Large-volume liposuction complicated by retroperitoneal hemorrhage: management principles and implications for the quality improvement process

Fluid Balance After Tumescent Infiltration: A Practical Guideline to Avoid Dilution Anemia in Circumferential Liposuction Based on a Prospective Single Center Study

BACKGROUND

Circumferential liposuction may cause a dilution anemia due to a high volume of infiltrated tumescent. Studies analyzing the percentage of absorbed tumescent as well as the safe limit of tumescent infiltration are currently lacking.

OBJECTIVES

The objective was to calculate the average volume uptake of administered fluids in power-assisted liposuction. Furthermore, we sought to calculate a practical formula to determine the amount of fluid that can safely be administered without inducing symptomatic dilution anemia or hypervolemia.

METHODS

Patients undergoing circumferential liposuction with power-assisted tumescent infiltration were included in a prospective clinical study. All relevant administered and excreted volumes during and after the operation were collected. Preoperative versus postoperative hemogram results were compared and the hemodynamic parameters were followed for 24 hours. The average volume uptake was calculated based on the measured volumes, as well as the ratio between administered volumes and the patient's blood volume.

RESULTS

30 patients were included during September 2021. The average volume uptake was 58% for a calculated 1.11 to 1 infiltration to aspiration ratio. There was a mean drop of 1.9 g/dl and 4.6% for the postoperative Hb and Hct, respectively, with a stable Red Blood Cell level. All patients remained hemodynamically stable without the need for blood transfusion or prolonged oxygen need. The average tumescent versus blood volume ratio was 85.0%.

CONCLUSIONS

In circumferential liposuction with power-assisted infiltration, the infiltrated tumescent volume should remain below 85% of the patient's blood volume to minimize the risk of a symptomatic dilution anemia or hypervolemia.

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.

Subcutaneous Migration: A Dynamic Anatomical Study of Gluteal Fat Grafting

BACKGROUND

Recent anatomical studies have demonstrated that fat placed subjacent to the fascia of the gluteus maximus muscle can migrate deep through the muscle into the submuscular space, possibly causing tears in the gluteal veins, leading to fat embolisms. The purpose of this study was to define and to study subcutaneous migration and to determine whether fat placed in the subcutaneous space under a variety of pressures and fascial integrity scenarios can indeed migrate into the deep submuscular space.

METHODS

Four hemibuttocks from two cadavers were used. Proxy fat was inserted using syringes with various fascia scenarios (1: fascia intact; 2: cannula perforations; 3: 6mm fascia defects) or using expansion vibration lipofilling (4: fascia intact). Subcutaneous pressures were recorded. After injections, anatomical dissections were performed to evaluate the migration of the proxy fat for each of the scenarios.

RESULTS

Scenario 1: pressure reached approximately 125 to 150 mmHg and then plateaued and all the proxy fat remained in the subcutaneous space. Scenario 2: pressure reached a 199-mmHg plateau and no proxy fat spread deeper into the muscle or beneath it. Scenario 3: pressure gradually rose to 50 mmHg then fell again and the submuscular space contained a significant amount of proxy fat. Scenario 4: pressure rose to a maximum of 30 mmHg and all of the proxy fat remained in the subcutaneous space.

CONCLUSIONS

The gluteus maximus fascia is a stout wall that sets up the dangerous condition of deep intramuscular migration with subfascial injections and the protective condition of subcutaneous migration with suprafascial injections. These persuasive findings are profound enough to propose a new standard of care: no subfascial or intramuscular injection should be performed, and all injections should be performed exclusively into the subcutaneous tissue.

Is There a Limit? A Risk Assessment Model of Liposuction and Lipoaspirate Volume on Complications in Abdominoplasty

BACKGROUND

Combining liposuction and abdominoplasty is controversial because of concerns for increased complications and potential for vascular compromise of the abdominoplasty flap. Also, the lipoaspirate volume in abdominoplasty is regulated in some areas to as little as 500 ml when performed with abdominoplasty. This study measures abdominoplasty complication rates when performed with and without trunk liposuction, and evaluates the effect of lipoaspirate volume on complications.

METHODS

Abdominoplasty and liposuction of the trunk procedures were identified in the Tracking Operations and Outcomes for Plastic Surgeons database. Multivariate regression models determined the effect of liposuction with abdominoplasty on complications compared with abdominoplasty alone and determined the effect of liposuction volume on complications.

RESULTS

Eleven thousand one hundred ninety-one patients were identified: 9638 (86.1 percent) having abdominoplasty with truncal liposuction and 1553 (13.9 percent) having abdominoplasty alone. Overall complication rates were 10.5 percent and 13.0 percent, respectively. Combined liposuction and abdominoplasty was independently associated with a reduced risk of both overall complications (p = 0.046) and seroma (p = 0.030). Given existing laws limiting liposuction volume to 500 or 1000 ml in combination with abdominoplasty, each of these thresholds was evaluated, with no effect on complications. Surprisingly, increasing liposuction volume was not independently associated with an increased risk of any complication.

CONCLUSIONS

When done by board-certified plastic surgeons, abdominoplasty with truncal liposuction is safe, with fewer complications than abdominoplasty alone. Regulations governing liposuction volumes in abdominoplasty are arbitrary and do not reflect valid thresholds for increased complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Ureteral tear at the ureteropelvic junction: a complication of liposuction

We report the case of a 47-year-old woman who presented to the emergency room with gross hematuria during liposuction of the abdomen. Computed tomography (CT) using hematuria protocol demonstrated extravasation of contrast at the right ureteropelvic junction and a small urinoma in the right perinephric space. The diagnosis of ureteral tear at the ureteropelvic junction (UPJ) was confirmed. A ureteral stent was placed at surgery. Visceral injuries and other complications associated with liposuction have been described. However, this is the first reported case of a ureteral tear related to liposuction.

Is dermolipectomy effective in improving insulin action and lowering inflammatory markers in obese women?

OBJECTIVE

Obesity is a major risk factor for coronary heart disease, and surgical treatment of obese patients as part of a multidisciplinary approach seems to provide faster results than diet therapy. The aim of this study was to evaluate the effect of dermolipectomy on insulin action and inflammatory markers in 20 obese women.

PATIENTS

At baseline and 40 days after dermolipectomy, 20 obese women underwent indirect calorimetry and hyperinsulinaemic glucose clamp. Twenty obese nonsmoking females (age range 25--40 years) volunteered for the study. All subjects had a stable body weight for 2 months before the study. No patient was affected by cardiovascular and/or pulmonary disease, type 2 diabetes, thyroid dysfunction, acute or chronic hepatitis, renal insufficiency or cancer. No patients was receiving any drug therapy and all measurements were made during the follicular phase of the menstrual cycle.

RESULTS

At baseline, fat mass (FM) correlated with plasma triglycerides (r=.58, P<0.009), free fatty acids (FFA) (r=0.73, P<0.001), insulin (r=0.70, P<0.002), leptin (r=0.55, P<0.01), adiponectin (r=-0.32, P<0.02) and resistin (r=0.31, P<0.01), insulin sensitivity (IS) (r=-0.59, P<0.005) and respiratory quotient (Rq) (r=0.62, P<0.002). With regard to inflammatory markers, FM was significantly correlated with plasma interleukin (IL)-6 (r=0.71, P<0.001), IL-10 (r=-0.67, P<0.002), tumour necrosis factor-alpha (TNF-alpha) (r=0.78, P<0.001) and soluble IL-6 receptor (sIL-6r) (r=-0.65, P<0.003). Dermolipectomy resulted in a significant decline in total FM of 2.3+/- 0.2 kg. A significant decline in BMI was also observed (30.0+/- 0.08 vs. 31.1+/- 0.7 kg/m(2)). After 40 days a significant decline in plasma resistin (P<0.001) and inflammatory markers and an increase in plasma adiponectin (P<0.03) were observed. Those metabolic changes were accompanied by a significant improvement in insulin-mediated glucose uptake (P<0.001), substrate oxidation and degree of inflammation. Changes in FM following dermolipectomy correlated with the changes in IS (P<0.01), substrate oxidation and FFA (P<0.001).

CONCLUSIONS

In obese patients, dermolipectomy is associated with weight lost, improved glucose handling and lower inflammatory markers.

Low-volume tumescent liposuction does not change plasma malondialdehyde levels: a preliminary study

To evaluate the effects of low-volume tumescent liposuction on plasma malondialdehyde (MDA) levels, a controlled clinical study was conducted. Venous blood samples were taken just before and 10 min after the completion of tumescent suction-lipectomy for 15 patients. The means +/- standard deviations for patients' data were as follows: of patients' age (29.81 +/- 13.2 years) aspirate volume (1,250 +/- 450 ml), and body mass index (24.5 +/- 1.2). There was no significant difference between the preoperative and postoperative plasma malondialdehyde levels (p > 0.05). The results show no evidence of increased lipoperoxidation in the systemic circulation during low-volume tumescent liposuction.

Practice Advisory on Liposuction

COMMITTEE STATEMENT: At the 69th annual meeting of the American Society of Plastic Surgeons (ASPS) in October of 2000, the ASPS Board of Directors convened the Task Force on Patient Safety in Office-Based Surgery Facilities. The task force was assembled in the wake of several highly publicized patient deaths involving plastic surgery and increasing state legislative and regulatory activity of office-based surgery facilities. In response to the increased scrutiny of the office-based surgery setting, the task force produced two practice advisories: "Procedures in the Office-Based Surgery Setting" and "Patient Selection in the Office-Based Surgery Setting." Since the task force's inception, professional and public awareness of patient safety issues has continued to grow. This heightened interest resulted in an increased need for plastic surgeons to communicate their views on the topic. To meet this challenge, the task force evolved into the Committee on Patient Safety, allowing the committee to address topics affecting the safety and welfare of plastic surgery patients, regardless of the facility setting. The "Practice Advisory on Liposuction" is the first advisory developed since the committee was formed. It was a lengthy and painstaking process for the committee, which included representatives from related plastic surgery organizations as well as the American Society of Anesthesiologists (ASA). Committee members included Ronald E. Iverson, M.D., chair; Jeffery L. Apfelbaum, M.D., ASA representative; Bruce L. Cunningham, M.D., ASPS/Plastic Surgery Educational Foundation (PSEF) Joint Outcomes Task Force representative; Richard A. D'Amico, M.D., ASPS representative; Victor L. Lewis, Jr., M.D., ASPS Health Policy Analysis Committee representative; Dennis J. Lynch, M.D., ASPS representative; Noel B. McDevitt, M.D., ASPS Deep Vein Thrombosis Task Force representative; Michael F. McGuire, M.D., The American Society for Aesthetic Plastic Surgery (ASAPS) representative; Louis Morales, Jr., M.D., American Society of Maxillofacial Surgeons representative; Calvin R. Peters, M.D., Florida Ad Hoc Commission on Patient Safety representative; Robert Singer, M.D., American Association for Accreditation of Ambulatory Surgery Facilities representative; Thomas Ray Stevenson, M.D., American College of Surgeons representative; Rebecca S. Twersky, M.D., ASA representative; Ronald H. Wender, M.D., ASA representative; and James A. Yates, ASAPS representative. The authors thank members of the committee for the insights they brought to this process. The final document represents their significant contributions to these efforts. They would also like to recognize DeLaine Schmitz and Pat Farrell of the ASPS staff for their work on and support of this project.

Lipoaspiration and Its Complications: A Safe Operation

Although lipoaspiration has been considered a safe surgical procedure for the last 30 years, reports indicate that this procedure has a high index of complications. This study was performed to analyze experience with patients in a clinical practice for the past 8 years who underwent lipoaspiration, either alone or in combination with another surgical procedure, and to compare the results with previous reports in the literature. The patients were divided into four groups: lipoaspiration alone of less than 5 liters, lipoaspiration alone of more than 5 liters, lipoaspiration combined with abdominoplasty, and lipoaspiration combined with another surgical procedure. Complications were divided into minor or major, depending on previous reports, and statistical analysis was used to determine any significant difference among the four groups. From January of 1994 to December of 2001, 1047 patients underwent lipoaspiration, either alone or in combination with another surgical procedure. A 21.7 percent incidence of minor complications was noted, as well as a 0.38 percent incidence of major complications. Minor complications included palpable and visible irregularities, seromas, cutaneous hyperpigmentation, overcorrection, cutaneous slough, and local infection. Major complications included fat embolism syndrome, cutaneous necrosis, and extended infection. No statistical difference was noted among the groups studied. The incidence of complications was similar to that in clinical reports in the world literature, being of a low percentage rate when compared with the reports of other types of surgical procedures. On the basis of these results, lipoaspiration continues to be a safe surgical procedure, but to maximally avoid complications, one should be mindful of all the factors that could predispose to them.

Liposuction of a pediatric giant superficial lipoma

Liposuction can be considered a preferable alternative to conventional surgery in pediatric lipomas that are bigger than 4 cm. Liposuction of pediatric lipomas has not been found in the English-language literature. The case of a 5-year-old girl who had liposuction of a large lipoma extending from the lower cervical to the right lumbar region is reported with a review of the literature on the technique, follow-up, and outcome of the procedure.