Total Definer E-Book

Alfredo Hoyos

• Herausgeber: Thieme Medical Publishers
• Kategorie: Fachliteratur
• Sprache: Englisch

Veröffentlichungsjahr: 2022

Beschreibung

A uniquely authoritative, artistic, and practical atlas on cutting-edge body sculpting techniques

Total Definer: Atlas of Advanced Body Sculpting by internationally-renowned aesthetic plastic surgeon Alfredo Hoyos is a visually stunning atlas that presents groundbreaking and advanced surgical, fat grafting, liposuction, and body sculpting techniques. Readers will learn how to perform High Definition (HD) and Dynamic Definition (HD²) Liposculptures. Invented by Dr. Hoyos, these innovative body sculpting techniques require extensive artistic skills building curves and sculpting muscles and in-depth knowledge of anatomy and modern medicine principles. HD techniques have revolutionized the practice of liposuction and enabled creation of beautiful, natural-looking contoured bodies.

Key Highlights

• Discussion of key topics such as surgical markings, anesthesia, equipment, postoperative care and complications help optimize patient outcomes
• Exacting details about muscles, the position of the fat, and concavities and convexities of each muscle enable recreating and sculpting beautiful bodies
• Stunning photographs provide visual insights on natural, nuanced, and artistic techniques and results
• High-yield algorithms and tables enhance acquisition of essential data and knowledge

This exquisite atlas is must-have reading for any aesthetic plastic surgery senior resident, fellow, or clinician who wishes to learn and incorporate groundbreaking total definer principles into practice.

This print book includes complimentary access to a digital copy on https://medone.thieme.com.

Leseprobe

Total Definer

Atlas of Advanced Body Sculpting

Alfredo Hoyos, MD Plastic Surgeon Private Practice; Founder and CEO Total Definer™ Academy Bogotá, Colombia

970 illustrations

ThiemeNew York • Stuttgart • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available with the publisher.

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USAwww.thieme.com [phone], [email protected]

Cover design: © ThiemeCover image source: © ThiemeTypesetting by Thomson Digital, India

Printed in Germany by Beltz Grafische Betriebe             5 4 3 2 1

ISBN 978-1-68420-255-3

Also available as an e-book: eISBN (PDF): 978-1-68420-256-0 eISBN (epub): 978-1-63853-708-3

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

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Thieme addresses people of all gender identities equally. We encourage our authors to use gender neutral or gender- equal expressions wherever the context allows.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage.

Contents

Preface

1.Artnatomy

2.Basics

3.Safety

4.Corporal Photography

5.Patient-Centered Care

6.Surgery General Aspects

7.Chest

8.Abdomen

9.Posterior Torso

10.Arms

11.Gluteal Region

12.Lower Limb

13.Excisional Body Sculpting

14.Secondary Procedures

15.Technologies for HD2

16.Masterpieces

Index

Preface

Is there any limit for body sculpting surgery? Every single field in medicine has shown a continuous and exponential growth in recent decades, since technology has pushed science forward to new developments to improve safety and ease the physicians’ job while providing them with new tools and options to guarantee a better service for our patients. Aesthetic plastic surgery remains as one of the top medical specialties around the world, not just because of its academical perception among medical graduates, but also because of the overgrowing interest among general population to seek for new ways to improve their physical appearance and, as a consequence, their self-esteem.

Time and experience are the best teachers in every aspect of our lives, and in our case, we have learned a lot from both achievements and mistakes, since our first cases in aesthetic body contouring surgery almost 20 years ago. It has been a long and difficult path which has allowed us to create, design, and improve our techniques in high definition (HD) liposculpture, dynamic definition (HD2) liposculpture, and excisional body contouring surgeries. Still, what is most certain is that a lot more stuff can be improved and changed, of course thinking ahead of our patients’ safety. Truth be told, most of plastic surgeons around the world have heard or have read about our techniques, some others have been trained in specific skills regarding its main concepts; but still, patients and surgeons have a huge number of questions when aiming to perform them. Recently, we published some papers with the aim to improve the understanding of the artistic concepts regarding grades of muscular definition for both males and females, excisional body contour surgery in female patients, and fat grafting techniques and their details regarding different body areas.

Consequently, we decided to get into further detail ­about our most recent advancements in body contour ­surgery and depict their main ideas in an easygoing way of learning for the human brain: visualization and repetition. We are inviting you to appreciate the Art of body sculpting, by keeping in mind its Basic concepts, and of course, performing a Safe and outstanding Surgery with the aid of our new ABS Book!

The text starts with an introductory chapter that discusses the intrinsic connection between artistic expression such as painting, music, and literature and the practice of medicine. Grounded in artistic concepts, HD and HD2 liposculpture techniques enable surgeons to enhance muscularization and body athleticism using adipose skin layers like sculptors use marble, bronze, or clay. The second chapter features a history of beauty from Ancient Egypt to the present day, followed by illustrated basics of anatomy, body types, muscular dynamics, and more. Chapters 3–6 provide invaluable guidance on safety, photography, point prep, and general aspects of surgery. Then you will immerse into six body-specific chapters which embrace procedures for the chest, abdomen, posterior torso, arms, gluteal region, and lower limb. In addition, the most relevant technologies used for HD liposculpture and the algorithm about straight forward techniques for excisional body contouring will be covered in Chapters 14 and 15, respectively. To close, this artistic atlas includes a fantastic Chapter 16 titled ‘Masterpieces’, which reveals the postoperative results in patients with different body contouring techniques and degrees of muscular definition.

Our main purpose is to show our readers a selection of real images and explain through them the art of HD and HD2 liposculpture by means of the first artistic atlas for plastic surgeons.

Enjoy it!

Alfredo Hoyos, MD

1

Artnatomy

“…In fine arts, the learning of the anatomical and biomechanical fundamentals will configure the morphology of motion expression.”

Synopsis

Art could be defined as the perfect tool to put across the knowledge of any performer through any way of expression. Art is meant to be appreciated for its own impressiveness and its emotional power. Medicine is the art of taking care of the human body in its whole: understanding it, healing it, preventing its harm, and even being compassionate with it. Historically, the practice of medicine has been linked to other forms of art like painting, music, and literature, so that these intriguing links have allowed their mutual development. During the Renaissance, biologic knowledge was merged under the concept of the human body as a basic reality of medicine; hence, anatomic dissections were considered a revolutionary way of teaching the future doctors. This initiative was widely supported by scholars and ­contemporary artists due to a growing interest in the physical shape perfection of the human body, which ultimately led to the production of magnificent artworks in addition to the huge improvement of medical knowledge. Giacomo Berengario da Carpi, Andreas Vesalius, Leonardo da Vinci, and Michelangelo were among the most outstanding anatomists of the time. Grounded in the artistic concepts, liposculpture surgery was given a new meaning with high definition and dynamic definition procedures in which the muscularization and body athleticism were enhanced by the surgeon using the adipose skin layers as the sculptor uses clay.

Illustrations

●Before the Renaissance, typical anatomical illustrations consisted of crude schematic drawings lacking scientific basis and were usually based on astrological factors.

●Anatomical illustrations were then characterized by their elaborate and scientific-based anatomy after the advent of the works by Da Vinci and Berengario da Carpi. This settled the basis for the anatomical illustration change from schematic and allegorical toward a more accurate and scientific.

●Andreas Vesalius developed a new technique for scientific illustration with his masterpiece “De humani ­corporis fabrica libri septem”, an astonishing work for the era.

Sculpture

●The Pietà (1498–1499) is one of the sculptures that established Michelangelo as the best-documented artists of the 16th century. In fact, he sculpted both the Pietà and David before the age of 30.

●The Pietà is the representation of a mother, Virgin Mary, holding the body of her son, Jesus Christ. The observer may perceive a sense of peace and serenity, since Christ’s face does not project suffering, and Mary is a young woman in grief.

●Michelangelo built the body size of Virgin Mary almost twice that of Christ, which allows the observer to see the son like a small child although he is in fact a grown adult.

●The son’s body lays on his mother’s arms and lap, his head is drooping, and his abdomen is curved. The son’s sculpture has a faithful abdominal definition; we can clearly appreciate the oblique muscles and the rectus abdominis, in addition, due to the convex position of the abdomen. There is a remarkable change in the lights and shadows when compared to other sculptures.

●David is one of the most iconic sculptures of the Renaissance and in the history of art. Michelangelo built this majestic 17-feet (5.7 m) tall marble sculpture between 1501 and 1504, in which he depicts a tense and assertive David just moments before the battle with Goliath.

●This masterpiece shows an athletic, strong, and youthful male human body, with a stupefying muscular definition which includes the deltoids, pectoralis major, serratus, biceps, rectus abdominis, and obliques. His pose is in contrapposto with a tense neck and a well-defined shoulder girdle. His left hand holds a sling that is draped over his shoulder and runs down through the back to his right hand, which holds the handle of the sling. His nudity reflects the story of David as stated in the Bible, contrary to prior sculptors who represented him as a warrior in armor.

●The perspective once again plays an important role in identifying both a large head and big hands, which, in addition to the small genitals, leads the observer (situated below) to focus in the former areas and kind of avoid the latter.

Planes

●Artistically, plane refers to the image surface that our eye perceives when looking at a two-dimensional picture. Paintings have a real surface, which we can touch with our hands, but they also have a conceptual surface called picture plane, which refers to the flat surface where the image is created upon (e.g., canvas, board, paper).

●Different picture planes allow us to create illusions through painting, such as the sensation of viewing through a window, the impression of seeing a real object instead of a drawing, or even giving a smooth appearance to paper drawings.

●To generate an effect of depth, the drawing is developed in layers and each layer presents a deeper and deeper part of the picture and when all the elements are put in order, a very harmonious pattern is generated with a clear effect of depth as if we were contemplating the painting through a window.

●Likewise, during high definition (HD) liposculpture, we have surgical planes such as the superficial and deep layers and just as a painter uses the picture plane to generate a depth or smooth effect, a plastic surgeon must use the surgical planes to replicate this effect but over the human body during body sculpting surgery (Fig. 1.1).

●The abdomen has a special significance in dynamic definition (HD2), since the most appealing characteristics of muscularization can be carved in this body segment. Different planes in the abdominal bellies and the chest can be seen through the skin in a lateral view. The chest forms two planes: a convexity in the upper pole that creates a different plane compared to the lower pole (Fig. 1.2a).

●In the abdominal area four planes can be observed from superior to inferior, each one divided by muscular and/or skeletal structure as follows (Fig. 1.2b):

–Superior plane: From the insertion of the abs into the rib cage until the free border of the costal margin (T10).

–Upper central plane: From T10 to the waistline (point W), usually at the level of the last floating ribs.

–Lower central plane: From point W to the anterosuperior iliac spine (ASIS).

–Inferior plane: From the iliac spine, following the oblique line, toward the pubis.

●Planes are extremely important when restoring the normal abdominal anatomy after excisional body sculpting procedures as well as in HD2 liposculpture alone.

Fig. 1.1

Fig. 1.2a

Fig. 1.2b

Shapes and Polygons

●Sculptors build their creations through a series of forms, which will in the end constitute a structure with distinctive three-dimensional conformation of a particular object.

●Just as roses have a stem, leaves, thorns, and petals, the human structure has a series of segments that comprise the body.

●A structure can be constituted by three basic shapes: spheres, boxes, and tubes. Although these shapes may ­substitute and simplify the complex anatomy of the human body, they need to be complemented with specific features of each body segment to result in a marvelous characterization (Fig. 1.3).

●HD liposculpture can impart accurate features of different body segments and turn a tubular arm into a toned, muscular, athletic, and youthful one (Fig. 1.4).

Fig. 1.3

Fig. 1.4

Lights and Shadows

●Contrast is the interplay of lights and shadows over an object. Traditionally, they are commonly polarized, although they actually need to be complementary.

●Artistically, light could be used to create movement, to tell a story, or to generate a perspective in a wide diversity of ways, while shadows allow perception of the shape, illumination, time, and volume.

●Tonal progression is defined as the succession of shades that smoothens the transition from light to dark and vice versa (Fig. 1.5).

●In nature, the light–shadow interaction is dynamic, and artists are challenged to create one. That said, the marble is for the sculptor what the human body is for the plastic surgeon.

●There are no flat surfaces in the human body, but actually a harmony between convexity and concavity, as well as between sharp and smooth borders.

●HD2 liposculpture uses this concept optimally by using dark to emphasize concavities and light to accentuate convexities (Fig. 1.6). For example, fat removal over both the midline and the pectoralis major lower crease emphasizes the muscle convexity through a shadowing effect. Then fat grafting will further highlight the convexity by improving the volume perception (Fig. 1.7).

Fig. 1.5

Fig. 1.6

Fig. 1.7

Sfumato versus Chiaroscuro: Female versus Male

●Sfumato (Italian word for “nuanced” or “gradually vanished”) is a technique in which contours are softly blurred allowing figures to become appreciated through a tonal effect starting from a dark background and without framing harsh outlines. This chiaroscuro procedure allows to obtain the maximum interpenetration between the figure and atmosphere. It is like painting without tracing lines.

●While sculpting a female body, it is important to enhance the lights and shadows by gently accentuating the contours and making smooth transitions between structures (Fig. 1.8).

●For the male body, sharp borders and profound lines are preferred with a marked contrast of shadows among different muscular groups (Fig. 1.9).

Fig. 1.8

Fig. 1.9

NOTE

Both the concepts of sfumato and chiaroscuro are used depending on the genre. The former befits more for the women’s ideal beauty and the latter more for the men.

From Planes to Muscles

●The unit of the torso is composed of the rib cage and the abdomen, which is connected to the hips. With regard to genders, the rib cage resembles a box and the thigh a tube for both, while the hips are similar to a sphere for women (Fig. 1.10) and a box for men (Fig. 1.11). Addition of thinner tubes and a sphere to the torso unit forms the upper limbs and the head, respectively (Fig. 1.12).

●The idea of an isolated shape makes no artistic sense, but rather provides us with the elemental structure for the forthcoming details that will characterize and give it a meaning.

●For instance, the smooth definition of the rhombus of Michaelis makes the tube structure of the female hip very attractive. Likewise, the definition of both the iliac crests and the gluteus muscles enhances the spherical structure of the female buttock. Additionally, the posterior torso of the female includes different planes that interplay a smooth transition between buttocks and a defined upper torso (Fig. 1.13).

●By contrast, the male muscularization includes the sharp definition of some specific muscles and the volumetric enhancement of other muscle groups (Fig. 1.14).

●A body sculptor analyzes the different planes and shapes of the human body to carve the muscular groups that will enhance either the male or female anatomical features.

Fig. 1.10

Fig. 1.11

Fig. 1.12

Fig. 1.13

Fig 1.14

Details in Motion

●Motion is generated by the interaction of muscular contraction, joint movement, and bone firmness. It allows human beings to express. Hence, it has been incorporated into both art and body sculpting.

●A musical score is a succession of notes that makes sense when played as a whole. Gesture is a movement between the forms that generate an expression and a reaction.

●Shapes are linked by an axis to which different structures can be attached. The curves we add to this axis will result in a different gesture and thus, a living appearance of the whole (Fig. 1.15). This curved effect constitutes the concept of contrapposto.

●Contrapposto (Italian for “counterpose”) refers to the harmonic opposition of the different segments of the human body, which results in a better perception of the shapes, and the perception of motion dynamics in a still figure.

●As an example, the pectoralis major muscle gives the chest a perception of volume when at rest, and a shadow zone in the subaxillary region when contracted highlights the serratus definition. Equally, the triceps brachialis provides volume perception and shadow zones when at rest (Fig. 1.16a) versus during contraction respectively (Fig. 1.16b).

Fig. 1.15

Fig. 1.16b

Fig. 1.16a

Superficial Anatomy

●Muscles of major relevance in the trunk: Rectus abdominis, external oblique, serratus anterior, pectoralis major, latissimus dorsi, erector spinae, and multifidus.

●Muscles in the shoulder and arm: Deltoids, triceps brachialis, biceps brachialis, and brachialis.

●Muscles in thighs and hips: Gluteus maximus, gluteus medius, iliopsoas, quadriceps, hamstrings, sartorius, adductor magnus, adductor longus, and gracilis.

●Muscles in the leg: Gastrocnemius and soleus.

●All these muscle groups will be explained in detail in the following chapters of the book.

Human Biotypes

●Beauty has been one of the most cosmopolitan terms in history. Each human being has different physical features that make us unique.

●Physical attraction has been the subject of research in several fields such as biology, anthropology, and psychology. Still, we don’t have an accurate or unique answer to what beauty is or what physical attractiveness is determined by. So, beauty somehow relies on the eyes of the beholder.

●Beauty and biological function have been historically related due to conception of healthiness and well-being. As a result, body biotypes were described and classified by ­Sheldon into endomorph (a), mesomorph (b), and ectomorph (c)(Figs. 1.17 and 1.18).

–Endomorph: Excess of corporal and visceral fat, underdeveloped muscular mass, and a typical posture (= overweight/obese patient).

–Mesomorph: Less fat with prominent bones in addition to a toned and defined body due to a well-developed musculature.

–Ectomorph: Fragile bone structure with poor development of the muscle mass. Thin, usually tall, individuals with low body fat and high metabolic rate, who struggle to gain weight.

Fig. 1.17a

Fig. 1.17b

Fig. 1.17c

Fig. 1.18a

Fig. 1.18b

Fig. 1.18c

Surgery

●HD liposculpture allows us to perform 360-degree liposculpture following artistic concepts by sculpting the superficial anatomy.

●In this way, medicine, the art of the human body, continues its overwhelming development. What kind of art could be greater than medicine? What form of expression could be higher than sculpting the human body, the pinnacle of the evolution?

Power versus Definition

●We human beings, as mammals, were basically designed for motion and our muscles evolved for that purpose. Theories about bipedalism describe the unique capability of the free-hand configuration of the Homo species to use tools, which secondarily changed the anatomic configuration of the upper extremity. Artistically, all muscles are not considered equal; just as machines entail multiple functional parts, the human body is made of power muscles and definition muscles.

●Concept: All muscle groups in HD2 must be subject to definition. However, power muscles are those requiring any degree of volume enhancement or projection by using intramuscular/subcutaneous adipose grafts to improve the physical appearance, while definition muscles are those requiring truly sharp edges.

●We have divided HD2 liposculpture according to gender as follows:

–Power muscles for men: ­Pectoralis major, biceps brachialis, triceps brachialis, trapezius, deltoids, and latissimus dorsi (Fig. 1.19).

–Power muscles for women: Gluteus maximus, vastus medialis and lateralis, biceps femoris, and gastrocnemius (Fig. 1.20).

–Definition muscles in men: Rectus abdominis, serratus anterior, obliques, quadriceps, and gastrocnemius (Fig. 1.21).

–Definition muscles in women: Rectus abdominis, obliques, deltoids, and biceps brachialis (Fig. 1.22).

Fig. 1.19a

Fig. 1.19b

Fig. 1.20a

Fig. 1.20b

Fig. 1.21a

Fig. 1.21b

Fig. 1.21c

Fig. 1.22

NOTE

Muscles classified as power muscles in men are usually definition muscles in the female counterpart and vice versa.

●The power muscles of the upper torso in males enhance the V shape of the masculine contour (Fig. 1.23a), while in women, the power muscles in the hips and thighs enhance the curvaceous appearance of the female silhouette (Fig. 1.23b).

●Comparatively, while in men the distinction power muscles and definition muscles is clear, it might be somewhat “vague” in women, so the surgeon must find a balance between muscle definition and volume for each case.

●Also, some muscles are considered as masculinizing, and they are not usually enhanced in the female patient (Fig. 1.24), such as:

–Deltoids.

–Trapezius.

–Triceps brachialis.

–Gluteus medius.

–Pectoralis major.

–Latissimus dorsi.

–Serratus anterior.

●It is the interaction between power and definition muscles that allows us to create specific features for both men and women including grades of definition. However, outcomes will depend on both their body biotype and individual preferences.

Fig. 1.23a

Fig 1.23b

Fig. 1.24a

Fig. 1.24b

Feminizing Facets

●For women we rather use the concept of feminizing facets: These are specific planes over different body segments that interact with each other to give the body a natural feminine silhouette; therefore, it is mandatory to respect them during HD liposculpture.

●For example, while the masculine arm has power muscles, the female arm needs the interaction of various planes (facets)—a whole cylindric shape, with a smooth transition between the deltoid and the lateral arm groove, and a posterior facet without further definition (Fig. 1.25).

●Different facets can be found in the female body that differ from those for the male:

–Slim arms with small muscle volumetrics.

–Muscle planes in the posterior torso in relation to the scapulae.

–Curved and defined waist related to the hips.

–Round gluteal shape with a soft, diffused contour from the waistline to the hips.

–Leg with an internal double-S continuum configuration and muscle planes in both the lateral thighs and calves.

–Tubular calves with a soft transition to a cone shape toward distal.

Fig. 1.25a

Fig. 1.25b

NOTE

Men could be subject to body contour feminization according to the patients’ preference. HD2 allows the surgeon to create the V shape of the male torso, and in the same individual enhance the feminine curvaceous lower body(Fig. 1.26a).

Fig. 1.26a

NOTE

Likewise, women could undergo body contour masculinization through HD2 by increasing the volumetric appearance of the power muscles in the upper body: Deltoids, triceps, biceps brachii, latissimus dorsi, and trapezius(Fig. 1.26b).

Fig. 1.26b

Suggested Readings

1.Collingwood RG. The principles of art. Ravenio Books; 1938

2.Von Staden H. Herophilus: The art of medicine in early Alexandria: Edition, Translation, and Essays. Cambridge University Press; 1989

3.A brief history of anatomical illustration | Anatomia Collection: anatomical plates 1522–1867. Accessed online: https://anatomia.library.utoronto.ca/about/history_illustration

4.Simblet S, Davis J. Anatomy for the artist. New York, NY: DK Publishing Inc.; 2021

5.Huston S. Figure drawing for artists making every mark count. Beverly, MA: Quarto Publishing Group; 2016

6.Mende K. Light and shadow in painting—concerning the expression of shadows in western painting. J Geom Graph 2001;5(1):53–59

7.Hoyos AE, Prendergast PM. The human form as art: contours, proportions, and aesthetic ideals. In: High Definition Body Sculpting. Springer Berlin Heidelberg; 2014:3–18

8.Sfumato. Chiaroscuro. Contrapposto. Picture Plane | Glossary | National Gallery, London

9.Sheldon WH (with Stevens SS, Tucker WB). The varieties of human physique: an introduction to constitutional psychology. New York, NY: Harper; 1940

10.Zarins U, Kondrats S. Anatomy for sculptors: understanding the human figure. Seattle, WA: Exonicus, LLC; 2019

2

Basics

SYNOPSIS

Multiple concepts and definitions have been described as necessary to understand high-definition and dynamic-definition liposculpture. The latter, based on the high-definition concepts, incorporates new notions about the basic structures, motion dynamics, and details of the human body that need to be considered in order to achieve true, natural, and harmonic results. The final purpose of any surgery is to restore the normal physique’s features and not modify physiologic and biologic functions. For body sculpting procedures the more natural the outcome is, the better it is. Some challenging problems in cosmetic plastic surgery are the fake results and the “static” appearance of the body structures in the postoperative. We will describe in this chapter the history of beauty and how to acknowledge its importance for the outcomes, in order to further comprehend why the naturality and the avoidance of a fake result are crucial for a well-performed body contouring procedure.

History of Beauty and Definition

●The concept of beauty is intrinsic to the human behavior and developmental environment. It has been studied and described since the dawn of civilization by many philosophers. Historically, beauty has been as valuable as truth, justice, and goodness.

●The concept of beauty is tied to cultural factors, lifestyles, and own precepts. So, no global definition actually exists.

●Augustin wondered whether things were beautiful because they gave delight, or they gave delight because they were beautiful; he concluded the latter statement as the most accurate.

●Plato linked the concept of beauty to a response of love and desire, also located it in the realm of the forms.

●Plotinus suggested that beauty depended on the forms in an idealistic concept following Plato’s philosophy, where ugly things were those without an entire mastering by a pattern.

●The Metaphysics from Aristotle gave beauty a mathematical concept where order, symmetry, and definiteness were considered the basis of beauty. In Poetics, beauty raised as an impression of magnitude and order. Kant defined beauty as a symbol of moral goodness.

●Beauty is multidimensional, and genetic changes could mean that attractiveness might be linked to longevity and the human species preservation.

●Men and women phenotypes and their sociocultural impact through time and among cultures mean that beauty is constantly changing and not universal.

Ancient Egypt

●Ancient Egypt is one of the most remarkable civilizations in history. They were the first to create perfumes and other beauty tools. Both genders used to shave their heads and to wear wigs made of human hair, pet hair, or plant fibers. They used kohl not only as makeup for sun and dust protection, but also as the representation of the linkage with “The eye of Horus,” the sacred falcon.

●Men were always depicted with a youthful, tall, and slender figure with broad shoulders and a long nose within a beardless face, which was a symbol of status among noble men.

●Women were portrayed with large hips, pendulous breasts, a slim figure, and a fine face with a special emphasis on makeup which highlighted the feminine features, as appreciated in Nefertiti’s bust.

Ancient Greece

●Epicurus is the father of Epicureanism; a thought doctrine conceived by a hedonistic ground in which all men strived for happiness; therefore, happiness was equated with pleasure. The body is still the main instrument for achieving pleasure.

●The combination of hedonism and the Epic cycle engaged the human body as a cornerstone in the social development of the time.

●Ancient Greeks contemplated the body as the harmony of the whole from each of its parts, instead of its adornments. Men were represented with athletic bodies, and women with curvilinear shapes with a wide waist and small breasts.

Ancient Rome

●Rome was the largest urban center in the ancient world; they managed to control territories on three continents throughout the Mediterranean “mare nostrum” (lit. our sea). So, many of the beauty canons of the Romans were inherited from the Greeks.

●The concept of Roman beauty was based on body’s perfection and harmony. Like the Greeks, the roman male ideal of beauty was based on heroes and athletes such as elite military men (e.g., centurions), with strong, toned bodies and a clear muscular definition representing strength and masculinity.

●The roman female ideal of beauty relied on small bodies, narrow shoulders, pronounced hips, small breasts, and wide thighs. For both genders, the pale skin was a symbol of social status, and the blonde hair was desirable, so nobles used to take milk baths and dyed their hair.

Middle Ages

●Lifestyle was governed by a strong religious influence in the mid age; hence, the soul’s purity and the worry of salvation ruled the standards of beauty while hair and body care as well as clothes were considered frivolous.

●Nudity was a taboo for women, but not for men. In fact, the masculine body was considered as an apology for perfection.

●Nonetheless, the pale skin, blonde fine hair, a narrow waist, and small breasts were considered ideal for women while an athletic physique with broad shoulders and narrow hips, long and pronounced legs were for men.

The Renaissance

●The Renaissance was an era full of innovation in several fields of the knowledge. Aristotle’s mathematical concept of beauty reached a climax with Da Vinci’s “Vitruvian man”, in which the math problem of how to calculate the same area for a square and a circle (quadrature of the circle) was solved by Leonardo da Vinci through the concepts proposed in the work “De Architectura” of Marcus Vitruvius.

●Vitruvius claimed that the navel was the center of the human body and described the almost-perfect relation between an individual’s wingspan and height, thus placing the body perfectly within a square.

●Vitruvian man exposes how a man can exist within all its elements and depicts his body with a clear muscular definition and symmetrical proportions. Philosophically it was perceived as a balance of creation and development capable of achieving perfection and as such beauty.

●The male was usually portrayed naked with muscular, tonified, and youthful bodies, while women were more voluptuous and curvilinear compared to middle-aged women.

Baroque

●Perception of the ideal male body was comparable to that from the renaissance with a well-defined superficial musculature and a tonified appearance, whereas the ideal woman body changed toward an increase in the proportions of breasts, arms, waist, and leg.

NOTE

Giovanni Pico Della Mirandola proposed that human beings had the capacity to occupy any position among Good and Evil through their actions (free will), which led to the conception of humanity as the center of the universe.

20th CENTURY

●At the beginning of the century a cultural milestone was the introduction of muscle magazines like physical culture, and the inauguration of competitions regarding physical appearance, especially of bodybuilding.

Romanticism

●Although tuberculosis surged as a devastating sickness during romanticism, the ill appearance of patients suffering from it was considered ironically beautiful by the time.

●Women were rendered by white skin, narrow waists, small hands, and wide foreheads, whereby they shaved the hairline. In turn, they tried to look sick by taking vinegar and even using eye drops of belladonna to obtain mydriatic and sick looking eyes.

1920s

●The prohibition of alcohol and speakeasies in the early 1920s represented the beginning of women’s emancipation from the male domination that governed the social context for so many years.

●Women began to incorporate into working activities, so the ideal of feminine beauty was stereotyped by short hair, thin bodies, with narrow hips, and mostly by clothing with simple costumes associated with their jobs.

●Charles Atlas was considered an iconic beauty standard and the clear representation of masculinity with voluminous and well-defined muscles with a wide V-shaped back.

1930s–1950s

●These decades were considered the Hollywood boom, where women preferred curvaceous bodies with large breasts, an hourglass figure and well-defined waist. During the Wars, Betty Grable was known as “The girl who waited at home for men to come back from war”.

●Marylyn Monroe was one of the greatest icons during the postwar period and represented the female beauty which boosted the new men’s entertainment magazines.

1960s–1970s

●“Love, peace, rebellion, and thinness” summarizes the events occurring during these decades. Pretty similar to the 1920s, women with thin bodies, long legs, and short hair were the main trends of the 1960s. The mini skirt was introduced to highlight the length of female legs.

●The 1970s were a time of revolution against social stigmas, against stereotype impositions, though thinness remained a standard. In the following years, a special focus was given to nutritional status and diets, exercise, and weight loss to avoid obesity.

1980s

●The 1980s marked the revenue of curves as an ideal of feminine beauty which was further commercialized by media and supermodels. Big breasts and buttocks with small waists were back on the scene; in fact, models began to get very good profit with their bodies.

●This phenomenon encouraged people to start attending the gym to improve their physical appearance and was actually considered a personal success. This resulted in a new era of bodybuilding competitions and fitness. Nevertheless, the common male or female ideal bodies were far from these standards.

●Adult magazines were filled with big breasts and defined waists, and some women wanted to achieve such bodies. However, a divergent society also considered smooth curves and a slim appearance as beauty standards.

1990s

●New “empowered” women decided to resist and get into the discipline of depriving oneself. So, the homeless appearance was fashionable as Kate Moss exhibited.

●This fascination for underweight models provoked the rising of eating disorders among the United States. Ana Carolina Reston was the living proof of these extreme beauty misconceptions and unhealthy behaviors. Her BMI was as low as 13 kg/m2; she later died from malnutrition complications.

●The millennial generation sought for other horizons rather than reproductive ones. The concept was to focus on a healthier lifestyle and participate more in water sport; however, sedentarism was prevalent which led to high rates of overweight and obesity.

21st Century

●The exponential growth of technology in addition to the internet allowed the massive dissemination of information.

●Although social media is nowadays the most powerful tool for marketing, photographic editing and deceitful representations have allowed a number of fake propagandas or scams. This has created not only false expectations among people, but also has affected the self-esteem of individuals.

●Beauty standards have become diverse, and women do not favor just one type of body. Thin, fat, curvy, slender, muscular, natural, unnatural appearances were and are still all valid in a new inclusive society where discrimination has no place at all.

2000s

●Tendencies are just temporary conducts or manners that seem to repeat after some time.

●The new millennium first dealt with all the glitches of year 2000 itself: Y2K the “Millennium bug,” Conspiracy theories, end of time, etc.

●Generation Z or “zoomers” are the children of generation X and have been dubbed “digital natives” since they were the first generation to be born during the Internet era (1990–2012).

●The Internet era led to a faster spread of information and dissemination of digital magazines, newspapers, bulletins, and posters, where tall and athletic women once again became popular for their front page.

●A new trend emerged among women: The curvy “fit” woman.

●The fitness lifestyle emerged as a new trend among the young population, where not only the body but also the inner peace was important, which also resulted in a more mindful perspective about the environment.

●The Zoomers trended for incorporating a healthier lifestyle but preserving the voluptuous shape in females and the muscular appearance in males.

●There was less emphasis on curves than the 1950s and 1980s but definitely more than the 1990s. In fact, the Brazilian super model Gisele Bündchen was claimed by the Rolling Stone magazine as the most beautiful girl in the world due to the perfect balance between athleticism and curvaceous body.

2010s

●In recent years, there has been an enormous change in how people perceive the physique and describe what beauty is.

●We are currently in the heyday of social media and digital marketing where everything one may need is just a click from your hand.

●Real-time information (news, sports, social trends) has a higher social impact than before.

●Digital marketing and the fitness lifestyle have allowed countless athletes, models, and even ordinary men and women to become entrepreneurs and use their bodies to do/promote both businesses and publicity.

●In fact, the world presence of supermodels is becoming more and more frequent in social media, which continuously pushes society forward to pursuing a healthy lifestyle, and a new standard of beauty of the occidental hemisphere: The Superfit woman.

●As a result, women have now not just a single standard but a spectrum that includes the slim figure, the voluptuous shape, and the fit appearance, that could be cross matched during aesthetic surgery to meet the wishes of a certain patient.

●Generation Alpha (born 2010s and later) succeeds Gen Z. Alphas are the children of the millennials, who are influencing their understanding of beauty and physique by blending concepts between what it was during the 1980s and what it is in the 21st century.

●During the last decade, the Kardashian/Jenner clan completed a 20-season reality show in which the audience could appreciate different body phenotypes (voluptuous, slim, athletic). With as much lovers as haters, this show’s outstanding success in fact reinforces our theory that beauty “standards” no longer follow a unique stereotype.

●Consequently, we are facing once again the popularity of the hourglass female shape though coupled to the fitness “touch,” both of which further supports the cyclic behavior of beauty trends.

●By today, artworks and sculptures have many different standards regarding beauty, and each society or ethnicity might have different ideals according to their own beliefs, perceptions, and even religion.

●In fact, feminine aesthetic preferences rely on three biotypes: The slim model from the 1990s, the curvaceous/voluptuous woman, and the fitness influencer, which bolsters the phrase “Beauty lies in the eyes of the beholder.”

●We will have to wait till the offspring from the Zoomers and then to that from the Alphas to see what new trends will pop up or rather which will get their “second wind.”

THE ADIPOSE

LAYER

●Fat anatomy is composed of three main layers (Fig. 2.1): A superficial adipose tissue (SAT) layer, an intermediate membranous layer (superficialis fascia), and a deep adipose tissue (DAT) layer. All of them are of extreme importance for the body contour plastic surgeon, since they mean what the marble is for the sculptor.

Fig. 2.1

Superficial Adipose Tissue

●SAT layer is characterized by fibrous septa that define polygonal lobes of adipose tissue; the thickness of this layer is relatively constant throughout the body, but could be modified by age, sun, or trauma (including surgical trauma).

Intermediate Layer

●It is a continuous fibrous membrane named Fascia Superficialis, abundant in elastic fibers, and formed by infiltration of fat into the superficial fascial system. The intermediate layer is usually thicker at intermuscular zones as compared to other regions, (e.g., between rectus abdominis muscles or the deltopectoral groove).

Deep Adipose Tissue Layer

●DAT layer lies under the fascia superficialis system; its fibrous septa groups large and flat lobes of adipose tissue which contributes to above-tissues support. The limit between this layer and the muscle consists of a filmy membranous sheet called the innominate fascia, whose thickness varies significantly throughout anatomical regions.

Anatomical Variations

●The interplay between the different fat layer thicknesses in some anatomical regions is vital for Dynamic Definition Liposculpture.

●SAT is thicker in the upper abdomen and thinner in the lower abdomen. DAT is always thicker in the periumbilical region and tapers laterally as it approaches the external oblique muscle.

●SAT thickness is relatively constant throughout the paralumbar region and the upper torso. DAT is always thicker.

●SAT thickness is relatively constant in the gluteal region, while the DAT is more prominent over the gluteal muscles and the iliotibial tract, with a maximum thickness of about 5 cm below the iliac crest.

●There is not a clear division between SAT and DAT in the legs, though the adipose tissue appearance, density, and structure is similar to the SAT of the trunk.

All or Nothing Lipoplasty

●There is no beauty and thrill in an incomplete artwork of the body as it is in when the sculptor finishes its entire carving. The mixture of a muscularized abdomen with fat arms and legs is simply unconceivable.

●Although the exemplification is a bit rude, the same principle applies to body sculpting surgery: the body should be conceived and treated as a whole!

●Every patient undergoing body contouring procedures seek a natural and an aesthetically pleasant result. So, ­every effort should be done by the ­surgeon to perform the best aesthetic procedure without leaving traces of it.

●High-definition (HD) and dynamic-definition liposculptures (HD2) are well known for their all-or-nothing conception, which means that an ­accurate knowledge of superficial anatomy (mainly myology and osteology) is mandatory, before starting the carving.

●Likewise, the attainment of the same degree of muscularization among the entire body segments according to each body biotype is compulsory for the most natural and best aesthetic outcomes (Fig. 2.2).

Fig 2.2

360-Degree Job

●High-definition liposculpture is not just fat removal but the optimal revealing of the underlying individual anatomy.

●This can be achieved by removing excess, adding when deficient and creating controlled deformities that highlight and improve the subjacent anatomic structures.

●Our body segments can be divided by a coronal plane into anterior and posterior, and in lateral and medial by a midline. All-or-nothing lipoplasty has to include all possible projections derived from these subdivisions, which ultimately means a 360-degree job.

●The arms have several landmarks in each facet:

–Concavities (lights) must be enhanced in the anterior plane to generate the effect of muscular volume over the biceps muscle (Fig. 2.3a).

–The muscle mass of the triceps brachialis and the lower-posterior portion of the deltoid generates the lights of the posterior arm (Fig. 2.3b).

–The deltoids concavities must be defined in the lateral facet of the arm.

Fig 2.3a

Fig 2.3b

THE FAKE PROBLEM: STATIC versus MOTIOn

●The accurate definition of corporal structures can only be done by following the patient’s anatomy: Markings are more than simple drawings of muscles over the skin.

●Some muscular groups are easier to define than others due to the fat distribution above them that may hide or expose their trophism.

●We have identified a typical order or phases of muscularization among individuals who start a healthy diet plus a workout routine on a regular basis. First changes are usually noted over the extremities (biceps, triceps, deltoids, calves, and thighs); later, the pectoralis major and upper abdominal muscles. The lower abdominal region with a full six pack, the trapezius, the serratus, and oblique muscles are the last to be defined (Fig. 2.4).

●We reproduced this physical evolution in HD and HD2 liposculptures to offer the patient a variable degree of muscular definition, as well as to keep an order on muscular carving while in surgery.

●The absence of naturality and harmony is unforgivable in body contour surgery, though they are not the only ones to consider, while facing the “fake problem.”

●A common mistake made while performing dynamic and HD liposculpture is the misunderstanding of “progressive muscularization.”

●Muscle contractions derive in a conformational change of the body segment they move, then muscular definition must be dynamic as well, (e.g., contraction of the triceps brachialis and pectoralis major muscles pushes up the posteroinferior deltoid crease and the lower pectoral border), respectively; therefore, shadows must be reproduced intraoperatively within the muscles’ limits to avoid a static or unnatural appearance.

NOTE

Patients with fake outcomes are those that appear to follow an altered order of muscularization. In the patient inFig. 2.5,the six pack is fully defined without the definition of the deltoids, triceps, the pectoralis major muscles, or the upper rectus abdominis muscles, which lets a standard observer to realize that there is no harmony in the patient’s body nor natural accordance of the muscular definition.

Fig 2.4

Fig 2.5

Variable Degree of Muscularization

●There is not a universal standard of what the ideal shape of the human body is. In fact, this concept has changed not only over time, but also among different cultures, geographical regions, and races.

●There are even many variations across socioeconomic and cultural groups within the same country.

●Genetics play a significant role for races: Asians tend to be slim, Afro-Americans tend to be athletic, Latins tend to be curvaceous, while Europeans and Americans tend to be tall and thin.

●Social and cross-sectional studies have reported a wide spectrum of predilections about the ideal body shape among populations; these reports suggest that people with high socioeconomic/educational status often prefer thinner bodies, while people with lower socioeconomic/educational status commonly prefer voluptuous contours.

Body Biotypes

●Body biotypes were initially called Somatic types by Sheldon in 1940 and classified in three groups: Endomorph, Mesomorph, and Ectomorph, based on the development of embryologic follicles (see Fig. 1.17and Fig 1.18 in Chapter 1).

●First step in HD2 procedures require the patient’s biotype classification and then choosing the best procedure to perform, considering their expectations and the plausible results for muscle definition.

●Patients usually seek to follow a public figure’s body stereotype, but results are not always achievable due to their anatomic specifics. Our job is to advise and give a professional assessment in what to expect and how the procedure would be performed.

BMX Algorithm

●Degree of definition requested by the patient + Individual assessment by the plastic surgeon: Basic, Moderate, Xtreme (BMX) (Fig. 2.6).

–Endomorph: Fat person → can be offered either grade B or M, seldom an X.

–Ectomorph: Slim person → can be offered a either grade B, M, or X.

–Mesomorph: Athletic person → can be offered either a grade M or X, but not a B.

●Endomorph patients:

Fig 2.6a

Fig 2.6b

Fig 2.6c

Muscular Dynamics

●Dynamic means motion; hence, the “Dynamic definition” concept is based on the effects that muscles produce over the skin when in contraction versus at rest (Fig. 2.7).

●Liposuction over the intermediate fat layer ­allows the surgeon to create shadows surrounding each muscle, which are necessary to enhance perception of naturality and muscular projection/motion, depending on the anatomical region (e.g., intermuscular grooves, dynamic zones).

●While DAT liposuction is about removing the extra fat, SAT liposuction aims to carve the details and generate the lights that will be necessary to achieve sharp borders.

●Markings are essential to follow the anatomical structures intraoperatively. Muscles are examined in the resting and contraction positions. The latter permits the appreciation of the anatomical grooves, the volume, the limits, and the surrounding tissue variation.

Fig. 2.7

Muscle Volumetrics

●Liposuction alone reveals the lights and shadows, which ultimately settles the frame for HD2 (Fig. 2.8). However, fat grafting is commonly necessary to enhance the muscle volume and/or projection.

●Fat grafting is otherwise a safe procedure. Although there is not a universal consensus about the best technique for the autologous approach, basic rules are:

–Select an appropriate donor site.

–Atraumatic harvesting method.

–Graft processing before injection.

–Lipoinjection procedure.

●Donor site: Choice based on the consensus between the patient and the surgeon. For HD2 we use the product from the entire liposuction.

●The inner thigh and lower abdomen have great amount of adipose-derived stem cells which can improve the graft’s long-term survival.

●Fat harvesting is done by either assisted liposuction or syringe aspiration. The latter usually preserves the adipocyte cellular function but could be exhausting for the surgeon.

●For large-volume extraction procedures such as HD2 we recommend assisted liposuction in low-negative pressure modes: between –1 mmHg and –20 mmHg.

●Graft processing: Decantation, Centrifugation, and Closed wash + filtration are the most common techniques. We allow decantation for almost the entire length of the procedure, then we remove the infranatant and add 2 g of clindamycin.

●Fat injection: Syringes filled with the supernatant (adipocytes + fat-derived stem cells) are attached to 3 to 4 mm, blunt tip, Mercedes cannulas which are prewashed with 4% chlorhexidine. Then the graft is placed using the Wells-Johnson high-volume precision (HVP) autograft infusion system through the expansion vibration lipofilling technique.

Fig 2.8

Suggested Readings

1.Diessner R, Solom RC, Frost NK, Parsons L, Davidson J. Engagement with beauty: appreciating natural, artistic, and moral beauty. J Psychol 2008;142(3):303–329 PubMed

2.White JD, Puts DA. Genes influence facial attractiveness through intricate biological relationships. PLoS Genet 2019;15(4): e1008030 PubMed

3.The Cambridge history of hellenistic philosophy. Cambridge University Press; 1999

4.Carruthers M. The experience of beauty in the Middle Ages. Oxford University Press; 2013

5.Magazù S, Coletta N, Migliardo F. The Vitruvian Man of Leonardo da Vinci as a representation of an operational approach to knowledge. Found Sci 2019;24(4):751–773

6.Ames-Lewis F, Rogers M, Rogers M. Concepts of beauty in Renaissance Art. Routledge; 2019

7.Berghoff H. Globalizing beauty: consumerism and body aesthetics in the twentieth century. Kühne T, ed. Basingstoke, UK; New York, NY: Palgrave Macmillan.

8.Hoyos AE, Prendergast PM, Hoyos AE, Prendergast PM. The concept of human sculpting: light, shadow, and form. In: High definition body sculpting. Berlin, Heidelberg: Springer; 2014:41–48

9.Hoyos AE, Prendergast PM. Fat anatomy, metabolism, and principles of grafting. In: High definition body sculpting. Berlin, Heidelberg: Springer; 2014:83–91

10.Hoyos AE, Perez ME, Domínguez-Millán R. Variable sculpting in dynamic definition body contouring: procedure selection and management algorithm. Aesthet Surg J 2021;41(3):318–332 PubMed

3

SAFETY

SYNOPSIS

The main interest of both high- and dynamic-definition liposculptures has always been patient safety and then the outcomes. Safety is paramount at all stages of the procedure and involves all the members who participate in the process: the surgeon, anesthesiologist, therapist, nurses, and even administrative staff. A “Swiss-cheese” model has been implemented in our practice to take care of the patient while avoiding possible adverse effects and preventing complications, not just in the OR, but also during the pre- and postoperative periods. The patient should go through a continuous smooth process, starting at the initial evaluation appointment and ending up with the long-term follow-up after high-definition (HD) and dynamic-definition (HD2) procedures. Complication rates in liposculpture are usually less than 5%, and most of them are considered minor, such as seroma, localized infections, abnormal skin retraction, small contour irregularities or asymmetries, and port burns. In contrast, major complications are usually devastating and affect the patient both physically and emotionally, which include major bleeding, deep venous thrombosis (DVT), pulmonary embolism (PE), fat embolic disease, and death. Still, the rate of fatal complications in liposuction surgery is 1 in 13,000 procedures, from which thromboembolic events account for more than 23%. In this chapter, we will describe how our process has considered numerous variables from high-definition body sculpting with the sole purpose to improving the patient’s safety.

General Guidelines

●Safety considerations for a patient who will undergo HDL and HD2 begin with the initial evaluation and require a multistep process.

●The team should be focused in every effort in order to ease patient preparation and follow-up and decrease anxiety and stress during any surgical procedure.

Prevention of Thromboembolic Events

●Preoperative risk stratification must include the probability of thromboembolic events (DVT, PE) and blood loss.

●Full history should be taken and complete physical exam should be conducted. Address individual preoperative risk modifiers, (e.g., weight loss, regular exercise, quit smoking at least for a 2-week period (ideally 4 wk), suspend oral contraceptives, defer if recent operative procedure).

●Altogether nongeneral anesthesia, elastic stockings, intermittent pneumatic compression (IPC) devices, normothermia, early ambulation, and shortened operative times help in reducing the risk of postoperative embolic events.

●The plastic surgery–validated Caprini score is performed for DVT/PE risk assessment. HDL and HD2 often represent a Caprini score of 3 or greater, then a thorough evaluation of the risk of developing thromboembolic disease is necessary to determine the need to administer pharmacological prophylaxis (Table 3.1).

●We designed a specific protocol for the prevention of thromboembolic events during HD2 procedures, which include preoperative, intraoperative, and postoperative interventions (Table 3.2).

Table 3.1 Caprini risk assessment model

1 point

Age 41–60 y

Varicose veins

History of inflammatory bowel disease

Obesity

Sepsis (<1 mo)

Abnormal pulmonary function (COPD)

History of major surgery (<1 mo)

Swollen legs (current)

OCP or hormone replacement therapy

Pregnancy or postpartum (<1 mo)

2 points

Age 60–74 y

Malignancy (previous or present)

Major surgery (>45 min)

Central venous access

Patient confined to bed (>72 h)

3 points

Age over 75 y

History of DVT/PE

Family history

Positive factor V Leiden

Elevated serum homocysteine

Positive lupus anticoagulant

Elevated anticardiolipin antibodies

Heparin-induced thrombocytopenia

Positive prothrombin 20210A

Abbreviations:

COPD, chronic obstructive pulmonary disease; DVT, deep vein thrombosis; LMWH, low-molecular-weight heparin; NSAID, nonsteroidal anti-inflammatory drug; OCP, oral contraceptives; PE, pulmonary embolism.

Score ≥7:

Chemoprophylaxis with LMWH (40 mg SQ per day) is recommended for 7–10 d after surgery.

Score 3–6:

Should consider chemoprophylaxis with LMWH (40 mg SQ per day) during patient hospitalization (extend to outpatient therapy based on individual risks).

Score ≤2:

No prophylaxis needed.

Table 3.2 Protocol for prevention of thromboembolic events

Abbreviations: HRT, hormone replacement therapy; OCPs, oral contraceptives.

a See Table 3.1.

WARNING!

●Abdominoplasty accounts for the highest percentage of DVT cases among all venous thromboembolism (VTE) cases in aesthetic procedures (>50%); use prophylaxis in these patients.

●Obesity (BMI ≥ 30 kg/m2), patients under oral contraceptives/hormonal replacement therapy, and patients undergoing circumferential excisional procedures are independent high-risk factors.

Perioperative Fluids

●Incorrect handling of liquids can lead to either hypovolemia (replacement is insufficient) or fluid overload (most common) with the subsequent risk of pulmonary edema.

●Keep IV fluids administration to its minimum. The subcutaneous infiltration of tumescent solution has a considerable rate of reabsorption into the bloodstream (approximately 70–75% within 160 min after administration).

●Fluid overload results because of its consistent replacement by the anesthesiologist due to patient’s fasting, trauma, and bleeding, in addition to the normal maintenance requirements.

●Recommended: Replace 1.8 mL and 1.2 mL of crystalloids per milliliter of lipoaspirate, if total liposuction volume is ≤5,000 mL and ≥5,000 mL, respectively. Maintenance crystalloids: 1.3 to 1.6 mL/kg/h.

Epinephrine

●Epinephrine is relatively safe during HDL and HD2. However, the surgeon must carry out a thorough cardiac evaluation in all patients to identify any predisposing factors for severe side effects.

●Although significant quantities of epinephrine are administered in liposuction, a plasma level that can be classified as toxic has not been identified.

●Manufacturers’ recommendation is to not exceed the 0.6-mg dose subcutaneously.

●Normal levels of epinephrine in the blood are ≤100 pg/mL, with an extra-short half-life of approximately 2 minutes.

●Peak levels of concentration (approx. two to three times normal concentration) are seen between 2 and 4 hours after infiltration.

●Acceptable: 1 mg of epinephrine per liter of tumescent solution.

●Ideal dose: 0.15 mg/kg.

●To prevent the nonsensible absorption of epinephrine: Do NOT use ≥9 mg total dose.

Lidocaine

●Use of local anesthetics in liposuction infiltration solutions is still under debate.

●Lidocaine and bupivacaine (highly lipophilic) have absorption rates of 90 to 99% just 10 minutes after infiltration. But, due to dilution effects and epinephrine, plasma concentrations peak around 8 to 18 hours for lidocaine and 20 hours for bupivacaine.

●Lidocaine + epinephrine concentration peaks in plasma in average after 12 hours.

●Then local anesthetic toxicity complications can appear up to 24 hours after surgery.

●