Cosmetic Liposuction: Preoperative Risk Factors, Major Complication Rates, and Safety of Combined Procedures

Risks and Complications Rate in Liposuction: A Systematic Review and Meta-Analysis

Liposuction is a surgical procedure used to remove localized excess adipose tissue. According to The Aesthetic Society's latest annual report, liposuction is the most commonly performed cosmetic procedure. Despite its popularity, the existing literature lacks a unified understanding of the risks associated with liposuction. The aim of this study was to measure complications of liposuction. A systematic review and meta-analysis was reported according to PRISMA guidelines and registered on the PROSPERO database (CRD42023471626). The primary outcome was overall complication rate. The absolute risk for individual complications was also assessed. From 2957 articles, 39 studies were selected for analysis. In total, 29,368 patients were included, with a mean age of 40.62 years and mean BMI of 26.36 kg/m2. Overall, the rate of any complication was 2.62 (95% CI, 1.78-3.84). The most common complication was contour deformity, with a prevalence of 2.35% (95% CI, 1.05%-5.16%). The prevalence of hyperpigmentation was 1.49% (95% CI, 1.12%-1.99%), seroma 0.65% (95% CI, 0.33%-1.24%), hematoma 0.27% (95% CI, 0.12%-0.60%), superficial burn 0.25% (95% CI, 0.17%-0.36%), allergic reaction 0.16% (95% CI, 0.050%-0.52%), skin necrosis 0.046% (95% CI, 0.013%-0.16%), generalized edema 0.041% (95% CI, 0.0051%-0.32%), infection 0.020% (95% CI, 0.010%-0.050%), venous thromboembolism 0.017% (95% CI, 0.0060%-0.053%), and local anesthesia toxicity 0.016% (95% CI, 0.0040%-0.064%). Liposuction is a safe procedure with low complications, of which contour deformity is the most common. Raising awareness of specific risks can enhance surgical outcomes and improve patient-physician understanding.

LEVEL OF EVIDENCE: 3

Acute upper airway obstruction due to cervical hematoma after cervicofacial liposuction

Liposuction is a surgical procedure performed worldwide. Although many fatal complications of liposuction have been reported, to our knowledge, no cases of fatal liposuction complications specifically related to the face region have been reported. Here, we present a case of a woman in her 30s who developed a cervical hematoma and upper airway obstruction following facial liposuction. We present this unique case to highlight the rare occurrence of fatal complications specific to facial liposuction. The patient underwent liposuction during surgery at a cosmetic surgical clinic and awoke from anesthesia after the procedure. Two hours later, she developed a neck swelling and dyspnea. While the anesthesiologist managed her airway, she went into cardiopulmonary arrest. She was then transferred to the emergency room but died on day 7 of hospitalization. The autopsy revealed swelling of the right cheek and mandible, a subcutaneous hematoma in the same area, and laryngeal edema. A damaged facial artery branch was identified, which was consistent with the computed tomography (CT) findings on admission. CT also showed that the hematoma compressed the right internal jugular vein, suggesting that venous outflow impairment caused by the hematoma may have exacerbated the airway obstruction. This case reveals that cervical hematoma caused by facial liposuction can cause fatal upper airway obstruction and the onset of the hematoma may be gradual.

Complicated Surgical Site Infection with Mycobacterium Abscessus After Liposuction and Affections of Corticosteroids in the Treatment Regimen: Three Cases Report and a Systematic Review

INTRODUCTION

Mycobacterium abscessus infection after liposuction/fat grafting is a rare complication that is hard to diagnose and treat. Misdiagnosis could result in treatment failure and prolonged hospital stays. The paradoxical reaction is another complication that rarely occurs in non-HIV patients infected with nontuberculosis mycobacteria. This study reported 3 cases infected with M. abscessus complicated by the paradoxical reaction after liposuction and fat grafting. It highlighted characteristics giving clues of the paradoxical reaction and a successful strategy. Also, a systematic review was conducted to comprehensively provide varied aspects of M. abscessus infection after liposuction and/or fat grafting.

METHODS

Three cases were retrospectively included reporting data characteristics of patients, cosmetic procedures, and treatment strategy. PubMed, Scopus, Virtual Health Library (VHL), and Global Health Library (GHL) were searched to find and include cases with M. abscessus infection after liposuction and/or fat grafting based on defined selection criteria. Relevant data were extracted and summarized. The risk of bias in included studies was assessed using JBI critical appraisal checklists.

RESULTS

Twenty-four articles were included in the systematic review. Symptoms often developed approximately 1 month after the cosmetic surgery. Culture, AFB, and PCR were common methods of diagnosis of M. abscessus after liposuction and/or fat grafting. It took about 33 days on average from the presentation to isolate and detect the pathogens. Antibiotics based on susceptibility testing results along with surgical interventions were effective methods of treatment. Our three cases which were complicated by the paradox were addressed by adding methylprednisolone for 2 weeks to the macrolide-based therapy.

CONCLUSIONS

Awareness of this disease should be widely raised among physicians for early diagnosis and proper treatments. Cultures of specimens and AFB should be repeated many times before excluding the possibility of Mycobacterium spp. A paradoxical reaction should be suspected if the symptoms were worse after the antibiotic therapy based on susceptibility testing results and proper surgical interventions, especially if patients had taken corticosteroids before being admitted.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Small Intestinal Perforation after 360-Degree Liposuction: A Case Report

OBJECTIVE

As one of the most commonly performed cosmetic procedures, liposuction is relatively safe. Bowel injury following liposuction is a rare but devastating complication, which necessitates hospital admission and surgical intervention. The authors highlight a case report describing the presentation, diagnosis, and management of a patient with bowel injury following liposuction.

CASE

A 58-year-old woman presented with abdominal pain, erythema, and discharge three days after 360-degree abdominal liposuction with concomitant fat grafting to bilateral buttocks at an outpatient surgery center. Bowel perforation was suspected after CT-scan revealed extraluminal gas in the abdomen and communication that traversed the peritoneum. Exploratory laparotomy was performed which demonstrated at least one site of distinct perforation of the small bowel and an area omentum noted to be inflamed, thickened and with a purulent rind. The patient underwent 20-cm small bowel resection and partial omentectomy temporarily closed with negative pressure wound therapy. After subsequent abdominal wall debridements the patient received ventral hernia repair with bridging mesh and abdominal closure.

CONCLUSIONS

While safe, elective cosmetic procedures are not without risk of serious and even fatal complications. Providers must be familiar with the presentation of bowel injury following abdominal liposuction to prevent delays in appropriate surgical and medical care.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Intraoperative Cardiac Arrest During Liposuction: A Case Report

Background

With the popularity of liposuction surgery, more awareness should be obtained regarding complications. Liposuction has been thought of as a safe procedure with a very low incidence of major complications. However, life-threatening risks of liposuction have rarely been reported.

Methods

We present a case of a 36-year-old woman who developed cardiac arrest during a liposuction procedure, and we present a literature review.

Results

She was previously healthy and had no risk factors for pulmonary embolism. The diagnosis was made based on clinical presentation and the presence of an electrolyte disorder and a positive sign on computed tomography pulmonary angiogram (CTPA). Mild hypothermia treatment, symptomatic treatment, and supportive therapy were applied. As the respiratory and circulation were smooth, she was discharged to a rehabilitation hospital. Seven months after discharge, the patient was still in a coma with eye opening.

Conclusions

Spinal anesthesia, pulmonary embolism, and hyperkalemia are the most probable contributors to the cardiac arrest observed during the liposuction procedure in this specific case. There is a heightened imperative to vigilantly monitor for critical incidents during these operations and to meticulously identify associated risk factors during liposuction.

A Procedure and Complication-Specific Assessment of Smoking in Aesthetic Surgery: A Systematic Review and Meta-Analysis

Background: The popularity of aesthetic surgery is on the rise, as is patients' expectations towards excellent surgical results. In order to meet these expectations, risk factors that hinder desired outcomes, such as smoking, need to be identified and addressed. To that end, the present study summarizes an updated systematic review focused on the effects of smoking on cosmetic surgical procedures and outcomes. Methods: A systematic review of studies comparing aesthetic surgical outcomes by procedure, between tobacco smokers and non-smokers was carried out, querying PubMed, Embase and the Cochrane databases. Data regarding surgical outcomes were extracted and meta-analyzed by a random effects model in conjunction with the Mantel-Haenszel statistical method. Results: Eighty-two studies were included in the final synthesis. Abdominoplasty/panniculectomy (n = 19 cohorts) and breast reduction (n = 27 cohorts) were the most common types of procedures included in this review. Other than mastopexy and rhinoplasty, smoking conferred a statistically significant increased risk of overall complications for all studied aesthetic procedures. Conclusions: The data demonstrates that smoking is a clear risk factor for the vast majority of aesthetic plastic surgeries studied. Although our meta-analysis suggests that smoking is not a risk factor for complications in mastopexies and rhinoplasties, these two specific analyses may have been biased, and should therefore be re-evaluated with future additional evidence. The results of this systematic review confirm the importance of smoking cessation and education relative to the outcomes of common cosmetic surgical procedures.

The Development and Implementation of an Evidence-Based Tumescent Liposuction Protocol, Online Educational Course for Perioperative Staff, and Discharge Instructions: A Quality Improvement Project

PURPOSE

The purpose of this quality improvement project was to improve perioperative management of patients undergoing tumescent liposuction (TL) through the development and implementation of a perioperative evidence-based protocol, educational course for perioperative staff, and patient discharge instructions.

DESIGN

The TL protocol was validated using the modified Delphi process. The educational course and discharge instructions used a pre and postimplementation design.

METHODS

An evidence-based protocol, an educational course for perioperative staff, and readable discharge instructions for patients undergoing TL were developed in accordance with best practice guidelines. The protocol was validated by subject matter experts at the facility and submitted for adoption. The evidence-based educational course was implemented, and the effectiveness of the course was evaluated for improving providers' knowledge and self-confidence. The evidence-based discharge instructions were implemented and evaluated for patient satisfaction and readability.

FINDINGS

Three items were removed from the protocol, 2 items were modified, and 25 items were accepted with no change from modified Delphi analysis. Provider knowledge scores improved from 85.7% ± 16.18 to 97.1% ± 4.88; however, this was not statistically significant (P = .066). There was a trend toward improved confidence scores (P = .180). Overall patient satisfaction scores slightly improved postimplementation; results were not statistically significant (P > .05).

CONCLUSIONS

All three phases of perioperative care in patients receiving TL were evaluated, reflecting best practice guidelines and successful adoption. There was no statistically significant improvement in provider knowledge, provider self-confidence, or patient satisfaction. A small sample size was a significant limiting factor.

Cosmetic Injection of Illicit Foreign Materials: Imaging Features and Patterns of Migration in 413 Cases

BACKGROUND

The injection of illicit, nonregulated foreign materials is increasingly common and has negative consequences relative to the inflammatory process that ensues.

OBJECTIVES

The aim of this study was to identify anatomical and imaging characteristics after the cosmetic injection of illicit foreign materials.

METHODS

A retrospective review of clinical and imaging records was performed. The issues analyzed were the anatomical site, type of injected substance, imaging method for diagnosis, and patterns of migration.

RESULTS

Data on 413 patients were collected. Most patients were female, with a mean age of 44 years. The most commonly infiltrated region was the buttocks (n = 284; 53.58%) followed by the breast (n = 99; 18.67%). Magnetic resonance imaging was the most common method of diagnosis in those patients who had an imaging study (159 out of 168). The most frequent depth of foreign material detected by imaging was the muscular plane (n = 103; 61.30%). Migration was detected in 56.55% of patients who had an imaging study. Most infiltrated substances were unknown; biopolymers were the most commonly identified substances. Depending on the type of substance, migration rates varied from 13% to 29%; rate differences were not statistically significant (P = .712). Migration was more common when the depth of infiltration was in muscle (77.66%) than in subcutaneous tissue (23.4%); this difference was statistically significant (P < .0001).

CONCLUSIONS

Deep infiltration is related to greater migration rates, apparently regardless of the substance injected.

LEVEL OF EVIDENCE: 3

Development and characterization of islet-derived mesenchymal stem cells from clinical grade neonatal porcine cryopreserved islets

BACKGROUND

Porcine tissues display a great potential as donor tissues in xenotransplantation, including cell therapy. Cryopreserving clinical grade porcine tissue and using it as a source for establishing therapeutic cells should be advantageous for transportation and scheduled manufacturing of MSCs. Of note, we previously performed encapsulated porcine islet transplantation for the treatment of unstable type 1 diabetes mellitus in the clinical setting. It has been reported that co-transplantation of islets and Mesenchymal stem cells (MSCs) enhanced efficacy. We assume that co-transplantation of porcine islets and porcine islet-derived MSCs could improve the efficacy of clinical islet xenotransplantation.

METHODS

MSCs were established from fresh and cryopreserved non-clinical grade neonatal porcine islets and bone marrow (termed non-clinical grade npISLET-MSCs and npBM-MSCs, respectively), as well as from cryopreserved clinical grade neonatal porcine islets (termed clinical grade npISLET-MSCs). Subsequently, the cell proliferation rate and diameter, surface marker expression, adipogenesis, osteogenesis, and colony-forming efficiency of the MSCs were assessed.

RESULTS

Cell proliferation rate and diameter did not differ between clinical grade and non-clinical grade npISLET-MSCs. However, non-clinical grade npBM-MSCs were significantly shorter and smaller than both npISLET-MSCs (p < 0.05). MSC markers (CD29, CD44, and CD90) were strongly expressed in clinical grade npISLET-MSCs and non-clinical grade npISLET-MSCs and npBM-MSCs. The expression of MSC-negative markers CD31, CD34, and SLA-DR was low in all MSCs. Clinical grade npISLET-MSCs derived from adipose and osteoid tissues were positive for Oil Red and alkaline phosphatase staining. The results of colony-forming assay were not significantly different between clinical grade npISLET-MSCs and non-clinical grade npBM-MSCs.

CONCLUSION

The method described herein was successful in of developing clinical grade npISLET-MSCs from cryopreserved islets. Cryopreserved clinical grade porcine islets could be an excellent stable source of MSCs for cell therapy.

Combined Surgery (Mommy-Makeover) Compared to Single Procedure (Abdominoplasty) in After-Pregnancy Women: A Prospective Study on Risks and Benefits

BACKGROUND

Mommy-makeover is becoming very popular to help them reshaping their own bodies and restoring self-perception, hardly stressed by childbearing-related changes. However, debate exists in the literature concerning safety and aesthetic outcome in patients undergoing combined procedures. The study aims to shed a light on advantages and disadvantages in mommy-makeover technique compared to conventional abdominoplasty with a particular attention to psychological aspects.

MATERIALS AND METHODS

In total, 37 women were enrolled at Campus Bio-Medico Hospital in Rome between October 2019 and January 2022. All of the patients were eligible for both abdominoplasty only and mommy-makeover. We proposed to the patients both procedures explaining risks and benefits; then, based on the preference of the single patient, we performed either mommy-makeover (Group A) or abdominoplasty alone (Group B). In order to evaluate patients' satisfaction and safety, multiple questionnaires were administered 9-month postoperatively (BUT, POSAS, visual perception, etc.).

RESULTS

The sample analyzed was composed of 37 patients (treatment group = 18, control group = 19). In the pre-post comparisons of BUT-A performed, there were statistically significant differences recorded in both groups and for all observed variables. The significance values were all less than 1% (p < 0.01).

CONCLUSIONS

Combined surgery proved not to be inferior in terms of patient safety. At the same time, the effectiveness in improving diastasis-related symptoms is fully comparable with single surgery. Treatment group showcases a considerable superiority in terms of body-image perception improvement and overall patient satisfaction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Liposuction Complications in the Outpatient Setting: A National Analysis of 246,119 Cases in Accredited Ambulatory Surgery Facilities

Background

Suction lipectomy (liposuction) is a popular cosmetic surgical procedure performed in the United States, but little has been documented regarding perioperative complications due to its outpatient nature.

Objectives

This cross-sectional study aims to analyze the most common complications that accompany liposuction-related procedures and importantly estimate the total complication rate occurring at ambulatory surgical facilities.

Methods

Adult patients who experienced liposuction-related complications from 2019 to 2021 were identified in the reporting database of the global surgery accreditation authority, the American Association for Accreditation of Ambulatory Surgery Facilities (QUAD A). Patients were then divided by complication type and procedure location. Demographics and facility-specific variables were analyzed. Descriptive statistics were performed.

Results

Overall, 984 patients were included, with a mean age of 44 years (interquartile range [IQR] 37-53) and a median BMI of 28.7 kg/m2 (IQR 25.7-32.2). The overall confirmed complication rate was found to be 0.40% (984/246,119). Unplanned emergency department presentation was the most common complication overall (24%). Wound disruption was associated with the longest median procedure length (261 min), and venous thromboembolism was associated with the highest median BMI (30.1 kg/m2). The Southeast had the most complications (431), which accounted for 13/21 deaths (61.9%). Out of all complications, death was associated with the highest average annual case volume (241).

Conclusions

Procedures that involve liposuction are associated with a variety of medical and surgical complications. Given the high frequency and variability in how liposuction is performed, a thorough assessment of complications is critical to improve the safety of this procedure.

Level of Evidence 3

Cryolipolysis in the United States-Review of the clinical data

BACKGROUND

Noninvasive body contouring is becoming more popular in the United States as an alternative to liposuction. The most popular of these methods, cryolipolysis, uses precisely controlled cooling to reduce focal adiposities. The number of cryolipolysis procedures performed annually has experienced rampant growth in United States markets, and the indications have likewise diversified. In light of this change, it is imperative to perform an updated review of available US safety and efficacy data on cryolipolysis.

AIMS

To examine the safety and efficacy of cryolipolysis treatments in the United States using data extracted from research performed exclusively at US-based sites.

METHODS

In order to identify relevant studies, a literature search was conducted on PubMed using the terms "CoolSculpting" OR "cryolipolysis" OR "lipocryolysis." Articles were manually reviewed to exclude literature reviews, research not performed on humans, studies on experimental combinations of techniques, and any studies not performed in the United States.

RESULTS

The initial literature search returned 246 results. Following manual review, a total of 18 studies were selected for data extraction. Mean reduction in fat thickness by ultrasound was 2.0-5.1 mm or 19.6%-32.3%; mean reduction by body caliper was 2.3-7 mm or 14.9%-21.5%. Side effects were mild and transient. Four instances of PAH were documented in 3453 treatment cycles.

CONCLUSIONS

Cryolipolysis is a safe, modestly effective method for reducing focal adiposity. Complications are rare and treatable. However, US-based studies are few in number and often of low power and/or quality. More high-quality research is needed for all aspects of cryolipolysis.

A 16-Year Review of Clinical Practice Patterns in Liposuction Based on Continuous Certification by the American Board of Plastic Surgery

BACKGROUND

The American Board of Plastic Surgery has collected data on cosmetic surgery tracers as part of the Continuous Certification process since 2005. The current study was performed to analyze evolving trends in liposuction from the American Board of Plastic Surgery database.

METHODS

Tracer data from 2005 through 2021 were reviewed and grouped into an early cohort (EC) (2005-2014) and a recent cohort (RC) (2015-2021). Fisher exact tests and two-sample t tests were used to compare patient demographics, techniques, and complications.

RESULTS

A total of 2810 suction-assisted liposuction cases were included (1150 EC, 1660 RC). In-office procedures increased (36% EC versus 41% RC). The use of general anesthesia remained the same (63% EC versus 62% RC). The use of power-assisted liposuction increased (24% EC versus 40% RC) and use of ultrasound-assisted liposuction decreased (5% versus 2%). With respect to body areas treated, liposuction of the abdomen (64% EC versus 69% RC), flanks (60% EC versus 64% RC), and back (22% EC versus 34% RC) increased; treatments of thighs (36% EC versus 23% RC), and knees (8% EC versus 5% RC) decreased. Intraoperative position changes are more common (30% EC versus 37% RC), as is liposuction of multiple areas in one case (28% EC versus 36% RC). The volume of lipoaspirate also increased (1150 cc EC versus 1660 cc RC).

CONCLUSIONS

This study highlights evolving trends in liposuction over 16 years. Liposuction is becoming more common as an outpatient procedure performed concomitantly with other procedures. Despite multiple emerging technologies, the popularity of power-assisted liposuction is increasing. Although adverse events have not significantly increased with these changes, the authors stress careful preoperative evaluation of patients to identify factors that increase the risk of complications.

The Safety of Large-Amount Liposuction: A Retrospective Analysis of 28 Cases

Aim

Our study aims to assess the safety of large amounts of liposuction in a new light.

Materials and Methods

This is a retrospective review of patients who underwent large-volume liposuction from August 2020 to April 2021. Patient demographics, liposuction areas, the amount of infiltrate and aspirate, the surface area of liposuction areas, anesthesia duration, pain score after surgery, preoperative and 4-h postoperative hemoglobin, and basic metabolic panel (sodium, potassium, creatinine, urea) were measured.

Results

Out of the 28 patients, 26 (92.85%) were females. The mean age was 37.1 years old. The mean preoperative hemoglobin was 13.73 g/dL. The average anesthesia time was 220.39 min. The average amount of liposuction infiltrated was 7.55 L, and the average amount of liposuction aspirate was 6.83 L. The mean hemoglobin 4 h postoperatively was 13.7 g/dL.

Conclusions

With proper patient selection and a comprehensive physical exam with preoperative blood workup performed in an accredited facility with a highly experienced plastic surgeon and anesthesiologist, mega liposuction can be safely performed as a day surgery procedure.

The Clinical Efficacy Evaluation of Thigh Liposuction Based on 3-Dimensional Digital Technology: A Quantitative Study

BACKGROUND

There is a lack of convenient and accurate objective methods to evaluate the clinical efficacy of thigh liposuction.

METHODS

This retrospective study involved the 3-dimensional images of 19 patients who underwent bilateral thigh liposuction. Data such as volume change and volume change rate before and after surgery, circumference change, and circumference change rate of 3 planes (upper, middle, and lower) were analyzed. The correlation between body mass index and volume change rate and between preoperative circumference and circumference change rate of different planes were determined.

RESULTS

There were significant differences between the preoperative and postoperative volume and circumference of 3 planes of 19 patients (38 thighs). The rate of change in total volume (16.90 ± 5.55%) correlated with the circumference change rate at the top of the thigh. There was also a linear relationship between body mass index and volume change rate, but not between preoperative circumference and circumference change rate.

CONCLUSIONS

Three-dimensional imaging technology can accurately quantify the volume and circumference change of the thigh to objectively evaluate the clinical efficacy of thigh liposuction.

Factors Affecting Postoperative Complications of Suction-Curettage by Arthroscopic Shaver for Bromhidrosis

BACKGROUND

Suction-curettage by arthroscopic shaver is the most effective treatment for bromhidrosis; however, postoperative complications require wound management and exhibit a high risk of hypertrophic scarring. We investigated factors affecting postoperative complications.

METHODS

We retrospectively evaluated data for 215 patients (430 axillae) with bromhidrosis treated with suction-curettage by arthroscopic shaver between 2011 and 2019. Cases followed for less than 1 year were excluded. Complications of hematoma or seroma, epidermis decortication, skin necrosis, and infection were recorded. Multinomial logistic analysis was used to calculate odds ratios and corresponding 95% confidence intervals for the complication of the surgery, adjusting for relevant statistically significant variables.

RESULTS

Complications occurred in 52 axillae (12.1%). Epidermis decortication occurred in 24 axillae (5.6%), with a significant difference for age (P < 0.001). Hematoma occurred in 10 axillae (2.3%) with a significant difference in tumescent infiltration use (P = 0.039). Skin necrosis occurred in 16 axillae (3.7%) with a significant difference for age (P = 0.001). Infection occurred in 2 axillae (0.5%). Severe scarring occurred in 15 axillae (3.5%), with complications related to more severe skin scarring (P < 0.05).

CONCLUSION

Older age was a risk factor for complications. Use of tumescent infiltration resulted in good postoperative pain control and less hematoma. Patients with complications presented with more severe skin scarring, but none experienced limited range of motion after massage.

An Innovative Surgical Technique to Obtain an Adipose-Derived Stromal Cell-Rich Graft for the Treatment of Osteoarthritis: Technical Note

Osteoarthritis (OA) is one of the main causes of disability worldwide and is caused by the progressive degeneration of joint tissues, ultimately leading to chronic pain and loss of function. Intraarticular delivery of mesenchymal stromal cells, such as adipose-derived stromal cells (ASCs), is being actively investigated due to their trophic properties observed in both preclinical and clinical studies. However, cell expansion and handling involve costly and time-consuming processes that limit their application. Recently, several devices and kits have been developed to isolate and process the stromal vascular fraction (SVF), a high biologically active compound of the adipose tissue, right at the patient’s bedside. In this study, we introduce a novel technique to obtain an SVF graft with a high content of ASCs for intraarticular injection directly from liposuction and with minimal equipment. In this technical note, we describe in detail the steps of the surgical technique as well as strategies to avoid common pitfalls and complications.

Efficacy of Cold Tumescent for Prevention of Intraoperative Bleeding in Patients Undergoing Liposuction: A Double-Blind Randomized Controlled Trial-Half-Side Comparison

BACKGROUND

Bleeding, a common intraoperative complication of liposuction, often causes pain and discomfort during recovery. Because of the vasoconstrictive effect of adrenaline in the tumescent solution, bleeding can be reduced; however, reports of postoperative bleeding persist. Cold temperatures also have a vasoconstrictive effect.

OBJECTIVES

This study aimed to determine the efficacy of cold tumescent solution in preventing and reducing intraoperative bleeding.

METHODS

This prospective randomized controlled trial was conducted between June 2018 and June 2019. The liposuction areas in each participant were divided into left and right sides; one side received operative room temperature tumescent solution (25 °C), and the other side received low-temperature tumescent solution (4 °C). The areas of ecchymosis, pain scores, and patient and surgeon satisfaction scores were compared and analyzed.

RESULTS

Ten patients with 36 pairs of liposuction areas were enrolled in the study. Cold tumescent liposuction resulted in a significantly lower lipocrit than was obtained on the standard tumescent side (1.56 ± 0.69 vs 2.92 ± 0.94; P < .001). The ecchymosis area and pain score were significantly lower in the cold tumescent group on days 2, 4, 7, and 14. The satisfaction evaluation scores did not differ between patients and surgeons at 12 months postoperatively.

CONCLUSIONS

The use of cold tumescent anesthesia significantly improved liposuction outcomes by reducing the intraoperative blood loss and the postoperative ecchymosis and pain, with no immediate or short-term complications in low-volume liposuction (<1000 mL) procedures. Furthermore, it generated a standard outcome and good patient satisfaction scores.

LEVEL OF EVIDENCE: 2

Undiagnosed Patent Foramen Ovale and Thrombophilic Gene Mutations Resulting in Pulmonary Embolism with Cryptogenic Stroke after Cosmetic Breast Surgery

Undiagnosed disorders or gene mutations can lead to life-threatening events even in cosmetic surgery. Herein, the authors present a case of a young and supposedly healthy 36-year-old woman who survived an episode of bilateral pulmonary embolism and cryptogenic stroke after cosmetic breast augmentation-mastopexy. Two days after cosmetic surgery, the patient presented at the emergency stroke unit after she collapsed at home, following frequent generalized seizures. After she was transferred to the intensive care unit, it was revealed that the patient had an undiagnosed patent foramen ovale and several thrombophilic gene mutations. During the stay, two episodes of active bleeding and beginning nipple-areola complex hypoperfusion led to bilateral implant removal. As a final result, the patient lost her breast implants and experienced persistent hypoesthesia of the entire left hemi body. However, this case might highlight deficits in current venous thromboembolism risk assessment and prophylaxis due to the missing considerations of undiagnosed disorders or gene mutations. Further, recommendations on dealing with implants or aesthetic outcome in crucial episodes should be introduced.

Necrotizing Soft Tissue Infection Post VASER-Assisted Liposuction and Lipofilling: A Case Report

Liposuction is a very common aesthetic procedure nowadays. The complication rate is very minimal, and it increases relatively when combined with other procedures. Infection is an expected complication in liposuction and its risk is below 1% in isolated procedures. Although the risk is very low, it might lead to fatal consequences. In this manuscript, the authors present a previously healthy female who presented to the authors' emergency department post-vibration amplification of sound energy at resonance (VASER)-assisted liposuction and lipofilling done in a private center. Her signs and symptoms started after the procedure and she visited the private center multiple times; however, no significant improvement was felt. Upon her presentation to the authors' facility, immediate resuscitation was initiated, and she was admitted for further investigations and management. Despite all resuscitation efforts and interventions, the patient's condition kept deteriorating. She was admitted to the surgical intensive care unit and taken to the operating theater twice with no observed significant improvement. The patient developed septic shock, a multiorgan failure state, followed by cardiac arrest. All resuscitation measures were taken, but the patient could not be revived and was declared dead. Early recognition of signs and symptoms of infection could be lifesaving. Aggressive resuscitation and surgical interventions (extensive debridement and antibiotics) might be necessary to produce successful outcomes.

Level of Evidence 5

Histotripsy of Subcutaneous Fat in a Live Porcine Model

PURPOSE

This study was designed to evaluate the feasibility and safety of histotripsy subcutaneous (SQ) fat treatment in an in-vivo porcine model, and evaluate evolution of the treated volume on MRI and pathology.

METHODS/MATERIALS

10 histotripsy SQ fat treatments were completed in 5 swine, divided into four groups based on pre-determined survival: day 0 (n = 4), day 7 (n = 2), day 28 (n = 2), and day 56 (n = 2). A 4.0 × 4.0x2.0 cm ovoid treatment was created in the fat pad of the posterior thorax. MRI of survived animals were obtained on day 7 (n = 6), day 28 (n = 4), and day 56 (n = 2), and reviewed for size and imaging characteristics. Technical success was defined as the creation of a treatment zone in the targeted SQ fat. Skin firmness and indentation were qualitatively scored.

RESULTS

Histotripsy had a 100% (10/10) technical success for creation of SQ fat treatments. Mean treatment time was 35.5 min (range 35-36.5). The volume of treated SQ fat demonstrated 92% volume reduction over the study. Day 0 gross pathology treatment had a mean volume of 12.6 cm³ (± 2.1) (prescribed volume of 16.7 cm³), which decreased to 8.3 cm³ (± 2.8) by day 7 (34% overall decrease), 3.0 cm³ (± 0.5) by day 28 (76% overall decrease), and 1.0 cm³ (± 1.2) by day 56 (92% overall decrease). Mean firmness and indentation scores showed no change from baseline at all time points, with no overlying skin injury.

CONCLUSION

Histotripsy safely and effectively treated SQ fat of an in-vivo porcine model, with volume reduction over time.

[Expert characteristic of fatal outcomes related to operative interventions in aesthetic plastic surgery]

THE AIM OF THE STUDY

Is to investigate fatal outcomes related to operative interventions in aesthetic plastic surgery for the period from 2010 to 2022 yrs., and to analyze the defects in health care delivery (DHCD), revealed during forensic medical examinations of fatal outcomes. The number of fatal outcomes equal 36, related to operative interventions in aesthetic plastic surgery, was analyzed. The data were collected from the expert's archival opinions (forensic medical examinations of corpse, commission forensic medical examinations based on materials of medical cases and expert opinions), and from judicial acts. The most frequent cause of death (19% of cases) was postoperative development of pulmonary artery thromboembolia, that requires further screening to assess the relationship between denoted reason and type of performed operative intervention as well as the use of anticoagulant therapy. In addition, 19% of the causes of death were related to the toxic lidocaine effects, that shows the necessity of strict control while using anaesthesia during operative interventions. During the forensic medical examination in 55.5% of cases were found the defects in health care delivery (DHCD), with an average of about two DHCD cases. Cause-effect relationship between identified drawbacks of health care delivery and fatal outcome was established in 18 (90%) of the 20 cases. Among them, the DHCD, which are extremely rare in other types of surgical specialty (health care delivery in an inappropriate place and by unqualified persons), were reliably determined in 30% of cases. The necessity of strict control by the relevant competent organizations in health care delivery for plastic surgery specialty, the need for a single system collection of information about fatal cases, associated with operative interventions in aesthetic plastic surgery, and the study of fatality structure and causes in this field were proved. The above mentioned will make it possible to develop unified approaches for the commission forensic medical examinations in this type of cases, and will also contribute to the fatal outcomes' prevention.

Abdominal Visceral Injury, a Devastating Consequence of Abdominal Liposuction: A Case Report and Literature Review

Abdominal liposuction is a commonly performed cosmetic procedure. However, as with any procedure, it can be associated with complications. One of the life-threatening complications of this procedure is visceral injury and bowel perforation. This complication is very rare, nevertheless general, and acute care surgeons must be aware of its possibility, its management, and its possible sequelae. We report a case of a 37-year-old female who underwent abdominal liposuction which was complicated by bowel perforation and was transferred to our facility for further care. She underwent an exploratory laparotomy in which multiple perforations were repaired. The patient then underwent multiple surgeries including stoma creation and had a long postoperative course. A literature review reveals the devastating sequelae of reported similar visceral and bowel injuries. The patient eventually did well and her stoma was reversed. This patient population will require close intensive care unit observation and a low threshold of suspicion for missed injuries during initial exploration. Further down the line, they will need psychosocial support and the mental health implications of this outcome must be cared for. The long-term aesthetic outcome is yet to be addressed.

Isolation and Cultivation of Adipose-Derived Mesenchymal Stem Cells Originating from the Infrapatellar Fat Pad Differentiated with Blood Products: Method and Protocol

Adipose-derived mesenchymal stem cells (ASCs) are a promising source for clinical application in regenerative orthopedics. ASCs derived from the infra-patellar fat pad (IFP)-a distinct adipose structure in the knee-show superior regenerative potential compared to subcutaneous-fat-derived cells. Furthermore, it has been shown that blood products enhance ASCs' viability. A major challenge for clinical translation of both ASCs and blood products is the low comparability of obtained data due to non-standardized harvesting, isolation and preparation methods. The aim of this method-paper is to provide reproducible protocols to help standardize basic research in the field to build a sound basis for clinical translation with an emphasize on practicability. The presented protocols include (i) ASC isolation from the IFP, (ii) blood product preparation and (iii) ASC incubation with blood products.

Office-based Plastic Surgery-Evidence-based Clinical and Administrative Guidelines

Outpatient procedures are extremely prevalent in plastic surgery, with an estimated 82% of cosmetic plastic surgery occurring in this setting. Given that patient safety is paramount, this practical review summarizes major contemporary, evidence-based recommendations regarding office-based plastic surgery. These recommendations not only outline clinical aspects of patient safety guidelines, but administrative, as well, which in combination will provide the reader/practice with a structure and culture that is conducive to the commitment to patient safety. Proper protocols to address potential issues and emergencies that can arise in office-based surgery, and staff familiarity with thereof, are also necessary to be best prepared for such situations.

Pneumothorax, Pneumomediastinum, and Pneumoperitoneum After Combined Abdominoplasty and Liposuction: Rare Adverse Events

ABSTRACT

Liposuction is a relatively safe surgical procedure, with most complications being minor in nature. However, there are a few life-threatening complications that should not be underestimated. We present a case of a patient who developed bilateral pneumothoraces, pneumomediastinum, and pneumoperitoneum after combined liposuction and abdominoplasty. Although this presentation is rare, clinicians should keep a high index of suspicion in patients presenting with shortness of breath, chest pain, and/or abdominal pain after liposuction.

Safety and Efficacy of Third-Generation Ultrasound-Assisted Liposuction: A Series of 261 Cases

BACKGROUND

The introduction of third-generation ultrasound-assisted liposuction (3rd UAL) allows for a less invasive modality of both deep and superficial lipectomy while offering improved skin retraction and reduced rate of complications. This study examined the efficacy and safety profile of this technology over 15 years of clinical experience.

METHODS

A consecutive series of patients treated from 2005-2020 by the senior author were reviewed for demographic and anthropometric measurements, intraoperative settings, surgical outcomes, and complications via retrospective chart review. Body-Q survey was used to assess patient satisfaction.

RESULTS

A total of 261 patients underwent 3rd UAL in 783 areas. There were 238 female and 23 male patients with an average age of 43.5 years and BMI of 27.4 kg/m². The most frequently treated areas were the trunk and lower limbs. An average of 2840 mL of wetting solution was used with an average of 2284 mL of lipocrit aspirate. About 65% of the cases were done in conjunction with another procedure. Overall complication rate was 4.6%, contour irregularity (1.9%), seroma (0.8%), cellulitis (0.8%), pigmentation changes (0.4%), and electrolyte imbalance (0.4%), with a minimum follow-up of 6 months. 78% of patient would undergo the procedure again and 86% would recommend it.

CONCLUSION

Third-generation ultrasound-assisted liposuction can be used effectively and safely, either alone, or in conjunction with other plastic surgery procedures. VASER liposuction allows surgeons to address superficial fat plane and enhanced skin tightening. Rate of complications are lower than that of traditional liposuction with equivalent or higher patient satisfaction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Circumferential Liposuction of the Thigh with Concomitant Fat Transplantation to the Infragluteal Region: A Promising Option for Preventing Postliposuction Gluteal Ptosis

BACKGROUND

Gluteal ptosis is a common complication of circumferential liposuction of the thigh. The authors propose a novel concept of combining circumferential liposuction of the thigh with concomitant fat transplantation to the infragluteal/posterior thigh junction region to prevent postliposuction gluteal ptosis.

METHODS

Patients underwent circumferential liposuction of the thigh with or without concomitant fat transplantation from 2015 to 2020 and were retrospectively reviewed. The postoperative changes in the grade of gluteal ptosis, length of hospitalization, time to recovery, postoperative complications, and patient satisfaction were evaluated.

RESULTS

A total of 109 patients were enrolled in this study, including 46 patients in the liposuction-only group and 63 patients in the liposuction plus fat transplantation group. There was no significant difference in fat removal volume between the liposuction-only group and the liposuction plus fat transplantation group ( p = 0.152). Aggravation of gluteal ptosis occurred in 43 patients (93.5 percent) in the liposuction-only group and four patients (6.3 percent) in the liposuction plus fat transplantation group ( p < 0.001). The length of hospitalization and time to recovery was not significantly different between the two groups ( p = 0.402 and p = 0.423, respectively). Complications were rare in both groups. With a minimum evaluation time of 6 months, patients in the liposuction plus fat transplantation group showed significantly higher satisfaction ( p < 0.001).

CONCLUSION

Concomitant fat transplantation to the infragluteal/posterior thigh junction region during circumferential liposuction of the thigh is effective in preventing postliposuction gluteal ptosis and improving patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The changing face of cosmetic surgery regulation: a review of controversies and potential reforms

Cosmetic surgery is becoming increasingly popular in Australia with the industry estimated to be worth over 1 billion dollars annually. Regulators both in Australia and internationally have been criticized for not keeping up with the rapidly changing field and keeping patients sufficiently safe in an environment that is problematically entrepreneurial. In this article, we explore the current regulation of and controversies surrounding cosmetic surgery in Australia, including the use of the title 'cosmetic surgeon', consent processes and the phenomenon of medical tourism. Lastly, we review the potential future reforms in Australia and how other countries have regulated the industry to keep patients safe.

Fat Embolism After Plastic Surgery: A Case Report

Fat embolism is an uncommon but life-threatening postoperative complication. The nonspecific symptoms associated with fat embolism could delay the diagnosis and result in a poor patient outcome. We report the case of a healthy 37-year-old woman who underwent a 6-hr breast and abdominal surgery with liposuction. Postoperatively, she displayed mild dyspnea, decreased oxygen saturation level, chest tightness, and fatigue. On Postoperative Day 3, pulmonary multislice computer tomography showed a fat embolus in her right pulmonary artery. She was treated with an anticoagulant to which she responded well and was discharged on Postoperative Day 7. This case demonstrates the need for surgeons, nurses, and anesthesia professionals to identify potential risk factors, recognize signs and symptoms, and implement effective treatment of pulmonary embolism to ameliorate the prognosis, improve the success of the surgery, and save the life of the patient.

Abdominal Laser Lipolysis Using a Microprocessor-Controlled Robotic Arm With Noncontact Heating and Cooling

BACKGROUND

A novel FDA-cleared device uses a 1064-nm laser to noninvasively induce apoptosis for lipolysis of subcutaneous abdominal fat while maintaining comfortable skin temperatures with a proprietary jet cooling system (eon; Dominion Aesthetic Technologies, Inc., San Antonio, TX). A programmable articulated robotic arm moves the treatment head without any subject contact, maintaining an appropriate 3-dimensional treatment path, compensating for patient movement.

OBJECTIVES

The goal of this prospective, single center, open-label study was to demonstrate the safety and effectiveness of this device for reducing subcutaneous abdominal fat when operated with an updated power delivery curve.

METHODS

Male and female subjects with Fitzpatrick skin types I to VI (N = 26) were treated. Four abdominal zones up to 150 cm2 each, customized in size and location for body habitus, were treated. Each zone underwent a single 20-minute treatment session. Follow-up visits occurred after 6 and 12 weeks. A standardized protocol was used to obtain ultrasound measurement of subcutaneous abdominal fat thickness, abdominal circumference, reported patient satisfaction and digital images.

RESULTS

The mean treatment area was 378.5 cm2. At Week 12, there was a 21.6% or 6.3 mm mean reduction in abdominal subcutaneous fat thickness and a 4.1-cm (1.6-inch) mean reduction in abdominal circumference. Most subjects (84.6%) were satisfied or very satisfied with their results. The mean pain score was 2.5 on an 11-point ordinal scale. There were no nonresponders. Only 2 adverse events were noted: mild transient erythema (n = 1, 3.8%) and localized subcutaneous firmness (n = 1, 3.8%) which resolved without intervention within 12 weeks.

CONCLUSIONS

This contact-free device is safe and effective for reducing subcutaneous abdominal fat and represents an improvement on the prior treatment protocol.

LEVEL OF EVIDENCE: 4

Summary document on safety and recommendations for aesthetic liposuction: Joint British Association of Aesthetic Plastic Surgeons (BAAPS)/British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) expert liposuction group

Liposuction is one of the commonest surgical aesthetic procedures performed worldwide. Despite being perceived to be a technically simple procedure, poor patient selection, sub-optimal technical execution or sub-optimal peri‑operative management could lead to significant harm. This guidance was produced on behalf of the British Association of Aesthetic Plastic Surgeons (BAAPS) and British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) by the expert liposuction group. The guidance is based on the evidence available in the literature along with specialist expert opinion in aesthetic liposuction to provide plastic surgeons with consensus recommendation. The aim is to identify best practice to maximise the safety of patients. This article summarises current practices and safety considerations and outlines recommendations covering various aspects of patient care.

Safety of Large-Volume Liposuction in Aesthetic Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Current literature clearly outlines the complication rates of liposuction in general; however, data specific to large-volume liposuction (LVL) remain unclear.

OBJECTIVES

The authors aimed to synthesize the current evidence on the safety of LVL with this systematic review.

METHODS

A comprehensive search in the MEDLINE, EMBASE, and CENTRAL databases was conducted for primary clinical studies reporting on safety or complications related to aesthetic LVL from 1946 to March 2020. The primary outcome measure was the incidence of surgical complication, and the secondary outcome measure was changes in metabolic profile. Meta-analyses were conducted to pool the estimated surgical complication incidence and metabolic changes.

RESULTS

Twenty-three articles involving 3583 patients were included. The average aspirate volume was 7734.90 mL (95% CI = 5727.34 to 9742.45 mL). The pooled overall incidence of major surgical complications was 3.35% (95% CI = 1.07% to 6.84%). The most common major complication was blood loss requiring transfusion (2.89% [95% CI = 0.84% to 6.12%]) followed by pulmonary embolism (0.18% [95% CI = 0.06% to 0.33%]), hematoma (0.16% [95% CI = 0.05% to 0.32%]), necrotizing fasciitis (0.13% [95% CI = 0.04% to 0.29%]), and deep vein thrombosis (0.12% [95% CI = 0.03% to 0.27%]). No fat embolism or death was reported in the included studies. The pooled overall incidence of minor surgical complication was 11.62% (95% CI = 6.36% to 18.21%), with seroma being the most common minor complication (5.51% [95% CI = 2.69% to 9.27%]). Reductions in lipid profile, glucose profile, body weight, and hematocrit level were observed after LVL.

CONCLUSIONS

The authors meta-analyzed and highlighted the complication rates specifically related to LVL in this study; however, the current data are limited by the lack of level 1 evidence.

LEVEL OF EVIDENCE: 4

Lower Limb Lymphedema Patients Can Still Benefit from Supermicrosurgical Lymphaticovenous Anastomosis (LVA) after Vascularized Lymph Node Flap Transfer (VLNT) as Delayed Lymphatic Reconstruction-A Retrospective Cohort Study

Background: For lymphedema patients who received a vascularized lymph node flap transfer (VLNT) as their primary treatment, what are the treatment options when they seek further improvement? With recent publications supporting the use of lymphaticovenous anastomosis (LVA) for treating severe lymphedema, we examined whether LVA could benefit post-VLNT patients seeking further improvement. Methods: This retrospective cohort study enrolled eight lymphedema patients with nine lymphedematous limbs (one patient suffered from bilateral lower limb lymphedema) who had received VLNT as their primary surgery. Patients with previous LVA, liposuction, excisional therapy, or incomplete data were excluded. LVA was performed on nine lower lymphedematous limbs. Demographic data and intraoperative findings were recorded. Preoperative and postoperative limb volumes were measured with magnetic resonance volumetry. The primary outcome was the limb volume measured 6 months post-LVA. Results: The median duration of lymphedema before LVA was 10.5 (4.9–15.3) years. The median waiting time between VLNT and LVA was 41.4 (22.3–97.9) months. The median volume gained in the lymphedematous limb was 3836 (2505–4584) milliliters (mL). The median post-LVA follow-up period was 18 (6–30) months. Significant 6-month and 1-year post-LVA percentage volume reductions were found compared to pre-LVA volume (both p < 0.001). Conclusion: Based on the results from this study, the authors recommend the use of LVA as a secondary procedure for post-VLNT patients seeking further improvement.

A Multicenter Evaluation of Paradoxical Adipose Hyperplasia Following Cryolipolysis for Fat Reduction and Body Contouring: A Review of 8658 Cycles in 2114 Patients

Background

Paradoxical adipose hyperplasia (PAH) is a rare, moderate-to-severe adverse event associated with cryolipolysis (CoolSculpting, CS).

Objectives

The aim of this study was to describe the incidence, diagnosis, and treatment of PAH occurring after CS for nonsurgical fat reduction.

Methods

A multicenter evaluation of all patients who underwent CS treatment between January 2015 and December 2019 at 8 Canadian medical centers was conducted. Data abstracted included symptoms, management strategy, outcome, operator characteristics, device characteristics, patient characteristics, body region, and CS treatment details. Incidence of PAH was calculated based on the number of treatment cycles.

Results

Our findings revealed incidence rates between 0.05% and 0.39%, which are slightly higher than the manufacturer’s quoted rate of 0.025% (1 per 4000 cycles). Incidence rates at all sites were dramatically reduced by over 75% with the implementation of newer models of CS units. Of patients who developed PAH, 55% were male and 77.8% were of European ethnic origin. The majority of cases (76.9%) were associated with older models of CS units.

Conclusions

Development of PAH may be related to a combination of factors, including older models of CS units and applicators, as well as individual characteristics that predispose certain patients.

Level of Evidence: 4

A Novel Artificial Intelligence-assisted Risk Assessment Model for Preventing Complications in Esthetic Surgery

Prevention of complications to reduce morbidity and mortality, and improve patient satisfaction is of paramount importance to plastic surgeons. This study aimed to evaluate the predictive risk factors for complications and to validate a novel risk assessment model, using artificial intelligence.

METHODS

A retrospective review of esthetic surgery procedures performed by the author between 2015 and 2020 was conducted. The Pearson correlation test was used to analyze the risk factors and complications. Differences in the mean risk scores among the three risk groups were tested using one-way analysis of variance. Risk scoring was validated using a machine learning process with a support vector machine in a Google Colaboratory environment.

RESULTS

Of the 372 patients, 28 (7.5%) experienced complications. The Pearson correlation coefficients between the risk score and body mass index (BMI: 0.99), age (0.97), and Caprini score of 5 or more (0.98) were statistically significant (P < 0.01). The correlations between the risk scores and sex (-0.16, P = 0.58), smoking habit (-0.16, P = 0.58), or combined procedures (-0.16, P = 0.58) were not significant. Necrosis was significantly correlated with dehiscence (0.92, P = 0.003) and seroma (0.77, P = 0.041). The accuracy of the predictive model was 100% for the training sample and 97.3% for the test sample.

CONCLUSIONS

Body mass index, age, and the Caprini score were risk factors for complications following esthetic surgery. The proposed risk assessment system is a valid tool for improving eligibility and preventing complications.

Novel cell sources for bone regeneration

A plethora of both acute and chronic conditions, including traumatic, degenerative, malignant, or congenital disorders, commonly induce bone disorders often associated with severe persisting pain and limited mobility. Over 1 million surgical procedures involving bone excision, bone grafting, and fracture repair are performed each year in the U.S. alone, resulting in immense levels of public health challenges and corresponding financial burdens. Unfortunately, the innate self-healing capacity of bone is often inadequate for larger defects over a critical size. Moreover, as direct transplantation of committed osteoblasts is hindered by deficient cell availability, limited cell spreading, and poor survivability, an urgent need for novel cell sources for bone regeneration is concurrent. Thanks to the development in stem cell biology and cell reprogramming technology, many multipotent and pluripotent cells that manifest promising osteogenic potential are considered the regenerative remedy for bone defects. Considering these cells' investigation is still in its relative infancy, each of them offers their own particular challenges that must be conquered before the large-scale clinical application.

Nontuberculous Mycobacteria Infection After Autologous Fat Grafting for Cosmetic Breast Augmentation

BACKGROUND

Autologous fat grafting has been widely applied in cosmetic breast augmentation in recent years. However, nontuberculous mycobacteria infection, as one of the multiple complications described in the literature, has been less well discussed.

OBJECTIVE

The aims of the study were to report 5 cases of nontuberculous mycobacteria infection after autologous fat injection for the cosmetic breast augmentation and to explore its causes.

METHODS

In this noncomparative, retrospective, and interventional case series, we identified 5 patients with nontuberculous mycobacteria infection. All patients had a history of previous autologous fat injection into the breast for cosmetic purpose, performed in different plastic facilities.

RESULTS

Five patients developed nontuberculous mycobacteria infection after autologous fat injection for cosmetic breast augmentation and came to our group for treatment. Grafted fat removal through multiple debridement and long-term intravenous and oral antibiotic therapy were required in our cases.

CONCLUSIONS

The number of nontuberculous mycobacteria infection after autologous fat injection into the breast is increasing. Surgeons should be aware of the complication, which rarely manifests during the procedure itself. Strict aseptic principles should be obeyed throughout the surgery.

Update on Liposuction: What All Plastic Surgeons Should Know

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the types of tumescence available for liposuction. 2. Explain the various modalities available for liposuction. 3. Describe the patient selection, staging, and complications associated with debulking liposuction. 4. Describe ways to optimize outpatient liposuction.

SUMMARY

Liposuction is one of the most common procedures performed by board-certified plastic surgeons and is likely greatly underestimated, given underreporting of office procedures and the number of non-plastic surgeons performing these operations. With the ever-increasing popularity of liposuction, various methodologies and technology have been designed to make this task simpler and faster for the surgeon and hasten the recovery for the patient. In the past 10 years, over 50 devices or techniques have been released to assist, refine, or altogether replace liposuction. With the advent of these newer tools, a thorough Continuing Medical Education study was performed to review the available literature.

The Role of Tranexamic Acid in Aesthetic Plastic Surgery: A Survey of the British Association of Aesthetic Plastic Surgeons

BACKGROUND

Tranexamic acid (TXA) can reduce intra- and postoperative bleeding as well as minimizing postoperative swelling and ecchymosis. It can be administered both intravenously and topically during surgery with minimal side effects.

OBJECTIVES

To assess the evidence of TXA use in aesthetic surgery and to complete a survey of current practice of full British Association of Aesthetic Plastic Surgeons members.

METHODS

The authors performed a literature review and online survey of full British Association of Aesthetic Plastic Surgeons members.

RESULTS

There is an increased indication of TXA utilization in aesthetic surgery. It provides multiple surgeon and patient benefits.

CONCLUSIONS

TXA is a useful adjunct in aesthetic surgery.

Necrotizing soft tissue infection after liposculpture; Case report

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Infections in isolated liposuction procedures are reported as only 0.1 % of cases

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One of the most serious complications of liposuction is necrotizing soft tissue infection (NSTI).

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Rapid recognition of NSTI is life saving; with urgent extensive debridement and prophylactic antibiotics as the mainstay of treatment for this condition

Introduction

Liposculpture procedures have a complication rate of 5%, with the majority being minor complications. Infections in isolated liposuction procedures are as low as 0.1 % of cases. Necrotizing infections can occur after major traumatic injuries, as well as after minor breaches of the skin or mucosa. Here we present a case of a 53-year-old female patient who underwent cosmetic surgery and developed a necrotizing soft tissue infection and we will discuss the importance of early diagnosis, risk factors and preventive measures, treatment options and our management of this particular case.

Presentation of Case

53-year-old female patient with a history of multiple cosmetic surgeries, with no significant past medical history, she presented fever and disabling pain at the surgical site with extensive bullae formation; during her fourth post operative day, she presented septic shock that required vasopressor support and mechanical ventilation, accompanied by acute renal failure which required admission to the intensive care unit.

The patient’s relatives requested air transportation to bring the patient to our center.

The patient remained hospitalized for 42 days in which 15 surgical interventions were performed including multiple surgical wound cleansing and debridement as well as placement of a negative pressure wound therapy system, flaps advancement, lesions reconstruction, graft procurements and insertions.

Discussion

Antibiotic prophylaxis is recommended preferably with a second-generation cephalosporin, one hour prior to surgery and should be continued for 5–6 days afterwards. Likewise, prophylaxis with Flucloxacillin or gentamicin is recommended in the case of liposuction and or abdominoplasty. The microorganisms most frequently isolated in post-liposuction infections are Staphylococcus aureus, Streptococcus group A, Streptococcous pyogenes, and synergistic infections with anaerobes and facultative pathogens.

Among the most severe complications of liposuction is necrotizing soft tissue infection (NSTI), which is an infection of the subcutaneous tissue that spreads to the underlying dermis and sometimes beyond including the fascia and muscle.

Conclusion

Rapid recognition of NSTI is life-saving and urgent, extensive debridement and prophylactic antibiotics are the mainstay treatment for this condition, multiple debridement procedures may be necessary for successful treatment.

Venous Thromboembolism Prophylaxis in Aesthetic Surgery: A Survey of Plastic Surgeons' Practices

BACKGROUND

Deep venous thrombosis and pulmonary embolism, collectively known as venous thromboembolism (VTE), are among the most feared yet preventable surgical complications. Although many recommendations exist to reduce the risk of VTE, the actual VTE prophylaxis practices of aesthetic plastic surgeons remain unknown.

OBJECTIVES

The primary aim of this study was to elucidate plastic surgeons' experiences with VTE, preferred VTE prophylaxis practices, and areas in which VTE prevention may be improved.

METHODS

Members of The Aesthetic Society were queried via a 55-question electronic survey regarding their experience with VTE as well as their VTE prophylaxis practices. Anonymous responses were collected and analyzed by the Mayo Clinic Survey Research Center.

RESULTS

The survey was sent to 1729 of The Aesthetic Society members, of whom 286 responded. Fifty percent, 38%, and 6% of respondents reported having had a patient develop a deep venous thrombosis, pulmonary embolism, or death secondary to VTE, respectively. Procedures performed on the back or trunk were associated with the highest rate of VTE. Lower extremity procedures were associated with a significantly higher rate of VTE than expected. Over 90% of respondents reported utilizing a patient risk stratification assessment tool. Although at least one-half of respondents reported that the surgical facility in which they operate maintains some form of VTE prophylaxis protocol, 39% self-reported nonadherence with these protocols.

CONCLUSIONS

Considerable variability exists in VTE prophylaxis practices among The Aesthetic Society responders. Future efforts should simplify guidelines and tailor prophylaxis recommendations to the aesthetic surgery population. Furthermore, education of plastic surgeons performing aesthetic surgery and more diligent surgical venue supervision is needed to narrow the gap between current recommendations and actual practices.

Cosmetic Surgery Safety: Putting the Scientific Data into Perspective

Optimizing patient safety and outcomes remains at the forefront of cosmetic surgery today. The five most commonly performed procedures are breast augmentation, liposuction, rhinoplasty, blepharoplasty, and abdominoplasty. Safety of all cosmetic surgery is a necessity for its successful, continued practice. This article seeks to elucidate the current literature detailing the major and minor complication profiles of the five most practiced areas in cosmetic surgery.

[Dealing with Acute Complications of Aesthetic Surgery Procedures Performed Abroad: Cost Analysis for the Swiss Health System]

Dealing with Acute Complications of Aesthetic Surgery Procedures Performed Abroad: Cost Analysis for the Swiss Health System Abstract. Aesthetic surgery tourism is a growing phenomenon, with a steady increase of people travelling abroad for surgical procedures. In our hospital, a relevant number of patients consulted the emergency department for complications after cosmetic surgery performed in foreign countries. This progressively increasing trend leads to multiple outpatient clinic consultations and surgical re-operations. We investigated this phenomenon at Lausanne University Hospital from May 2015 to December 2018, with the aim to give a review of the surgical and hospital care costs, finally affecting the Swiss insurance system.

Improvement in Brazilian Butt Lift (BBL) Safety With the Current Recommendations from ASERF, ASAPS, and ISAPS

BACKGROUND

In 2017, the ASERF Gluteal Fat Grafting Task Force reported gluteal fat grafting to be a high-risk procedure and recommended specific surgical techniques to decrease the risk of pulmonary fat embolism (PFE).

OBJECTIVES

The aim of this study was to determine whether ASAPS and ISAPS members were aware of the 2017 recommendations, what their current surgical techniques were, whether they had changed their techniques based on the 2017 recommendations, and whether the incidence of PFEs had changed since the recommendations were published.

METHODS

An anonymous web-based survey was conducted among members of ASAPS and ISAPS. It included the questions from the 2017 survey, as well as questions about awareness of the Task Force recommendations and subsequent change in surgical techniques.

RESULTS

In the 2 years following the publication of the recommendations, the incidence of any PFE was 1 in 2492 compared with 1 in 1030 reported in 2017 (P = 0.02). Trends indicated a decreased mortality rate from 1 in 3448 in 2017 to 1 in 14,952 in 2019. Ninety-four percent of respondents were aware of the recommendations. Only 0.8% of surgeons in the current survey reported injecting in deep muscle, compared with 13.1% in 2017 (P < 0.01). Compared with 4.1% in 2017, 29.8% of respondents in our survey reported that they only injected with cannulas ≥4.1 mm (P < 0.01). Only 4% of respondents reported angling the cannula down in the current survey, compared with 27.2% in 2017 (P < 0.01).

CONCLUSIONS

It appears that members were aware of the 2017 recommendations. There was a significant decrease in recent PFE and trends showed a change to safer techniques and an improvement in safety of the procedure.

Pneumothorax as a Complication of Liposuction

Background

Pneumothorax is a rare complication of liposuction resulting from injury to the lung parenchyma.

Objectives

This study aimed to determine the incidence of pneumothorax complicating liposuction, describe an archetypal presentation, identify risk factors, and propose options for risk reduction.

Methods

In a retrospective chart review, liposuction procedures performed over a 16-year period by 8 surgeons in 1 practice were screened for pneumothorax. Cases featuring pneumothorax were analyzed to ascertain risk factors, presentation, and pathogenesis.

Results

Among the 16,215 liposuction procedures performed during the study period, 7 pneumothoraxes were identified (0.0432%). Six (85.7%) were female. Three (42.9%) had previous liposuction. Six cases (85.7%) included liposuction of the axillary region. All cases featured depression of intra/postoperative oxygen saturations as the initial sign. Three (42.9%) were identified intraoperatively. All patients were transferred to a hospital for imaging. Five (71.4%) underwent chest tube placement. Two (28.6%) were treated with observation alone. Pneumothoraxes were left-sided in 4 cases (57.1%), and right-sided in 3 cases (42.9%). In early cases, 1.5-mm infiltration cannulas were used; in 2016 cannula size was changed to 3-4 mm for infiltration and 4-5 mm for liposuction.

Conclusions

Possible risk factors for pneumothorax include liposuction of the axilla, use of flexible infiltration cannulas, and scarring from previous liposuction. We recommend including pneumothorax as a potential complication during informed consent, performing infiltration with a stiff >3.5-mm cannula, minimizing positive-pressure ventilation, emphasized awareness of cannula tip location in all patients but particularly in patients with previous liposuction or scar tissue, and increased caution when operating in the axillary area.

Level of Evidence: 4