Cultural and ethnic differences in the acceptance or rejection of liposuction instrumentation entrance marks

Journal of Drugs in Dermatology, Jan, 2007 by Lawrence M. Field

Abstract

The acceptance of visible marks on the skin as a result of surgical procedures varies by the necessity of the procedure (ie, cosmetic or not) and by the cultural interpretation of those sequelae. As liposuction has become the most commonly performed major cosmetic procedure in the US, and perhaps throughout the world, the visible stigmata resulting from the surgical invasion may be of major consequence to some while they remain of little or no consequence to others. This article explores the national, cultural, racial, and ethnic variations in the acceptance or rejection of visible marks on the skin in several parts of world.

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Differences in scar acceptability vary throughout the world depending on factors such as the indication for surgery (ie, necessary or cosmetic), the culture, the nationality, and variations in racial ethnicity. The general parameters of healing in pigmented people are well-documented with reference to keloid propensity, hypopigmentation, and hyper-pigmentation. General nutrition and pre- and postoperative care vary widely, primarily relative to income, physician and nursing care, nutrient availability, and environment for surgical care. Taking these variables into consideration, what can we determine about the acceptability or rejection of cosmetic scars around the world, with special reference to residual cutaneous defects following entrance wounds for liposuction procedures?

Investigation reveals a multitude of instruments used for entrance wounds, including the #15 blade, the #11 blade, the Pokar (a concept of Fournier, P of Paris, France; ie, an ice pick-like device that penetrates through collagen and elastin by spreading but without cutting them), and variously-sized hollow trephines (1.5-3 mm in diameter) that are now only rarely sutured, thus allowing drainage. Each of these is utilized according to surgeons' preferences, some with very few penetrations, some with planned patterns, and others with very liberal and random approaches. Indeed, with a surgeon's approach it is possible to view the entire abdomen, hips, flanks, medial thighs, anterior thighs, and knees through a single periumbilical incision (H. Tobin, unpublished data, circa 1975), a #11 blade angled obliquely to the surface circumambulating the entire abdomen every several centimeters (P. Lillis, unpublished data, circa 1998), and using "punches" to core out 2 mm approaches and drainage sites in 4 to 6 predetermined loci (J Klein, unpublished data, circa 2002). Each approach tends to leave its own signature and heals slightly differently.

Those of us who have dealt primarily with well-healing light-skinned Caucasians have been fortunate as we frequently do not have to consider the long-term aesthetic effects. Although many feel it makes no difference in Caucasian skin, the author's experience has been to the contrary. Even though individual preferences do occur, every surgical intrusion into the skin should be planned to give the best healing possible. In pigmented skin, this dictum becomes even more rigid. Although the small dimpled defect of hollow-core punches is almost invisible in white skin, it may still leave white cicatrix, sometimes occurring in an ice-pick-like configuration. This may be totally unacceptable in darker skin with its increased light or white scar visibility. All pigment types may show hyperpigmented frictional loci (Figures 1-2), progressively darkening with increased melanin availability and inflammatory response in healing. The placement and number of these loci may be matters of great import to particular patients and particular cultures. Therefore, it is absolutely mandatory for each and every liposuction surgeon, regardless of where he or she practices, to demonstrate to each and every patient exactly where entrance wounds will be made and what the likely esthetic consequences of those intrusions will be. In a wonderfully erudite letter, Daly writes "at pre-op consultation, I show potential LSS patients photos of how my other patients' liposuction marks look from the Columbia Manual of Dermatologic Cosmetic Surgery textbook, to be sure they understand how their (tiny #15 blade stab along Langer's lines) marks will look and how stretch marks and cellulite are not corrected and even look worse after LSS." Daly further takes the time to precisely steri-strip her entrance wounds with a crisscross technique, reapproximating the stab wound along Langer's lines. She further supplements scar therapy with vascular lasers and triamcinolone. "Multiple postinflammatory hyperpigmentation marks from intrusion at the inner thighs were considered due to cannula tip choice, ultrasound/laser-assisted LSS with excess heat, or maybe just super aggressive strokes up at the underside of the poor dermis. A series of intralesional Kenacort 2 and 5 mg/cc and hydroquinone 4% were of assistance" (D. Daly, written communication, 2006). It was further noted in a multiracial and mixed cultural population that: