Please note that some of the images in this article have been edited to preserve patient privacy.
Today, Dr. Luis Botero has invited me to observe surgery at IQ Interquirofanos in the Poblado section of Medellin. He is performing full-body liposuction and fat grafting of the buttocks.
The facility: IQ Interquirofanos
IQ Interquirofanos is an ambulatory surgery center located on the second floor of the Intermedica Building across the street from the Clinica de Medellin (sede Poblado). The close proximity of this clinic to a hospital is an important consideration for patients in case of a medical emergency.
The anesthesiologists estimate that 90% of the procedures performed here are cosmetic surgeries but surgeons also perform gynecology, and some orthopedic procedures at this facility.
The are seven operating rooms that are well-lit, and feature modern and functional equipment including hemodynamic monitoring, anesthesia / ventilatory equipment/ medications. There are crash carts available for the operating rooms and the patient recovery areas.
There are fourteen monitored recovery room beds, while the facility currently plans for expansion. Next door, an additional three floors are being built along with six more operating rooms.
Sterile processing is located within the facility with several large sterilization units. There is also a pharmacy on-site. The pharmacy dispenses prosthetics such as breast implants in addition to medications.
The only breast prosthetics offered at this facility are Mentor (Johnson & Johnson) and Natrelle brand silicone implants (Allergan). In light of the problems with PIP implants in the past – it is important for patients to ensure their implants are FDA approved, like Mentor implants.
In the past seven years, over 31,000 procedures have been performed at Interquirofanos. The nurses tell me that during the week, there are usually 30 to 35 surgeries a day, and around 15 procedures on Saturdays.
Prior to heading to the Operating Room:
Prior to surgery, patients undergo a full consultation with Dr. Botero and further medical evaluation (as needed). Patients are also instructed to avoid aspirin, ibuprofen and all antiplatets (clopidogrel, prasugrel, etc) and anti-coagulants (warfarin, dabigatran, etc.) for several days. Patients should not resume these medications until approved by their surgeon.
All patients are required to purchase complication insurance. This insurance costs between 75.00 and 120.00 dollars and covers the cost of any treatment needed (in the first 30 days) for post-operative complications for amounts ranging from 15,000 dollars to 30,000 dollars, depending on the policy. All of his clients who undergo surgery at IQ Interquirofanos are encouraged to buy a policy from Pan American Life de Colombia as part of the policies for patient safety at this facility. International patients may also be interested in purchasing a policy from ISPAS, which covers any visits to an ISPAS-affiliated surgeon in their home country.
Today’s Procedures: Liposuction & Fat Grafting
Liposuction – Liposuction (lipoplasty or lipectomy) accounts for 50% of all plastic surgery procedures. First the surgeon makes several very small slits in the skin. Then a saline – lidocaine solution is infiltrated in to the fat (adipose) tissue that is to removed. This solution serves several purposes – the solution helps emulsify the fat for removal while the lidocaine-epinephrine additives help provide post-operative analgesic and limit intra-operative bleeding. After the solution dwells (sits in the tissue) for ten to twenty minutes, the surgeon can begin the liposuction procedure. For this procedure, instruments are introduced to the area beneath the skin and above the muscle layer.
During this procedure, the surgeon introduces different canulas (long hollow tubes). These tubes are used to break up the adipose tissue and remove the fat using an attached suctioning canister. To break up the fat, the surgeon uses a back and forth motion. During this process – one hand is on the canula. The other hand remains on the patient to guide the canulas and prevent inadvertent injury to the patient.
Due to the nature of this procedure, extensive bruising and swelling after this procedure is normal. Swelling may last up to a month. Patients will need to wear support garments (such as a girdle) after this procedure for several weeks.
Types of liposuction:
In recent years, surgeons have developed different techniques and specialized canulas to address specific purposes during surgery.
Standard liposuction canulas come in a variety of lengths and bore sizes (the bore size is the size of the hole at the end of the canister for the suction removal of fat tissue.) Some of these canulas have serrated bores for easier fat removal.
Ultrasound-assisted liposuction uses the canulas to deliver sound waves to help break up fat tissue. These canulas are designed for patients who have had repeated liposuction. This is needed to break up adhesions (scar tissue) that forms after the initial procedure during the healing process.
Laser liposuction is another type of liposuction aimed at specifically improving skin contraction. This is important in older patients or in patients who have excessive loose skin due to recent weight loss or post-pregnancy. However, for very large amounts of loose skin or poor skin tone in areas such as the abdomen, a larger procedure such as abdominoplasty may be needed.
During laser liposuction, a small wire laser is placed inside a canula to deliver a specific amount of heat energy to the area (around 40 degrees centrigrade). The application of heat is believed to stimulate collagen production (for skin tightening). Bleeding is reduced because of the cautery effect of the heat – but post-operative pain is increased due to increased inflammatory effects. There is also a risk of burn trauma during this procedure.
There have been several other liposuction techniques that have gone in and out of fashion, and many of the variations mentioned are often referred to by trademark names such as “Vaser”, “SmartLipo”, “SlimLipo” which can be confusing for people seeking information on these procedures.
Fat grafting is a procedure used in combination with liposuction. With this procedure, fat that was removed during liposuction is relocated to another area of the body such as the buttocks, hands or face.
In this patient, Dr. Botero injects the fat using a large bore needle deep into the gluteal muscles to prevent a sloppy, or dimpled appearance. Injecting into the muscle tissue also helps to preserve the longevity of the procedure. However, care must be taken to prevent fat embolism*, a rare but potentially fatal complication – where globules of fat enter the bloodstream. To prevent this complication, Dr. Botero carefully confirms the placement of his needle in the muscle tissue before injecting.
Results are immediately appreciable.
Patient was appropriately marked prior to the procedure. The patient was correctly prepped, drapped and positioned to prevent injury or infection. Ted hose and sequential stockings were applied to lessen the risk of developing deep vein thrombosis. Pre-operative procedures were performed according to internationally recognized standards.
Sterility was maintained during the case. Dr. Botero appeared knowledgeable and skilled regarding the techniques and procedures performed.
His instrumentadora (First assistant), Liliana Moreno was extremely knowledgeable and able to anticipate Dr. Botero’s needs.
Circulating nurse: Anais Perez maintained accurate and up-to-date intra-operative records during the case. Ms. Perez was readily available to obtain instruments and supplies as needed.
Overall – the team worked well together and communicated effectively before, during and after the case.
Anesthesia was managed by Dr. Julio Arango. He was using an anesthesia technique called “controlled hypotension”. (Since readers have heard me rail about uncontrolled hypotension in the past – I will write another post on this topic soon.)
However, as the name inplies – controlled hypotension is a tightly regulated process, where blood pressure is lowered to a very specific range. This range is just slightly lower than normal (Systolic BP of around 80) – and the anesthesiologist is in constant attendance. This is very different from cases with profound hypotension which is ignored due to an anesthesia provider being distracted – or completely absent.
With hypotensive anesthesia – blood pressure is maintained with a MAP (or mean) of 50 – 60mmHg with a HR of 50 – 60. This reduces the incidence of bleeding.
However, this technique is not safe for everyone. Only young healthy patients are good candidates for this anesthesia technique. Basically, if you have any stiffening of your arteries due to age (40+), smoking, cholesterol or family history – this technique is NOT for you. People with high blood pressure, any degree of kidney disease, heart disease, peripheral vascular disease or diabetes are not good candidates for this type of anesthesia. People with these kinds of medical conditions do not tolerate even mild hypotension very well, and are at increased risk of serious complications such as renal injury/ failure or cardiovascular complications such as a heart attack or stroke. Particularly since this is an elective procedure – this is something to discuss with your surgeon and anesthesiologist before surgery.
The patient today is young (low 20’s), physically fit, active with no medical conditions so this anesthesia poses little risk during this procedure. Also the surgery itself is fairly short – which is important. Long/ marathon surgeries such as ‘mega-makeovers‘ are not ideal for this type of anesthesia.
However, Dr. Arango does an excellent job during this procedure, which is performed under general anesthesia. After intubating the patient, he maintained a close eye on vital signs and oxygenation. The patient is hemodynamically stable with no desaturations or hypoxia during the case. Dr. Arango remains alert and attentive during the case, and remains present for the entire surgery. Following surgery, anesthesia was lightened, and the patient was extubated prior to transfer to the recovery room.
He also demonstrated excellent knowledge of international protocols regarding DVT/ Travel risk, WHO safety protocols and intra-operative management.
Surgical apgar score: 9 (however, there is a point lost due to MAP of 50 – 60 as discussed above).
Results of the surgery were cosmetically pleasing.
Post -operative care:
Prior to discharge from the ambulatory care center after recovery from anesthesia the patient (and family) receives discharge instructions from the nurses.
The patient also receives prescriptions for several medications including:
1. Oral antibiotics for a five-day course**. Dr. Botero uses this duration for fat grafting cases only.
2. Non-narcotic analgesia (pain medications).
3. Lyrica ( a gabapentin-like compound) to prevent neuralgias during the healing period.
The patient will wear a support garment for several weeks. She is to call Dr. Botero to report any problems such as unrelieved pain, drainage or fever.
Note: after some surgeries like abdominoplasty, patients also receive DVT prophylaxis with either Arixtra or enoxaparin (Lovenox).
Dr. Botero will see her for her first follow-up visit in two days (surgery was on a Saturday). He will see twice a week the first week, and then weekly for three weeks (and additionally as needed.)
* Fat embolism is a risk with any liposuction procedure.
**This is contrary to American recommendations as per the National Surgical Care Improvement Project (SCIP) which recommends discontinuation within the first 24 hours to prevent the development of antibiotic resistance.