Post Operative Care
The Tumescent Technique
The tumescent technique for liposuction uses a large volume of a dilute solution of lidocaine and epinephrine. The tumescent technique for liposuction has become the worldwide standard of care for liposuction because it has eliminated the common problem of surgical bleeding associated with older techniques. The dilute tumescent fluid contains both lidocaine for local anesthesia and dilute epinephrine that shrinks capillaries. After liposuction, a large volume of blood-tinged tumescent anesthetic solution remaining trapped under the skin may slow postoperative recovery.
Open Drainage and Bimodal Compression
This is a new method for post-liposuction care. It provides improved patient comfort, shortens the healing time, and decreases the number of postoperative visits to the surgeon. Open-drainage with bimodal compression is a modern technique that greatly reduces the degree of pain, swelling, bruising and convalescence time. Nevertheless, many surgeons and nurses continue to use antiquated post-liposuction care techniques that were used before the invention of the tumescent liposuction. This chapter will introduce you, and perhaps your surgeon to the newer technique for accelerating post-liposuction recovery known as Open-Drainage and Bimodal Compression.
Traditional After-Liposuction Care Methods
Traditional After-Liposuction Care Methods rely on 1) the closure of incisions with sutures and 2) the prolonged use of high compression elastic garments for two weeks or more. Most liposuction surgeons would agree that these traditional methods of caring for patients after liposuction leave much room for improvement. The common undesirable characteristics of the healing phase after liposuction include protracted swelling, bruising, tenderness, as well as time-consuming post-operative follow-up visits with the surgeon.
Minimizing Swelling, Bruising, & Tenderness
Swelling, bruising, tenderness are the result of 1) persistent blood-tinged tumescent anesthetic solution trapped under the skin after liposuction, and 2) injury to subcutaneous lymphatic capillaries caused by the liposuction procedure. Lymphatic capillaries are small vessels that drain fluid away from injured body tissues. Temporary injury to lymphatic capillaries as a result of liposuction cannot be avoided. However the persistence of blood-tinged tumescent solution trapped under the skin can be prevented. Older techniques for post-liposuction care do not facilitate rapid drainage of this blood-tinged anesthetic solution. The newer technique known as "open drainage" diminishes the swelling and speeds recovery after tumescent liposuction.
Prolonged High-Compression In the Old Days
Prolonged High-Compression in the old days was necessary. Before the tumescent technique for liposuction, bleeding was the major problem associated with liposuction. After a liposuction had been completed, patients had to wear a high compression garment for many weeks in order to minimize the problems caused by so much bleeding. Immediately after surgery the high compression garments were required to compress the bleeding vessels and stem the loss of blood. Patients continued to wear high compression garments for up to six weeks in order to decrease the swelling caused by the blood trapped beneath the skin.
Prolonged Compression Now Makes Matters Worse
Now that tumescent technique has become the standard of care, the traditional post-liposuction techniques, established before the invention of the tumescent technique, may now contribute to delayed healing and prolonged swelling. With tumescent liposuction there is no need for prolonged high compression because there is no significant bleeding during surgery, and virtually no blood remains trapped beneath the skin. After tumescent liposuction, closing incisions with sutures will prevent drainage of residual blood-tinged anesthetic solution, and encourage swelling. In addition, the prolonged use of excessive compression after tumescent liposuction will compress the subcutaneous lymphatic capillaries and impair the lymphatic drainage system that is responsible for removing fluid from injured tissues. After tumescent liposuction, the goal is to maximize the rate of drainage of residual blood-tinged tumescent anesthetic solution.
Preventing swelling, bruising and inflammation before they occur by removing the subcutaneous blood-tinged fluids and encouraging lymphatic drainage is the ideal method for post-liposuction care. The method known as Open-Drainage achieves these results by 1) encouraging open drainage by not closing incisions with sutures, 2) the use of special pads that both absorb the messy blood-tinged drainage and reduces bruising by uniformly distributing the compression of elastic garments, and 3) using special elastic compression garments designed for optimal drainage as well as patient convenience and comfort.
Open-Drainage after tumescent liposuction refers to the technique for maximizing the drainage of blood-tinged tumescent solution by 1) using small adits which are tiny round holes (1 mm, 1.5 mm or 2 mm in diameter) made by skin-biopsy punch to facilitate postoperative drainage, 2) placing adits in strategic locations in order to maximize gravity-assisted drainage, 3) allowing the adits to remain open instead of being closed with sutures.
Fewer Postoperative Visits
Fewer postoperative visits to the surgeon's office can save time and hassle for the patient and the patient's family. Because there are no sutures to be removed, the patient can eliminate the need to return to the surgeon to have the sutures removed. Because there is less swelling, and pain with Open-Drainage, there is less need for the patient to return to see the surgeon in the early postoperative period for time-consuming follow-up examinations. Patients should feel free to return to see the surgeon if there is any concern about the healing process. On the other hand, if everything is healing well and the patient has no significant concerns then the first follow-up visit is often not until six weeks after surgery.
These prevent staining clothes and furniture, and to avoid the "sight of blood" that would otherwise accompany the drainage of blood-tinged tumescent fluid. For example, the HK Pads that measure 12 x 20 inches weigh just 6 ounces and have the capacity to absorb more than a liter (two pounds= 32 ounces) of water, or more than 5.5 times their own weight. In practice, the absorbent pads have two distinct functions. First, they absorb the large volume of tumescent drainage to improve patient comfort and hygiene, and secondly the pads distribute the elastic garment's compressive force more uniformly. This uniform compression narrows the gaps between interstitial collagen bundles in the dermis and prevents red blood cells from moving toward the skin surface where it appears as a bruise. HK Pads (US Patent 6,162,960) are the only commercially available pads of this type.
Adhesive Foam Pads
Adhesive foam pads such as Reston foam can decrease bruising, but not swelling, when applied to the skin over an area treated by liposuction. Reston foam has been associated with an increased risk of infection, skin ulceration and skin necrosis. Some surgeons continue to use Reston foam after liposuction. The manufacturer of Reston foam, the 3M Corporation, has advised surgeons that Reston foam is not intended to be used for liposuction.
Bimodal Compression refers to the sequential use of two different stages of post-liposuction compression. During the first stage of bimodal compression, a high degree of compression is maintained for as long as drainage persists, plus an additional 24 hours past the time when all drainage has ceased. The second stage of bimodal compression begins 24 hours after all drainage has ceased, and employs either moderate compression or no compression. Some patients prefer to continue wearing a minimally compressive garment for comfort. Optimal compression garments should maximize the rate of open drainage, while minimizing the risk of complications due to excessive compression such as blood clots in the legs and lungs. An ideal garment must also be able to accommodate bulky absorbent pads, and be easy for the patient to apply and remove without assistance.
The Ideal Elastic Compression Garment
The ideal elastic compression garment must be easily put-on and taken-off by the patient without assistance, and it must easily accommodate the use of bulky super-absorbent pads that are necessary when open-drainage is used to accelerate healing.
Traditional Elastic Compression Garments
Most of the available elastic compression garments have a traditional design. Traditional garments usually have a zipper on the side and are made of an elastic cloth that is relatively resistant to stretching. Traditional garments are relatively difficult to put-on or take-off without assistance. This difficulty is especially troublesome for someone who has just had liposuction and is sore, swollen and unable to easily bend-over and wiggle into a tight garment.
Why don't more surgeons use open drainage?
Some surgeons simply do not appreciate the advantages of open-drainage after tumescent liposuction. Other surgeons persist in the opinion that the prolonged high compression provided by traditional compression garments is necessary and they do not feel confident using any other type of garment. Traditional compression garments are difficult to put-on when bulky, super-absorbent pads, have been placed on the patient. It is easier to simply close all of the incisions with sutures, and thus the problem of messy drainage. The use of open-drainage without the use of super-absorbent pads, would produce a very messy situation. The blood-tinged fluid would drain out of incisions and onto the patient's clothing, bedding, carpets and furniture. Another solution to this problem is to use garments that provide both high compression and that can accommodate the use of super-absorbent pads.
Garments Designed for Open-Drainage
HK garments produced by HK Surgical, Inc., are examples of elastic compression garments that provide high compression, that are designed to accommodate bulky super-absorbent pads, and that are easy to put-on and take-off without assistance. HK Torso Garments are elastic garments worn over the torso with additional elastic binders to provide adjustable compression after liposuction of the abdomen, hips, waist, or breasts HK Over-all Garments, are usually worn two at a time, one on top of the other, and are used after liposuction of the thighs or hips, or abdomen. Each garment when worn alone provides a moderate degree compression, but when two garments are worn at the same time, their compression is additive, and together they provide a high degree of compression. It is much easier for a patient to put on two moderate-compression garments which can be done without assistance, than it is to apply a single high-compressive garment that often requires the assistance of a spouse or friend.