anti-scarring therapy.

Safe extensive tumescent liposuction with segmental infiltration of lower concentration lidocaine under monitored anesthesia care.

Tumescent anesthesia makes it feasible to perform liposuction in an office setting. There are often patients who desire extensive liposuction on approximately 30% of total body surface area, which means the lidocaine total dose might be over the dosing recommendation. So the segmental infiltration is applied, although the concentration of lidocaine in tumescent fluid is gradually reduced to 0.0252%. Moreover, supplemental intravenous (IV) sedation using monitored anesthesia care is usually applied concurrently to help alleviate discomfort and pain of the patients during tumescent anesthetic infusion and fat extraction which in turn increases the risks of potential lidocaine toxicity due to possible drug interactions. This study was to demonstrate the safety of segmental infiltration of tumescent fluid with lower lidocaine concentration combined with IV sedation in extensive liposuction and determine whether the risk of lidocaine toxicity is increased in this protocol. Ten female patients who requested the extensive liposuction participated in the study. The targeted areas were divided into 2 segments and treated in turn in 1 session. Lidocaine (1600 mg) was infiltrated into the first segment, and approximately 928 mg lidocaine was subsequently infiltrated after accomplishment of the first segment operation. Serum levels of lidocaine were taken every 4 hours during the first 24 hours after the second infiltration. The average time of the procedure is 222 (33) minutes. The dose and total amount of lidocaine injected are 40.7 (5.8) mg/kg and 2528.2 (155.2) mg, respectively. The total volume of the infusates and aspirates are 9918.1 (494) and 6325 (1461.6) mL, respectively, the ratio of total infusates to total aspirates is 1.66 (0.45). The total aspirated fat and fluids are 3280 (1051.8) and 3045 (824.1) mL, respectively. The peak lidocaine levels [2.18 (0.63) µg/mL] occurred after 12 to 20 hours [16.4 (2.27) hours]. No significant correlation between dose per kilogram body weight or total dose of lidocaine infiltrated and its peak levels or time existed. The extensive liposuction covering the 30% total body surface areas was well tolerated by the patients under tumescent anesthesia in combination with the supplemental IV sedation. Our previous study on the fluid management has demonstrated the risk of hypovolemia or fluid overload is very low with this technique, although the patients who received only maintenance fluid (500 mL) in the operating room and could discharge and resume oral intake after 6 hours of recovery room stay. The adequate anesthesia support is available in our office-based setting with adequate recovery facilities in place. It has a high margin of safety, without increasing of lidocaine toxicity or adverse cardiopulmonary sequelae while using a segmental tumescent infiltration with lower concentration of lidocaine.

Reconstruction of lymph vessel by lymphatic endothelial cells combined with polyglycolic acid scaffolds: a pilot study.

Restoration of lymphatic drainage using lymph vessels or tissue grafting is becoming an efficient method for alleviating obstructive lymphedema. However, the lack of ideal lymphatic grafts is the key problem that limits the application of lymphatic transplantation, but now that may be resolved with tissue-engineered lymph vessels. In this study, the feasibility of reconstructing lymph vessels was explored using lymphatic endothelial cells (LECs) combined with polyglycolic acid (PGA) scaffolds. The highly purified human dermal LECs can be isolated from human dermis by immunomagnetic bead sorting and multiplied in culture. The viability and growth potential of subcultured LECs make it possible to obtain large amount of cells in vitro. Light and scanning electron microscopy (SEM) showed that the prefabricated PGA scaffolds, with three-dimensional structure, can support cell adhesion, growth and spreading. The constructs formed with LECs combined with PGA scaffolds were cultured in vitro for 10 days and then implanted subcutaneously into nude mice. Six weeks after implantation, the portions of implanted tubules were harvested. Gross and histological observation demonstrated that the tubular structure still remained in the experimental groups but not in the control groups. Immunohistochemical staining and RT-PCR assay of the implanted vessels revealed positive staining in experimental groups for the lymphatic specific markers Podoplanin, VEGFR-3 and LYVE-1. The results indicate that LECs can serve as seed cells and be successfully combined with PGA scaffolds, and the tissue-engineered tubular structure using implanted LECs-PGA compounds showed preliminary characteristics of lymph vessels. A gap between the nearly normal or functional lymph vessel still exists as we have only the endothelial cell-lined duct, but this study demonstrates that it is feasible to construct tissue-engineered lymph vessels using LECs combined with a biodegradable material.

[Interstitial high-resolution MR lymphangiography in patients with lower extremity lymphedema].

OBJECTIVE: To assess the feasibility of interstitial magnetic resonance lymphangiography (IMRL) with intracutaneous injection of gadobenate dimeglumine--a commercially available, non-ionic, extracellular paramagnetic contrast agent. METHODS: We studied 10 patients with lower extremity lymphedema. A mixture of 7.5 ml gadobenate dimeglumine and 0.5 ml 2% lidocaine were evenly subdivided into 8 portions and injected intracutaneously into each web space of both feet. For IMRL, a 3D fast spoiled gradient-recalled echo T1-weighted images with a fat saturation technique (T1 high resolution isotropic volume excitation, THRIVE) was performed. RESULTS: The beaded appearance of lymphatic vessels extending from the injection site were detected in 11 of 12 lower legs and the best delineation of lymphatic vessels was present at 15-30 minutes after injection. In 6 of 12 affected thighs, lymphatic vessels could be also visualized with the strongest enhancement at 45 minutes. CONCLUSION: IMRL is a safe and technically feasible new method which can effectively visualize the pathological lymphatic vessels in lower extremity lymphedema.

[Experimental study of gene therapy with human vascular endothelial growth factor-c in lymphedema].

OBJECTIVE: To study the efficacy of gene therapy with human vascular endothelial growth factor-c (VEGF-C) on obstructive lymphedema. METHODS: Two animal models of lymphedema were created: one in the right hind limb of adult New Zealand white rabbits and the other in SD mouse tail. Each model was randomly divided into two groups to receive intradermal injection of either VEGF-C gene (experimental group), or saline(control group). In rabbit model, the volume change of affected limb was measured. In mouse model, biopsy was performed after 3 weeks treatment to detect the expression of VEGF-C mRNA and proteins. The lymphagenesis was evaluated by immunohistochemical examination with lymphatic endothelium hyaluronan receptor antibody. RESULTS: The volume of the affect rabbit limb decreased by (24.40 +/- 1.08) ml in experimental group, compared with (5.80 +/- 1.92) ml in control group (P = 0.0001). The expression of VEGF-C mRNA and protein increased markedly in experiment group, but not in controls. More lymphatic vessels with large caliber were seen in experiment group (P = 0.0004). CONCLUSIONS: VEGF-C gene therapy may alleviate or treat lymphedema by inducing lyphmangiogenesis.

[Reconstruction of nasal defects using a reverse preauricular flap by microsurgical technique].

OBJECTIVE: This article reports the design and application of a free reverse preauricular flap for one-stage reconstruction of nasal defects. METHODS: A preauricular flap was designed according to the nasal defect, which was harvested with the reverse superficial temporal vessels as its vascular pedicle. The flap size ranged from 3.0 cm x 2.5 cm to 6 cm x 2 cm without any hair-bearing skin. In flap transferring, its pedicle of the superficial temporal vessels was anastomosed with the facial vessels in the nasolabial fold. RESULTS: The flap survived uneventfully in these three patients. The defects in the distal nose were reconstructed with satisfactory results. The donor site scar was similar to that of face-lift incision. CONCLUSIONS: This is the first report of clinical applications of the free reverse preauricular flap by microsurgical technique. Microsurgical technique allows successful transfer of this flap in a one-stage procedure. Because of its similar color and texture to the facial skin, this flap provides excellent tissues for coverage of the nasal defect. This technique may have even wider applications for other facial cutaneous defects.

[Treatment of primary lower limb lymphedema with ultrasonic assisted liposuction].

OBJECTIVE: To observe treatment effects of primary lower limb lymphedema using ultrasonic assisted liposuction. METHODS: Internal ultrasonic liposculpture system combined postoperative continual elastic stockings or bandages were used for reducing lymphatic burdens of the affected limbs by partly removal of lymphedematous tissues. RESULTS: Edema regression in the affected limbs were obvious at 2 weeks postoperative and kept to stable without recurrence during 1 year follow-up. CONCLUSIONS: Ultrasonic assisted liposuction combined with elastic compression is safe and effective for the treatment of primary limb lymphedema.

[Microvascular nasal repair using a reversed superficial temporal artery auricular flap.].

OBJECTIVE: A reversed superficial temporal artery auricular flap was presented to explore a new method for reconstructing the defects of the distal nose by microsurgical techniques. METHODS: A reversed superficial temporal artery auricular flap had been used on fifteen patients with nasal defects, including thirteen patients with alar defects and two patients with nasal tip defects. The reversed superficial temporal vessels of the flap were anastomosed with the recipient facial vessels. The size of the flap was 2.5 cm x 2. 0 cm - 4.0 cm x 2.5 cm, the length of the vascular pedicle was 5 - 8 cm, average 6.5 cm RESULTS: The flap survived uneventfully in all fifteen patients. RESULTS: demonstrated satisfactory symmetry between the reconstructed ala and the contralateral side as well as an excellent tip projection. The donor-site defect was minimal. CONCLUSIONS: The reversed superficial temporal artery auricular flap offers an adequate length of vascular pedicle of the flap, it delivers a good solution to the problem of the vascular pedicle shortage of the proximal superficial artery auricular flap. This technique may become the top choice in the microvascular auricular transfer.

[Metabolism of hyaluronic acid and extremity lymphedema].

OBJECTIVE: To investigate the possible influence of the impairment of lymph fluid on the metabolism of hyaluronic acid (HA) in the lymphedematous skin tissue. METHODS: Tissue fluid was collected in lymphedematous limbs and the contralateral healthy limbs of 39 patients and HA content was measured with radioimmunoassay. The protein contents were also measured. RESULTS: The HA contents in interstitial fluid of lymphedematous limb were significantly (8 fold) higher than that of normal limb. The protein concentration in the tissue fluid did not show significant differences between lymphedema and those with normal tissue. CONCLUSION: The result suggests blockage of regional draining lymphatics may impairs breakdown of HA and the stagnation of HA in the limb may exert a deleterious effect on the interstitium.

[Repair of foot defect with a reverse fascial pedicled posterolateral lower leg flap].

OBJECTIVE: To explore the applications of ipsilateral reverse fascial pedicled posterolateral lower leg flap in foot defect repair. METHODS: A fasciocutaneous flap was designed over the gastrocnemius muscle to repair the defects in the foot or the lower third of the leg. The flap was based on a perforator branch between the lateral malleolus and the Achilles tendon, coming from the vessel network of the ankle as well as the deep fascia. RESULTS: This method was used in 6 cases, including 2 children of 5-6 years old. All the flaps survived without necrosis and venous congestion. CONCLUSIONS: The operation is simple and a large flap over the whole gastrocnemius muscle can be raised without sacrifice of a main blood vessel. It is an excellent method for repair of the defects in the heel, medial and lateral malleolus, dorsum pedis and the lower third of the leg.