The Tumescent Technique By Jeffrey A. Klein MD
Postliposuction Care: Open Drainage and Bimodal Compression
The goal of postliposuction care is to minimize edema, bruising, and patient discomfort. The postoperative pain and edema resulting from sutured incisions and prolonged postliposuction compression are unnecessary traditions from the days before the tumescent technique.
Early liposuction was so bloody that patients often had to donate and bank their own blood before surgery and receive a transfusion after surgery. Because of this significant bleeding, providing hemostasis and preventing hematomas or seromas were the primary goals of postliposuction external compression. Prolonged high-grade compression was thought to be necessary to prevent or diminish the size of hematomas and seromas.
With the advent of the tumescent technique, with its profound vasoconstriction and surgical hemostasis, the imperatives of postliposuction care have changed. Some surgeons, however, are still unfamiliar with the technique of open drainage and bimodal compression.
This chapter explores techniques that minimize postliposuction discomfort and accelerate the patient’s return to normal activities. The reader is encouraged to evaluate the suggested procedures by performing simple clinical comparisons between the newer methods of open drainage and traditional methods of sutured incisions.
Liposuction causes subcutaneous bleeding and damage to subcutaneous lymphatic capillaries (see Chapter 11). The combination of subcutaneous bleeding and impaired lymphatic drainage entraps large, osmotically active molecules, resulting in prolonged osmotic edema. Any technique for postliposuction care that contributes to this osmotic edema will increase the degree of postliposuction edema, pain, and bruising.
Traditional liposuction and postliposuction techniques often produce an unnecessary degree of prolonged healing and edema, as follows:
- Incomplete tumescent infiltration leads to subcutaneous bleeding, encourages postoperative subcutaneous inflammation, and augments postoperative edema. The superwet technique is an example of suboptimal tumescent infiltration.
- Sutured liposuction incisions prevent percutaneous drainage of residual blood-tinged anesthetic solution and encourage subcutaneous edema.
- Long-term use of high-compression, postliposuction elastic garments compresses and impairs subcutaneous lymphatic capillaries and further blocks lymphatic uptake of large, osmotically active molecules.
A more efficient and effective method is available for postliposuction care.
The ideal method for postliposuction care prevents problems before they occur. Prolonged edema, excessive bruising, and persistent inflammation are the most bothersome and most common undesirable sequelae of liposuction. These problems largely can be avoided with a rational, scientific approach to postliposuction care.
One successful method of postliposuction care utilizes open drainage, special superabsorbent pads that provide distributive compression, and bimodal compression.
Open drainage after tumescent liposuction refers to the technique for maximizing the drainage of blood-tinged anesthetic solution through the following:
- Using adits or minuscule punch excisions to facilitate postoperative drainage
- Placing adits in strategic locations to encourage gravity-assisted drainage
- Allowing incisions to remain open instead of being closed with sutures
Open drainage requires the use of superabsorbent, high-capacity, and comfortable absorptive pads.
Compression. Compression sponges are a combination of superabsorptive sponges and compression pads (Figures 30-1 and 30-2).
Absorptive sponges are required for containment of postoperative blood-tinged drainage. Containing the drainage avoids alarming the patient and prevents staining of clothing and furniture. Complete absorption and containment of the drainage allows the patient to be mobile and sociable.
The copious drainage after tumescent liposuction requires absorptive pads with a special design. Compared with disposable paper diapers, the post–tumescent liposuction absorptive pads have twice the thickness of absorptive paper pulp and twice the amount of superabsorbent powder (SAP) to provide maximum absorptive capacity (see later discussion).
Compression pads are postoperative cushions placed over liposuctioned areas to distribute the compression provided by an elastic garment in a smooth and uniform manner. Uniform, gentle compression of subcutaneous tissue after liposuction compresses or shrinks the gaps within the interstitial collagen of the dermis. Thus dermal compression prevents bruising by blocking the percolation of red blood cells toward the epidermis.
Technique. An effective, practical means of applying the compression-absorption pads over the targeted areas is to use a combination of few strips of paper tape and elastic tube netting, similar to the method of applying dressings over burn wounds. After the compression-absorption pads are well positioned, one can apply the elastic compression garment. The optimal garment in this regard must be able to accommodate bulk of the pads, and the pads must be easy for the patient to doff and don without assistance (Figure 30-3).
Bimodal compression refers to the sequential use of two degrees of postliposuction compression as follows:
- A high degree of compression is maintained while drainage persists and for 24 hours after drainage has ceased.
- Mild compression is sufficient beyond the 24 hours after all drainage has ceased.
Improved postliposuction care using open drainage, distributive compression, and bimodal compression is the result of uncomplicated clinical research. It was developed by comparing different clinical techniques in terms of postoperative edema, bruising, tenderness, comfort, convenience, personal hygiene, and patient preference. The clinical advantages of using open drainage and bimodal compression instead of prolonged high compression and sutured incisions become apparent and make a formal statistical test unnecessary.
Risk Reduction. With early liposuction, cannulas were large and required large incisions, which in turn required sutures for proper healing. With the tumescent technique and microcannulas, incisions are minuscule, and postliposuction healing is better when incisions are not closed with sutures.
Using sutures to close an incision was seen as necessary to prevent infections. Since the advent of nearly bloodless tumescent liposuction, many of the problems that necessitated closure of incisions with sutures no longer exist. Without tumescent vasoconstriction there was a relatively high incidence of hematomas and seromas, which provide an avascular medium for bacterial growth and infection. An open incision was believed to be a portal of entry for an infection.
With the tumescent technique, hematomas are rare, and the incidence of seromas is virtually eliminated by open drainage and good compression. Tumescent lidocaine further reduces the risks of infection because residual interstitial lidocaine is bactericidal.
Thus, the tumescent technique has reduced the risk factors for infection, and open drainage further reduces the risks.
Box 30-1 describes an exercise for a bilateral comparison of open drainage and sutures.
The trauma associated with tumescent liposuction differs from other types of trauma. The discriminating trauma of tumescent liposuction is controlled and precisely limited to adipose tissue. The superjacent dermis and subjacent muscle are not traumatized.
In contrast, the nondiscriminating trauma of crush injuries or the thermal trauma of burn injuries is typically associated with the third-spacing phenomenon. Third spacing results from the massive fluid shift from the intravascular space and interstitial space into the third space of a wound.
The high interstitial hydrostatic pressure and the intense vasoconstriction produced by tumescent technique preclude the occurrence of third spacing. Consequently, no intravenous (IV) fluid replacement is necessary with tumescent liposuction.
The tumescent technique’s profound vasoconstriction minimizes trauma-induced hemorrhage, inflammation, and edema. The most significant factors producing edema and inflammation after tumescent liposuction are as follows:
- Residual blood-tinged anesthetic solution, which contains trauma-induced inflammatory mediators and whole blood (approximately 1% to 2% by volume)
- Residual traumatized or necrotic adipose tissue
After tumescent liposuction the residual subcutaneous blood-tinged anesthetic fluid contains an excess of osmotically active macromolecules. After the widespread disruption of subcutaneous lymphatic capillaries by liposuction, these macromolecules cannot be resorbed and remain within the subcutaneous wound. The resulting osmotic gradient slowly produces net diffusion of fluid out of the intravascular space and into the subcutaneous wound. The clinical effect of this persistent subcutaneous hypertonic fluid is an insidious, protracted lymphatic edema (Figure 30-4).
To prevent this posttumescent liposuction edema, the surgeon actively promotes the rapid drainage of the inflammatory hyperosmotic fluid by using adits, leaving the incisions open (without sutures), and using bimodal compression.
Prevention or Treatment
Once postliposuction edema has occurred, little can be done to facilitate its resolution safely. Chronic lymphostasis may improve with mild intermittent compression, which augments lymphatic drainage.
For acute postliposuction edema, little evidence supports the assertion that therapeutic maneuvers such as massage therapy, intermittent external compression, or external ultrasound help resolve swelling. The temporary lymphostasis associated with routine tumescent liposuction rarely requires any therapeutic intervention other than early ambulation and physical activity. Postliposuction massage therapy may provide some short-term improvement, but no evidence indicates long-term beneficial effects.
The best approach to dealing with edema is to prevent its occurrence in any way possible. Open drainage and bimodal compression make a dramatic difference by decreasing the immediate postliposuction edema, bruising, and pain.
Even with open drainage, mild edema has its onset after drainage has ceased (Figure 30-5). With or without continued compression, this prolonged low-grade edema gradually decreases over several weeks. Because mild compression provides additional comfort during the initial weeks after surgery, some patients continue to wear a mild-compression garment for several days or weeks. Other patients, especially males, find the hassles of wearing an elastic compression garment outweigh its benefits.
Optimal postliposuction healing requires rapid and maximal drainage of blood-tinged tumescent anesthetic solution. This is best achieved by the following:
- Adits and open incisions (nonsutured)
- Superabsorbent compression sponges
- Optimal bimodal elastic compression garments
Adits. A microadit used in tumescent liposuction is a minuscule circular hole made by a tiny (1.0-mm, 1.5-mm, or 2-mm) skin biopsy punch. Adits facilitate and promote the open drainage of residual blood-tinged anesthetic solution associated with tumescent liposuction (see Chapters 27 and 28).
These small skin biopsy punches leave virtually no scars. Thus these punch excisions can be placed over any liposuction area with minimal risk of scarring. Adits are especially helpful over areas such as the thighs and the abdomen, where postoperative edema and bruising can be more pronounced than in other areas.
A 16-gauge or 14-gauge microcannula can easily pass through a 1.5-mm adit. In the thin elastic skin of the female breast, a 1.0-mm adit will accommodate both 16-gauge and 14-gauge microcannulas. Almost no epidermal friction occurs as the microcannula is pushed and pulled through the skin. A 12-gauge microcannula often requires a 2-mm adit. With careful liposuction technique, especially in an area of thin skin such as the inner thigh, a 1.5-mm adit can accommodate a 12-gauge microcannula with minimal epidermal trauma (see Chapter 27).
For the outer thigh the best site for an adit is the most dependent margin of the targeted area. A 16-gauge or 14-gauge microcannula is inserted through the tiny hole to create multiple liposuction tunnels to funnel the postoperative drainage to the adit opening.
The most important advantage to using round adits is that round holes remain patent for a longer period than a slit incision. Round 1.5-mm and 2-mm adits allow better drainage than simple incisions. The edges of a microincision may close and heal before the blood-tinged anesthetic has been completely drained, thus entrapping blood-tinged anesthetic solution in the subcutaneous space.
Several 2-mm punch excisions placed along the lower margin of the abdomen, above the pubic area, allow more drainage than tiny slit incisions. These adits and firm, uniform compression eliminate postliposuction ecchymosis and seromas and dramatically reduce postoperative swelling and tenderness (Figures 30-6 and 30-7).
Even with a large cannula and closure of incisions with sutures, the judicious use of adits provides all the advantages of open drainage. Their strategic use (1) improves the rate of recovery by decreasing the duration of postoperative bruising, swelling, and tenderness and (2) reduces the incidence of seromas and hematomas.
Elimination of Sutures. The most significant advantage of placing adits or eliminating sutures is the dramatic acceleration of recovery and reduction of postliposuction edema. Closing incisions with sutures contrasts greatly with allowing adits or incisions to remain open (Figure 30-8).
Using sutures has few advantages. Closing a relatively long incision with sutures may reduce scar formation. Nevertheless, sutures do not benefit a 4-mm microincision. Some surgeons close incisions with sutures because of a concern that the profuse drainage will alarm the patient and necessitate increased nursing care.1 With superabsorptive compression pads, however, drainage is no longer a concern.
The advantages of not using sutures include the following:
- More complete drainage results in less edema, less tenderness, and less ecchymosis.
- Adits and microincisions (5 mm or less) heal better without sutures because no suture-induced inflammation, foreign body reactions, or cross-hatch scars develop.
- Patients do not need to return for suture removal.
Patients become less apprehensive about the disconcerting appearance of blood-tinged drainage once it has been explained that the greater the drainage, the less the postliposuction bruising, swelling, and soreness.
Compression Sponges. Compression sponges or pads have two distinct functions. First, they completely absorb the copious tumescent drainage and thus improve patient comfort and hygiene. Containing SAP and cellulose, a 25 × 50–cm (10 × 20–inch) compression sponge can absorb up to 1000 ml of watery fluid.
Second, as noted earlier, these compression sponges or pads distribute the compressive force of an elastic garment over the treated area in a smooth, uniform manner. By uniformly compressing the dermal interstitial collagen, the interstices between the dermal collagen bundles are narrowed, and red blood cells are prevented from moving toward the skin surface. Thus bruising is prevented (Figure 30-9).
Superabsorbent compression sponges eliminate postoperative bruising in a way similar to adhesive-backed, closed-cell foam (e.g, Reston) when applied postoperatively over an area treated by liposuction. Compression pads are superior to foam, however, since adhesive foam must remain on the skin for several days, which precludes showering daily. The compression sponges are replaced once or twice daily, allowing patients to shower. Foam only reduces bruising; compression pads reduce (1) bruising by compression and (2) osmotic edema by facilitating open drainage.
The tradition of long-term use of high-compression garments after liposuction is a vestige of the earliest days of liposuction during the late 1970s and early 1980s.
Before the tumescent technique, liposuction created a proteinaceous mélange of clotted blood, inflammatory cytokines, prostaglandins, and fragmented adipose tissue. By closing incisions with sutures, this inflammatory detritus was trapped within the subcutaneous wound. Patients were required to endure weeks of being wrapped mummylike in special elastic adhesive “French” tape. Taking a normal shower or bath was not an option. Removing the tape could be so painful that some patients required systemic narcotic analgesia.
Eventually surgeons replaced the use of French tape with high-compression elastic garments. Either type of compression (graduated or uniform) resulted in a high rate of seroma formation, massive bruising, prolonged swelling, and tenderness. The patient’s return to normal activity was significantly delayed.
Tumescent liposuction, with its profound vasoconstriction, surgical hemostasis, and use of microcannulas, accelerated postoperative healing and virtually eliminated hematomas. Postoperative care, however, still needed improvement.
Misconception of High Compression
Chronic venous edema and acute postliposuction edema are different pathophysiologic processes. Leg edema due to venous disease is best treated and prevented by providing graduated leg compression beginning at 15 mm Hg, to more than 30 mm Hg distally, and decreasing proximally. In contrast, local edema due to tumescent liposuction can be largely prevented by open drainage and uniform (nongraduated) bimodal compression.
It is a misconception that the pathophysiology of acute postliposuction leg edema resembles chronic postphlebitic venous disease. Chronic venous insufficiency is caused by venous valvular incompetence, which leads to venous hypertension and a hydrostatic pressure gradient that favors chronic leakage of intravascular fluid into the interstitial tissues. Acute postliposuction edema is caused by posttraumatic hemorrhage, inflammation, and an osmotic pressure gradient.
This misconception has prompted many surgeons to assume, by analogy, that preventing edema after liposuction requires relatively prolonged, graduated high compression. In fact, high compression may exacerbate postliposuction edema by (1) compressing lymphatic vessels to the point of obstruction and (2) preventing the lymphatic clearance of large molecular and hyperosmolar exudates.
Effects of Excessive Compression. Prolonged high compression is only necessary when drainage is impeded by closing incisions with sutures. With traditional liposuction the subcutaneous voids and tunnels were filled with blood, clot, or hematoma. When traumatic exudate of liposuction is trapped within the subcutaneous space, high compression is unlikely to prevent development of a seroma, although it might impede enlargement of a seroma.
Constant external compression does not increase lymphatic pumping action or facilitate lymph flow. Constant compression applied externally to the skin tends to squeeze the delicate subcutaneous lymphatic capillary, causing the lumen to collapse on itself and preventing interstitial fluid from entering. Thus excessive, continuous external compression may impede lymphatic drainage and exacerbate postoperative edema. Without open drainage the compression delivered by traditional postliposuction garments could be detrimental.
When the interstitial pressure relative to atmospheric pressure is greater than 1 mm Hg, the rate of lymph fluid flow is maximal. Additional external pressure will not increase the rate of lymphatic fluid flow above the plateau value achieved at 1 mm Hg.2 An external compression garment producing 15 to 30 mm Hg, for example, will not increase the rate of lymph flow.
High compression without open drainage after liposuction may be harmful. In my experience, prolonged high compression that is continued after cessation of all drainage is unnecessary.
Graduated Versus Bimodal Compression
Therapeutic compression after liposuction differs from the type of compression used to treat leg vein disease. Varicose vein treatment requires compression to overcome venous hypertension. Prevention of perioperative deep venous thrombosis (DVT) requires compression to prevent the venostasis associated with the general anesthesia–induced loss of sympathetic vascular tone.
In contrast, compression after tumescent liposuction is used to expel the subcutaneous fluid containing the mixture of blood, fragmented adipocytes, and trauma-induced inflammatory exudate.
Lower extremity venous stasis is treated by a graduated compression garment. Graduated compression is necessary to counter the hydrostatic (gravitational) forces inside veins with incompetent valves.3 Because the hydrostatic force exerted by a vertical column of fluid increases as a function of the column’s length, venous pressure in leg veins with incompetent valves increases distally when the patient is upright. Graduated compression is necessary to counteract the progressive increase in physical forces exerted by fluid contained within the “closed” hydraulic system of the lower extremity.
After tumescent liposuction with open drainage, the goal is simply to maximize drainage. It is not necessary to combat intravascular hydrostatic pressure gradients. Graduated compression is not necessary after tumescent liposuction. For expelling blood-tinged anesthetic solution, open drainage and bimodal compression are more efficient and more comfortable. Bimodal compression garments are easier to apply and remove than graduated compression garments.
Bimodal Technique. Proper postoperative compression after tumescent liposuction requires two degrees of compression applied sequentially. That is, the compression after tumescent liposuction is bimodal. Bimodal compression involves two therapeutic phases: drainage and postdrainage.
Drainage Phase. During the drainage phase, high compression is applied immediately after liposuction to encourage drainage from adits and open microincisions. Uniform high compression maximizes drainage from the suctioned subcutaneous adipose tissue onto the absorptive dressings and minimizes postliposuction edema. With open drainage and high compression the tumescent drainage usually ceases in 24 to 72 hours. After liposuction of an unusually large abdomen or thigh, drainage may persist for several days.
Once all the drainage has ceased, external compression is no longer essential. The ultimate cosmetic result does not depend on continued compression after tumescent drainage has stopped.
Postdrainage Phase. During the postdrainage phase, after all the blood-tinged anesthetic solution has ceased draining, only a mild degree of compression is needed. After external drainage, lymphatic uptake is the only means of clearing the subcutaneous tissue of protein-laden edema fluid.
The function of mild compression is to augment interstitial fluid hydrostatic pressure just enough to counterbalance the increased interstitial fluid osmotic pressure and thereby slow the transudation rate of intravascular water. Mild compression also provides a sense of security during physical activity. For many patients, mild compression offers analgesia and comfort.
Trimodal Breast Compression
Most areas of the body do not require an exceptionally high degree of compression after liposuction. The breasts are an exception and require extra compression for the first 12 to 18 hours after tumescent liposuction.
This extra compression is necessary for optimal hemostasis. Without adequate external compression immediately after breast liposuction, there is an increased risk of postoperative bleeding, excessive ecchymosis, or hematoma. If the compression is too tight, the patient may experience pain or difficulty breathing.
The solution is to use an adjustable compression garment and apply maximal compression as tolerated. An adjustable compression garment is essential so that the patient can vary the tightness at any time. Special postoperative breast garments are available that allow the patient to adjust the degree of high compression to tolerance (see following physics section).
Immediately after liposuction of the female breasts, the degree of compression should be as tight as the patient can tolerate; this will optimize postoperative hemostasis.
After 12 hours of this extrafirm compression the immediate risk of hematoma and severe bruising is significantly less. Thus the day after surgery, if drainage is still occurring, the compression may be adjusted to a more moderate level.
Ultimately, after all drainage has ceased, the compression is again adjusted to a minimal level that is still sufficient to provide comfort and support.
Need for Improvement
The history of liposuction is marked by a lack of objective research directed toward improving postliposuction care. The standard technique consists of first closing all liposuction incisions with suture and then instructing the patient to wear a high-compression garment for 2 weeks or more. I know of no objective clinical evidence to support or justify this form of postoperative treatment.
A strongly held belief in the benefits of closing incision sites with suture and prolonged use of a high-compression garment is not a substitute for objective documentation. Advocates of a specific wound treatment tend to confuse conjecture with fact and to equate strong conviction with certainty.
Surgeons have an obligation to question ingrained dogma. Every therapy is imperfect and can be improved incrementally. With standard or traditional methods for postliposuction care, “common-sense” beliefs must be validated by the scientific method and improved accordingly.
Physics of Compression Garments
Understanding the forces of compression can help surgeons (1) evaluate techniques for postliposuction care and (2) appreciate the benefits of open drainage and bimodal compression after liposuction.
The physical forces acting on a stretched rubber band are the same as those affecting a cross section of a cylindrical compression garment. The analysis of a postliposuction compression garment can be simplified by considering the two-dimensional forces acting on a stretched rubber band.
Stretch, or deformation, is the fractional or percentage change in the length of a specimen. In mathematic symbolism, stretch = ΔL/L, where L is a unit of length.
In a static system, the elastic force vector (F) produced by a stretched rubber band is exactly countered by the force vector necessary to maintain the degree of stretching. The elastic force of a rubber band is defined as a force that is equal but opposite to the external force causing a deformation.
Within the range of useful applications, elastic force and stretch are proportional to each other. The constant of proportionality is called a modulus of elasticity (E), resulting in the following equation:
Elastic force = Modulus × Stretch
F = E (ΔL/L)
where ΔL/L is a dimensionless quantity, and E has the same dimension as force. Within a certain range the elastic force is a linear function of stretch.
If the force or stretch is increased beyond a certain limit, the yield strength, a rubber band quickly loses its ability to stretch and becomes permanently deformed. With an additional increment of applied force, the rubber band exceeds its ultimate strength and snaps.
Elastic Compression and Applications
Now suppose a rubber band is stretched around a cylindrical body. The magnitude of the force vectors is a direct function of the length of stretch.
In this static equilibrium situation, we know that the vector sum of all the external forces acting on the cylinder must be zero. Also, the vector sum of all the external torques that act on the cylindrical body, as measured at any point, must be zero. An elastic force vector is the vector sum of a tangential force vector and the perpendicular compression vector. Because the tangential vectors are equal in magnitude but opposite in direction, their vector sum must be zero, and the effect of the two opposed tangential vector forces can be ignored.
We only need to consider the net effect of the elastic compression vector, which is equal in magnitude but opposite in direction to the outward force exerted by the cylinder on the elastic garment. It is the compression vector that has true therapeutic significance when an elastic garment is applied to a cylindrical body.
Three interesting consequences of elastic compression have important applications to the use of compression garments.
1. Compression Sponges Increase Compression. When a circular elastic band is stretched around any circular cylinder without exceeding the range of elasticity, the greater the radius of the cylinder, the greater is the magnitude of radial (perpendicular) compression. In other words, the magnitude of radial compression at any point on the cylindrical circumference is directly proportional to the elastic force being applied by a stretched elastic garment (the tighter the garment is stretched in a tangential direction, the greater the degree of perpendicular compression).
Thus, for any given garment, the greater the circumference of the cylinder over which it is stretched, the greater is the degree of stretching, and thus the higher the degree of therapeutic compression. The effect of placing bulky compression sponges beneath a garment is to increase the stretch of the garment and increase the effective compression delivered to the patient’s body.
2. Two Garments Are Better Than One. The effect of two compression garments is additive. Consider two ribbons of elastic fabric A and B having identical length (L) and width. If the force required to stretch fabric A over a distance ΔL is half the force required to stretch fabric B over the same distance, A has an elastic modulus with a magnitude half that of B. If two well-fitting compression garments, each having an elastic modulus of 1, are worn simultaneously, their combined compression will be equivalent to a single garment with an elastic modulus of 2.
It is often easier for a patient to don or doff two garments with a low elastic modulus than one garment with a high modulus. Furthermore, when these two garments have a combined modulus that is greater than the single garment, their combined compression is better than the single high-compression garment. Using two garments, each with a modulus of 1.25, is therefore easier and provides more compression than a single compression garment with an elastic modulus of 2.
An elastic fabric with a high degree of resistance to stretching does not necessarily deliver the most effective therapeutic compression.
3. Degree of Curvature Affects Compression. The greater the degree (radius) of curvature at a point on a noncircular cylindrical body, the smaller is the compression vector (at that point) delivered by an elastic band under constant stretch. In other words, the compression vector is inversely proportional to the radius of curvature at any point on a noncircular cylindrical surface. Therefore, for any given cylindrical body at an area of abrupt surface curvature, a small radius of curvature exists, and the garment will produce a relatively high degree of compression. On another area of the same cylindrical body where the surface is flat, the radius of curvature is essentially infinite, and the degree of compression is negligible.
This observation has some useful clinical applications. By effectively decreasing the local radius of curvature, a bulky pad placed over a wound will accentuate the relative degree of compression beneath the pad.
- Pitman GH: Liposuction and aesthetic surgery, St Louis, 1993, Quality Medical Publishing.
- Guyton AC, Hall JE: The body fluid compartments. In Textbook of medical physiology, Philadelphia, 1996, Saunders.
- Straudinger P: Compression therapy: low or short stretch bandage and graduated compression stockings for leg edema, Dermatol Surg 21:106, 1995 (letter).
Figure 30-1 Six layers of compression sponge. 1, Absorptive layer of nonwoven mesh fabric is placed in direct contact with skin. 2, Dispersion layer consists of meshed fibers that transport fluids laterally. 3, First sponge layer of cellulose (plant fiber). 4, Layer of superabsorbent powder (SAP) becomes a gel as it absorbs large volume of water. 5, Second sponge layer of cellulose (plant fiber). 6, Impermeable plastic sheet provides waterproof barrier to prevent leakage of liquid onto clothing and beyond.
Figure 30-2 Compression sponges of various sizes are available. A, 25 × 25 cm; B, 25 × 37.5 cm; C, 25 × 50 cm. Impermeable plastic sheet backing is wrapped around edges of pad to prevent leakage caused by gravitational forces when patient is upright.
Figure 30-3 Technique for application of compression sponges and garments. A, Immediately after liposuction of abdomen, with patient supine, compression sponges are placed over treated area. Applying paper tape along edges reduces leaking. B, Elastic tube netting is applied over compression sponges. C, Elastic garment is donned; Velcro strips prevent binders from slipping out of place. D, Two elastic binders are placed around torso in overlapping fashion and tightened to degree patient can comfortably tolerate.
Figure 30-4 Open drainage reduces edema. A to C, Asymmetric edema is present in three different patients 24 hours after lateral thigh liposuction. Adit was placed on right lateral thigh at distal margin of treated area. In contrast, no adit was placed on left lateral thigh. No open drainage resulted in prolonged edema, bruising, and tenderness. This asymmetry typically persisted for several weeks.
Figure 30-5 Prolonged localized pitting edema is common sequela of impaired lymphatic capillary function after trauma caused by liposuction cannula. This type of edema occurs with or without use of open drainage and decreases progressively over 2 to 4 months.
Figure 30-6 Female abdomens. Anterior and lateral views of two female patients before abdominal liposuction and 48 hours after surgery. A1 to A4, First patient. B1 to B4, Second patient. Areas covered by compression sponges show minimal bruising or swelling. Bruising is apparent only on areas not covered by superabsorbent compression pads.
Figure 30-7 Male abdomen. A, Before tumescent liposuction. B, Compression sponges, adjustable torso garment, and binders in place immediately after liposuction of 950 ml of supranatant fat. C, Use of adits, open drainage, and bimodal compression 48 hours after surgery. Bruising or swelling is minimal except in areas where compression was minimal.
Figure 30-8 Sutures versus open drainage. After liposuction of both lateral thighs, sutures were placed in incisions on left side. Incisions on right side were left open to encourage drainage. A, Intense and extensive bruising results from closing incisions with sutures. B, Open drainage after liposuction of right lateral thigh results in minimal bruising.
Figure 30-9 Uniform compression prevents bruising. Wherever compression is insufficient, accentuated ecchymosis is more likely. This photograph demonstrates effects from embossed pattern on absorptive surface of old-style absorbent pad. Wherever embossed pattern on sponge’s absorptive surface impairs direct contact between sponge and skin, a corresponding pattern of bruising is seen. Ideally, compression sponge provides a uniformly smooth contact surface with skin and resists wrinkling.
|BOX 30-1 Clinical Experiment: Open Drainage Versus Sutures|
|Every liposuction surgeon must test the assertion that maximizing postoperative external drainage of blood-tinged anesthetic solution will minimize postliposuction edema, pain, and disability. Bilateral liposuction of the outer thighs provides an excellent opportunity for a simple and objective comparison of techniques for postliposuction care.|
|1. On the left outer thigh, after doing routine liposuction, place sutures in all incisions. This will minimize postoperative drainage.|
|2. On the right outer thigh, place one or more 1.5-mm punch excisions (adits) or routine slit incisions for cannula access. At least one adit should be located distally at the most dependent part of the treated area. To facilitate drainage, liposuction should be done through each adit. For maximal drainage, these adits should remain open without sutures. If such large cannulas are used that all incisions require sutures for proper healing, a few more adits should be placed specifically to facilitate drainage and strategically to maximize drainage.|
|3. Place superabsorbent pads over the treated area to manage the drainage and prevent leakage onto clothing and furniture.|
|4. Use an elastic garment to maintain a comfortably high degree of compression until all drainage has ceased (approximately 24 to 48 hours).|
|5. For the purposes of this clinical comparison, maintain external compression bilaterally for as long as you believe it is necessary.|
|a. Optimal prevention of edema on the thigh with the adits appears to require bimodal compression: high compression until all drainage has ceased, then mild compression. This mild compression comforts the patient and reduces the prolonged edema.|
|b. The ultimate cosmetic results are not affected by whether or not compression is maintained after all drainage has ceased.|
|6. Note that an excessively high degree of compression that is continued even after all drainage has ceased may be counterproductive. Prolonged high compression can impair the lymphatic uptake of edema fluid by compressing the lymphatic capillaries. Excessive postoperative edema of the lower extremities may predispose to deep venous thrombosis.|
|7. When using open drainage and bimodal compression, continued use of compression garments after drainage is recommended for comfort but is not required.|
|To evaluate the two methods of postoperative care (open drainage and closure with sutures), examine the patient twice during the week immediately after liposuction. You can expect to see an obvious difference in edema, ecchymosis, and tenderness. Analogous to the tumescent technique’s dramatic reduction of surgical bleeding, open drainage dramatically reduces postoperative edema, bruising, and tenderness. The clinical difference is apparent, and statistical analysis is unnecessary to decide which is the superior technique.|