SAFETY OF LARGE-VOLUME LIPOSUCTION, DANIEL LANZER, M.D.
INTERNATIONAL JOURNAL OF COSMETIC SURGERY and AESTHETIC DERMATOLOGY
Volume 4, Number 3, 2002 © Mary Ann Liebert, Inc.

ABSTRACT

Large-volume liposuction in excess of 4 liters supernatant fat can be performed safely. However, it requires special care and treatment. The following paper illustrates the author’s approach, which is directed to reduce the risks of the potential causes of mortality. The study outlines the guidelines that the author followed in treating more than 5,000 patients over a ten-year period.

INTRODUCTION

LIPOSUCTION has been practiced for more than 20 years. Initial liposuction performed by Giorgio Fischer in Italy in 1975 was a procedure associated with blood loss and other significant complications. The major breakthrough occurred in 1987 with the development of the tumescent technique by dermatologic surgeon Jeffrey Klein.(1) He showed that by infiltrating extremely large volumes of a dilute local-anesthetic- containing solution he was able to reduce bleeding, and the procedure could be performed under local anesthetic or light sedation. Many specialties have taken to liposuction. However, a study by Grazer and de Jong(2) of plastic surgeons indicated that there has been a significantly high death rate from liposuctions during the last few years. Although other specialties have shown a significantly lower rate of mortality, there are lessons for all surgeons to learn.

GRAZER AND DE JONG’S RESULTS

In their study there were 95 liposuction-related fatalities in nearly half a million procedures by members of the American Society of Plastic and Reconstructive Surgeons (Table 1). This yielded a death rate of 1:5000 procedures. Despite the fact that the study did not show that the volume of fat removal was related to death rate, there has been a general conservative approach taken by most Colleges to make liposuction as safe as possible. It is the author’s definition that large-volume liposuction involves removal of in excess of 4L supernatant fat on one occasion. However, in the correct setting, 7L supernatant fat can be removed at one time. Preoperative assessment should include the general health of the patient, the overall body mass, and the entire clinical picture. The author has performed more than 5,000 liposuctions, with a significant proportion involving removal of more than 4L. This article will assess the causes of death reported in the article by Grazer and de Jong and establish an approach to liposuction in large volumes that produces the safest outcome. In approaching the safety factors for largevolume liposuction, it is appropriate to look at the main causes of death and to direct our therapies to preventing these. In each factor the surgeon needs to focus on the preoperative, operative, and postoperative factors.

CAUSES OF DEATH

Infection
Infection is the easiest complication to prevent, and all patients need a general work-up. Patients who have underlying diabetes or who are smokers have a higher risk of infection with all procedures. Liposuction is not contraindicated in this clinical setting; however patients need to be made aware both by oral and written communication that the risks are higher and that there is potential consequence of an infection. All patients should commence preoperative antibiotics the night before the procedure; oral cephalosporins in the range of 500 mg twice daily are sufficient. Antiseptic washes should be applied to the entire body, in particular to the flexures, both the night before and immediately before surgery. During the procedure all standard sterile techniques must be utilized. This is important regardless of whether the patient is in the accredited day surgery of a hospital or in an outpatient setting. All patients undergoing large-volume liposuction should receive intravenous antibiotics at the start of the operation. It has recently been shown that lidocaine is also antibacterial and this may be the reason for the low incidence of infection in liposuction. Using the tumescent technique, in which large volumes are infiltrated to the maximum volume, probably will reduce the risk of infection. It is important to use the latest liposuction techniques with fine cannulas to reduce deep bruising and seromas, which could enhance the risk of infection. Cannulas should always be 4 mm or smaller in diameter. A girdle should be worn postoperatively to reduce empty dead space following the removal of large volumes of fat. The surgeon needs to observe the skin and wounds regularly postoperatively. Any signs of erythema or other indications of infection need to be treated aggressively, such as with a combination of amoxicillin (Augmentin Duoforte) and metro-nidazole (Flagyl). It is important to treat potential gram-positive and negative cocci and anaerobic infections. The surgeon should not wait for obvious pus or ulceration before commencing treatment with antibiotics. Necrotizing fasciitis is a serious condition and needs to be treated aggressively. Patients presenting with unusual pain, tenderness, or surface blistering should be treated aggressively with antibiotics as these may be early signs. Intravenous antibiotics should also be considered if the signs of infection are progressing.

Perforations
The clinical assessment preoperatively should include observation for any signs of hernias or previous scars. In these instances the peritoneum of the abdomen could in theory be attached to the skin and perforation would occur with liposuction. Therefore, the mobility of the scars from the underlying tissue needs to be assessed. Divarication of the abdominal musculature is common. It is important to point this out to patients so that they will not be surprised that the stomach is not flat postoperatively and so that the surgeon will take particular care in this region and not damage the peritoneum. During the procedure, technique is critical in order to prevent perforations. Infiltrate the tumescent fluid to its maximum capacity. This will help to separate the fat from the underlying abdominal wall. Liposuction performed under local anesthetic is probably safer with regards to perforation, because patients would be aware if the cannula was passing too deep towards the abdomen. Surgeons should always use the contralateral hand to feel the position of the liposuction cannula. When removing large quantities of fat, deeper layers of fat can also be removed. A technique whereby the surgeon elevates the skin with the contralateral hand and then continues to pass the cannula horizontally is also effective and safe. Surgeons should use multiple entries to keep the cannula in a comfortable and horizontal position. Particular care needs to be taken when passing the cannula upwards towards the ribs: many perforations have occurred in this region with the cannula slipping under the rib cage. The author also recommends the superficial liposuction technique. This involves aggressive liposuction on the surface under the skin. The advantage is that it maximizes the amount of fat removed, causes significant skin contraction, and allows a safe layer-by-layer removal of fat, thus lowering the risk of deep perforations. Surgeons and nursing staff need to be aware of the potential risk of perforation postoperatively. There have been reported cases of patients complaining about severe and persistent pain, and the perforation has not been detected until severe peritonitis was in place. Any unusual pain or tenderness should be investigated fully.

Hemorrhage
Preoperative blood tests are critical to assess the patient’s bleeding diathesis. A full history of drug use may be important, particularly aspirin and anticoagulants. Patients should be asked if they have a bleeding tendency. The surgical technique also prevents bleeding. A number of surgeons are hesitant to infiltrate the tumescent fluid to its maximum capacity and thereby do not get the full affect of the epinephrine with the localized pressure, which produces the maximum vascoconstriction. There is also some merit in waiting 10–15 min before suction commences in order to maximize the vasoconstriction after the infiltration period. The surgeon should keep a watchful eye on the suction tube throughout the liposuction and move away from areas where bleeding is noticed. Cannula size plays a role in the tendency for bleeding and postoperative hematoma. A 4 mm diameter cannula should be the largest used. Bleeding and deep hematomas are particularly likely on large abdomens and tend not to occur on other areas. Surgery on very large abdomens should be split into two stages to reduce the risk of bleeding in this region. Ice applied postoperatively will reduce the bleeding tendency, as will wearing of a firm pressure garment.

Anesthesia
Patients need to be assessed preoperatively as to their general health, especially liver function, since lidocaine is broken down by the liver. Many drugs have been reported to interfere with the breakdown of lidocaine.(1) The generally accepted maximum lidocaine level is 55 mg/kg. Surgeons have attempted to use higher levels, but this is now considered unwise. An advantage of performing large-volume liposuction under general anesthetic is that the amount of lidocaine can be reduced due to the general anesthetic. The author’s approach is generally to use a quarter strength lidocaine concentration when patients are under general anesthesia. In an 80 kg patient who is having eight L bags of fluid infiltrated, the patient would tolerate a maximum dose of 4400 mg, based on a 55 mg/kg regimen. This would amount to 550 mg per bag. If the procedure is done under general anesthetic, the lidocaine dose would be reduced to one-quarter strength: 125 mg per bag. As a result, the patient would receive only a total of 1000 mg. This would amount to only 12.5 mg/kg, which is well below the safety recommendation of 55 mg/kg. Even though the patient is under general anesthesia, it is still recommended to add lidocaine to the infiltrating fluid to reduce postoperative pain, reduce infection, and allow administration of a general anesthetic under a light laryngeal mask. Surgeons need to be aware that the peak concentration of lidocaine often occurs 12 h after the operation. All patients undergoing very large-volume liposuction should be kept in the hospital for observation overnight. Surgeons and nursing staff should be aware of early signs of lidocaine toxicity, such as disorientation and tingling around the mouth. Oxygen is the initial treatment. Cardiorespiratory failure Infiltrating large quantities of tumescent fluid at the start of surgery in theory could cause excessive absorption and cardiac failure. Patients undergoing liposuction are generally in good health and those having large-volume liposuction certainly should not have pre-existing cardiac disease. Patients who are compromised in any way should have the procedure done in two stages. Older patients may require preoperative investigations such as an electrocardiogram and chest x-ray. During the operation there is a balance between the need to infiltrate the fluid rapidly in order to shorten the length of the operation and the need not to induce fluid overload. The author believes that a maximum limit of 10L infiltration fluid in one sitting is appropriate. As a general rule, the amount of fluid that is removed matches the amount of fluid infiltrated. Generally the supernatant fat is between 60 and 70% of the total amount of fluid removed. Patients undergoing very-large-volume liposuction should have the procedure performed in two or three stages. It is worthwhile to use two stages for abdominal procedures, since this is the area most likely to develop postoperative hematoma and infection. Postoperative patients should not receive intravenous fluids other than to keep a line open. Inpatient monitoring would be necessary for large-volume liposuction.

Deep venous thrombosis/pulmonary embolus
There may be a genetic and personal tendency for pulmonary embolus in patients and this should be identified on their personal history. Drugs that may enhance clotting should also be ceased. During the procedure the surgical time is the critical factor in reducing the risk of pulmonary embolism. By having two surgeons operating simultaneously on either side of the bed when a patient is under general anesthesia, most large-volume liposuctions can be completed within 90 min. Liposuction should not be combined with other procedures that will significantly enhance the length of the operation, such as face lift. This is one of the findings shown in the Grazer and de Jong study. Liposuction generally should not be combined with lipectomy. Lipectomy has a significantly higher risk of pulmonary embolism, and combining the two certainly raises the risk. Subcutaneous enoxaparin (Clexane) 20 mg is given towards the end of the procedure and may reduce deep venous thombosis. There is a dispute as to whether calf stimulation is of any assistance in reducing deep venous thombosis and may be used if thought necessary. Patients should become active soon after the procedure. There have been cases of deep vein thrombosis from excessive compression due to garments pressing into the groin, and this needs to be observed.

Hypothermia
Although this is a rare cause of death, the infiltration of large quantities of fluid at room temperature may cause significant hypothermia. The surgeon and nursing staff need to be aware of this, and a bair hugger or heated space blanket should be applied during the procedure. This is a dispute as to whether preheating the fluid may be worthwhile; the problem with that is the increased vasodilatation and bleeding.

CONCLUSIONS

Large-volume liposuction can be performed safely (Fig 1, 2). It needs particular care and attention. Doctors need to be aware of the causes of death and to make sure that their treatment and approach are oriented to reducing the risks of these. The author has performed over 5,000 liposuctions, many of which would be classified as large-volume liposuction. Large-volume liposuction can be performed under local anesthetic, sedation, or general anesthetic. The author’s preference is general anesthetic because this allows him to remove more fat more rapidly with less lidocaine. The patients tend to experience less stress from the procedure as well. It is the preference of the author that patients remain in the hospital overnight for monitoring. Preoperative assessment is critical, particularly for patients’ general health, drug use, and commencement of antibiotics. The operative procedure used plays a significant role in the safety of liposuction and there are varying techniques. The author believes in large-volume infiltration, small cannulae but not microcannulae in this setting, together with aggressive controlled superficial liposuction. Postoperative close care is also essential and aggressive treatment of any complications is required.

REFERENCES

1. Klein, J.A.: Tumescent Technique, Tumescent Anesthesia and Microcannular Liposuction. St. Louis: CV Mosby, 2000.
2. Grazer, F.M., and De Jong, R.: Fatal outcomes from liposuction-census survey of cosmetic surgeons. Plast Reconstr J, 2000;105(1).
3. Kaminer, M.S. Tumescent liposuction council bulletin. Derm Surg 2001;27:6.

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