Liposuction: How to Avoid the Danger Zones

It happened in outpatient surgery facilities in Miami and Naples, Fla. It happened in a facility in Ventura, Calif. It happened in Texas. It's happened at least five times in New York City. In fact, according to two recent studies, it may happen as often as once every 5,000 or even once every 1,000 cases. Could death following liposuction occur in your facility?

If you do the procedure, experts say the answer is probably yes. Patients can be subject to serious complications, including pulmonary thromboembolism, fluid imbalance, and lidocaine toxicity, and there is no way to completely eliminate the possibility that these complications will occur. Fortunately, though, experts say there are ways to greatly minimize the risk. If you implement the right safeguards, liposuction can be one of the safest procedures you perform in your facility and one of the most satisfying for your patients. In this article, we'll discuss how.

Make sure the surgeons in your facility are credentialed and have specific training in performing liposuction procedures.

Qualify Your Surgeons
Lured by the prospect of easy cash for performing what seems like an easy procedure, many doctors have jumped into offering liposuction without getting adequate training; in some cases, physicians have started doing liposuction after attending a weekend training course. There are few federal and state laws governing what a physician must do to designate him or herself a specialist, so it's important to credential surgeons carefully. "Choosing surgeons carefully is perhaps the most important determining factor for safety in liposuction," says Rod Rohrich, MD, chair of plastic surgery at the University of Texas-Southwestern and a board member of the American Society of Plastic Surgeons (ASPS).

Plastic surgeons and dermatologists perform most liposuction cases; the latter account for more than one-third of all the procedures done each year, according to the American Academy of Dermatology (AAD). The ASPS and the AAD have both published physician qualification guidelines for liposuction. A summary:
– Both organizations state that physicians should be board certified or board eligible.
– The AAD and the ASPS recommend specific training in liposuction via one of the following:
– Training during an accredited residency or fellowship; or
– Completion of an appropriate liposuction training course, which should include instruction in fluid replacement, management of post-op complications, and hands-on training.

Both organizations suggest that physicians be proctored for at least their first few procedures. The ASPS further suggests that physicians performing liposuction in any setting have hospital privileges for the procedure, with specific privileges to operate on the area of the body in which the liposuction is performed.

Ideally, you should look beyond these minimum requirements and make sure your surgeons have done a significant number of these procedures successfully-it takes a highly skilled surgeon to get not just good, but excellent results. "True body sculpting requires three-dimensional thinking and artistic talent," says Dr. Rohrich. Physicians without these talents run the risk of creating irregular contours, dents, and unhappy patients.

Screen Your Patients
In a case published in the May 2000 issue of Plastic and Reconstructive Surgery, an obese 47-year old woman died from cardiopulmonary arrest after undergoing large-volume liposuction. She probably never should have undergone the procedure in the first place. It's widely accepted that liposuction is not a cure for obesity and works best on localized areas of fat in healthy patients who are no more than 30 percent above their normal body weight. Obese patients are prone to hypertension, pulmonary disease, and sleep apnea (making recovery from anesthesia difficult).

The experts with whom we spoke recommend convening your medical board and setting formal protocols on which patients you will and will not accept. They recommend requiring a baseline history and physical and possibly an EKG and blood work if the patient is over 40 or has any medical problem. "In short," says Dr. Rohrich, "surgeons should only perform liposuction on healthy patients with no significant medical problems, especially a history of deep venous thrombosis or pulmonary problems."

Set a Volume Limit
In one well-publicized case in 1997, a California woman died after her surgeon subjected her to a 10-hour procedure, where he removed 20 pounds of fat. Although there have been no studies directly linking "large volume liposuction" (removal of more than 5000 ccs or 10 pounds of fat and fluid) to deaths, these procedures generally involve larger lidocaine dosages, larger infusions of tumescent solution, and more prolonged recovery. Surgeons generally remove an average of 2,000 to 4,000 ccs of fat in a normal outpatient liposuction procedure (in general, dermatologists are more cautious than plastic surgeons about removing large amounts in one sitting; they usually elect to do serial procedures). Whatever your surgeons' specialty, they should never attempt large volume liposuction in an outpatient facility.

Set a limit of 5,000 ccs on the amount of fat that can be removed during one procedure, recommends Gerald Pitman, MD, a board-certified plastic surgeon based in New York. For some patients, even 5,000 ccs or less will be too much to remove in the outpatient setting; when there is a question, refer the patient to an inpatient facility.

Protect Against Pulmonary Thromboembolism
In two independent surveys commissioned by the ASPS and the American Society of Aesthetic Plastic Surgeons, pulmonary thromboembolism was found to be the major complication causing liposuction fatalities. According to the surveys, this complication causes 23 percent of all deaths linked to the procedure. Deep venous thrombosis (DVT) of the legs, which can lead to pulmonary thromboembolism, is a risk in any procedure, but becomes more likely in longer procedures involving liposuction of the legs or when the surgeon performs concomitant procedures, such as abdominoplasty. If your surgeons are doing these more complex procedures, they should place compression garments on the patient intraoperatively to put pressure on and stimulate the leg veins, reducing the risk of DVT, says Dr. Rohrich. The garments should stay on until the patient is walking. Patients also usually wear some kind of compression garment for two to six weeks post-op to help reduce swelling and bruising.

Keep Fluid Balance in Check
In a case published last year in the New England Journal of Medicine that studied five deaths linked to liposuction, one patient died after receiving 13 liters of fluid over the course of a 4.5 hour liposuction procedure, resulting in severe hemodilution. Although this is an extreme case, fluid overload is a potential complication in all liposuction cases. This is because most cases are done using the tumescent technique, which involves injecting a wetting solution containing salt solution, lidocaine (for analgesia), and epinephrine (to constrict blood vessels) prior to liposuction to make the fat easier to remove, minimize blood loss, and reduce post-op swelling. Although the tumescent technique avoids the risks of general anesthesia, it creates a new risk-fluid overload. To avoid it:

– Calculate the maximum amount of fluid that can be used in the case beforehand, recommends Mary Gingrass, MD, a board-certified plastic surgeon from Nashville, Tenn. In her OR, a nurse uses a standardized form to calculate the maximum amount of fluid, based on patient weight and the complexity of the procedure.
– Carefully monitor the total amount of fluid being delivered to the patient and the amount of fat being suctioned out at all times during the procedure. Dr. Rohrich recommends admitting the patient to an inpatient facility if you infuse greater than 5,000 ccs of fluid.

Protect Against Lidocaine Toxicity
The same article in the New England Journal of Medicine blamed two other liposuction deaths on lidocaine toxicity. This conclusion was later questioned, since both patients received lidocaine doses far below the recommended limit of 35 mg/kg. In any case, it is crucial to make sure you prepare the tumescent solution accurately.

To ensure that the solution is mixed properly, make sure only qualified, trained technicians prepare it, and try to ensure that the same people prepare it every time, says Dr. Gingrass. In her practice, the same nurses prepare every bag of tumescent solution in the same location (the standard makeup is 1000 ccs of Lactated Ringers solution, 25 ccs of 1% xylocaine (lidocaine), and one cc of 1:1000 epinephrine). The bags are clearly marked with a "T" and made up well before the start of the operation.

Plastic surgeons perform most cases under general anesthesia: dermatologists tend to use local. No matter which method your surgeons use, make sure they have the right support and that emergency equipment is readily available.

Provide Anesthesia Support
Anesthesia technique is a key area where plastic surgeons and dermatologists tend to differ. The former claim that general anesthesia allows them to perform more effectively and do complex procedures, and, in most cases, the patients want to be put to sleep. Dermatologists, on the other hand, do most of their cases under local anesthesia; they claim that most liposuction deaths can be attributed to anesthesia complications.

Dr. Pitman uses propofol or Versed to achieve heavy sedation, where the patient is completely amnestic. A fair number of his cases-about 25 percent-are done under general anesthesia; he feels that having the patient asleep is particularly useful for treating larger patients and patients who are positioned prone on the table. He does all of his cases with an anesthesiologist in attendance. Dr. Gingrass feels comfortable using supervised nurse anesthetists, with whom she's been working for years. She does most of her procedures under general anesthesia. "There's no patient movement, so I feel I can perform the procedure more easily," she says. "My nurse anesthetists are highly skilled and my patients don't get sick afterwards, so I really feel the risk of general anesthesia is miniscule." William Coleman, MD, a clinical professor of dermatology at Tulane University School of Medicine in New Orleans, does most of his procedures (2000 ccs fat removal on average) using local anesthesia. "The AAD guidelines of care are to provide primarily local anesthesia and minimal general," he says. "There's no doubt that pure local increases safety-the risk of complications decreases dramatically and recovery time is shorter." General anesthesia also increases the cost by an average of $2,000 per case, he says. Rhoda Narins, MD, a New York-based dermatologist who performs liposuction in her own AAAHC-approved facility, agrees. When she first started doing liposuction, she did most of her cases under general, but she says that moving to local is "a positive progression."

Deciding what kind of anesthesia surgeons should be allowed to do at your facility is a complex question-the answer will no doubt depend on your and your medical board's comfort level with a particular surgeon. But, no matter who is operating at your facility, make sure they've done plenty of successful procedures with their anesthesia method of choice, and make sure the proper staff and resuscitative equipment is available to them at all times. Obviously, if the surgeon is using intravenous sedation or general anesthesia, monitoring with a pulse oximeter, cardiac monitor, thermometer, and blood pressure device is mandatory. No matter who is administering your anesthesia, it is critical that the anesthesia professional, not the operating surgeon, monitor the patient intraoperatively, notes Dr. Rohrich.

Protect Patients Against Hypothermia
Patients are usually completely unclothed during the procedure, and if they are given general anesthesia, they tend to lose body heat quickly. This can lead to shivering, hypothermia, or even cardiac arrhythmia. To avoid this, keep the OR warm, and be sure to cover exposed areas of the patient, particularly the head and neck area, says Dr. Rohrich. Dr. Pitman keeps his OR at 78 to 80 degrees F and uses a forced hot air heating blanket postoperatively to help maintain a normal core body temperature. Dr. Gingrass covers the areas she's not working on during the procedure with a warming blanket.

Hypothermia can also occur if the surgeon infuses large amounts of cool tumescent solution, but pre-warming it can reduce the risk. Jonlyn Nation, RN, a nurse on Dr. Gingrass's staff, warns against making the solution too warm, however. If it's significantly above normal body temperature, it may counteract the effect of the epinephrine in the tumescent solution, vasodilating the blood vessels.

Make Sure the Patient Has an Escort Home
The ASPS-ASAPS surveys revealed that many deaths occur during the first night after discharge home, highlighting the importance of vigilant observation and having the patient stay with a friend or family member overnight. "Sometimes these patients don't want anybody to know that they're having the procedure done-they think they'll just be able to go home in a cab and be by themselves post-op," says Dr. Gingrass. Make sure you emphasize to all liposuction patients that not only will they need a ride home (standard protocol in most facilities), but also that a friend or family member must stay with them overnight. "If you have any doubt about where the patient will be and who will be with them, admit them for one night," says Dr. Rohrich.

Chances are that despite all the brouhaha over liposuction, the market will remain strong. It's already grown into the most popular cosmetic surgery procedure in the US, fueled by an appearance-conscious society and a strong economy. By taking common-sense steps and proceeding with caution, you can ensure that your patients stay safe while helping them look their best.