EVIDENCE-BASED MEDICINE MAINTENANCE OF CERTIFICATION ARTICLE: LIPOSUCTION

Introduction

Since the latter half of the twentieth century, there has been an increasing focus on the body as a vehicle for identity and self expression with a greater recognition of the role of appearance and the desire for self improvement¹. In 2014, liposuction replaced breast augmentation as the most frequently performed surgical procedure with a 16% increase over 2013 and more than 1 billion USD being spent on the procedure in the United States alone².

Pre-Operative Assessment

It is important for the physician early into the consultation to assess the patient’s motivations for surgery as well as the degree of concern they have about their current physical state in order to meet their expectations. Patients with body dysmorphic disorder (BDD) will not benefit from surgical intervention and have been observed in aesthetic surgery settings to seek surgical enhancement at a reported prevalence of 6% to 15%³. The current recommendation is for the patient to be within 30% of the ideal body mass index (BMI) but whether liposuction can be a contributing factor to weight loss in high BMI individuals is an area of controversy⁴. Massive weight loss patients may have persistent areas of lipodystrophy amenable to liposuction. In a recent study using multivariate regression models incorporating the interaction between liposuction volume and body mass index. The authors’ risk assessment model demonstrates that volumes in excess of 100 ml per unit of BMI confer an increased risk of complications⁵. The results of this study may help surgeons in surgical planning and expectation management.

Medical History

Many patients take vitamins, minerals, and supplements and do not report this to their practitioner as they feel they are inconsequential. Stopping all non-essential agents before surgery can reduce the risk of a bleeding related complication⁶.

The percentage of the US population using at least 1 psychotropic medication increased from 5.9% in 1996 to 8.1% in 2001⁷. First line antidepressants include  selective serotonin reuptake inhibitors (SSRI’s). These medications along with others can compete with lidocaine for metabolism in the liver increasing the risk of toxicity⁸. Drugs that potentially interfere with lidocaine metabolism should be discontinued at least 2 weeks before using tumescent technique for local anesthesia when high doses of lidocaine are anticipated. If it is not reasonable to discontinue a drug that might interfere with lidocaine metabolism, then the surgery should be limited to smaller total doses of lidocaine or be done under general anesthesia⁹. Smoking is an independent risk factor for wound healing complications. The ameliorating effects of cessation are supported by level 1 evidence, which suggests that the optimal duration of preoperative cessation of any form of nicotine is four weeks or longer¹⁰. Diabetes mellitus (DM) is an increasingly common medical condition affecting approximately 8% of the population of the United States¹¹. Infections account for 66% of postoperative complications and nearly one quarter of perioperative deaths in patients with DM. Fortunately, tight glycemic control has been shown to have a profound effect on reducing the incidence of many of these complications in a variety of surgical populations¹². Complication rates in orthopedic surgery have been shown to be lower in patients whose HbA1c is less than 6.5%¹³.

Venous thromboembolism (VTE) is a serious complication with risks for short-term mortality and long-term morbidity. VTE has been shown to be the single largest cause of mortality in patients undergoing high-volume liposuction⁴. Caprini’s risk assessment model is a useful and effective tool to stratify plastic and reconstructive surgery patients for VTE risk even in oral sedation tumescent liposuction cases¹⁴.  Using regional or tumescent anesthesia alone has been shown to have statistically significant lower incidences of post-operative deep vein thrombosis¹⁵. If patients are on beta-blockers for hypertension it should be confirmed they are cardioselective to prevent a hypertensive crisis from an unopposed alpha vasoconstriction¹⁶. According to the American College of Cardiology/American Heart Association Guidelines, functional status is a reliable predictor of perioperative and long-term cardiac events.¹⁷.

Physical Exam

A carefully directed history and physical should look for stigmata and sequelae of chronic disease. When examining the abdomen, the physician should pay particular attention to surgical scars as potential sources of hernias. Visceral perforations are most common in the small intestine in patients with abdominal hernias¹⁸. Classification and documentation of the extent of diastasis recti and visceral fat component is essential. Skin quantity and quality should be assessed and differences between excisional procedures and liposuction should be discussed with the patients.

Informed Consent and Photography

Accurate photographic documentation has become essential in reconstructive and cosmetic plastic surgery both for clinical and scientific purposes¹⁹.  Generally, ‘‘informed consent’’ requires that the patient be informed of the risks of treatment, the prognosis, and alternative treatments before consenting to treatment. Surgical consent has evolved and is not an event or a signature on a form but is an ongoing process of communication that continues throughout preoperative, perioperative, and postoperative care.

Location of Surgery

Most surgical procedures are performed in one of three outpatient settings: hospitals, free-standing ambulatory surgery centers, or office- based surgery facilities²⁰ . Office-based surgery has several potential benefits over hospital-based surgery, including cost containment, ease of scheduling, and convenience to both patients and surgeons. In a review of 3,615 consecutive patients who had undergone office-based plastic surgery with monitored anesthesia care or sedation there were no deaths, ventilator requirements, deep venous thromboses, or pulmonary emboli. This study helped show that office-based surgery with intravenous sedation, performed by board-certified plastic surgeons and nurse anesthetists, is safe²¹. Many surgeons still prefer to perform the majority of liposuction cases under general anesthesia²². Tumescent anesthesia was initially developed in 1987 by Jeffery Klein in an attempt to perform liposuction procedures with the sole use of local anesthesia²³. In a review of 4,380 consecutive patients undergoing tumescent liposuction by the same surgeon, no serious complications requiring hospitalization were found²⁴. It was found that hospital-based liposuction had three times the rate of malpractice settlements when compared with office-based liposuction surgery²⁵. To promote its members to practice with the utmost safety and integrity as of July 1, 2002 facility accreditation is a requirement for active membership in the American Society for Aesthetic Plastic Surgery(ASAPS). Physicians should follow State specific regulations on total aspirate permitted at a surgical setting.

MEDICATIONS IN WETTING SOLUTIONS

Lidocaine

In 1943, lidocaine was the first drug of the amino amide type to be introduced into clinical practice, and its rapid onset and moderate duration of action ensure its widespread use today²⁶. Lidocaine is rapidly eliminated by hepatic metabolism²⁷. Any drug that inhibits CYP3A4 enzymes, any condition that reduces hepatic blood flow, along with any disease that effects liver function can reduce lidocaine clearance²⁸. Not all patients should be treated equally in terms of lidocaine doses. For example, lower limits of lidocaine should be used in thinner patients with smaller volumes of distribution²⁹. The maximum recommended doses typically do not take into consideration the site of injection or factors that may influence tissue redistribution, metabolism, or excretion. The Xylocaine (lidocaine hydrochloride) (Astra Pharmaceutical Products, Inc. Westboro, MA) package insert reads that the dose of lidocaine at any one time should not exceed 3 mg/kg for plain solutions or 7 mg/kg for preparations including epinephrine³⁰. By measuring sequential lidocaine blood samples after tumescent infiltration along with graphing the peak plasma concentrations as a function of the lidocaine dosage (mg/kg), a safe maximum dosage for tumescent lidocaine was shown to be 35 mg/kg by Klein³¹ . While it is generally accepted that lidocaine doses up to 50mg/kg³² and even 55mg/kg³³ are safe to use in tumescent liposuction, the ASPS guidelines recommend 35 mg/kg as the maximum dose.  Lidocaine may also contribute to the extremely low incidence of infection seen in liposuction due to its bacteriostatic effect. Data suggest that, for patients undergoing general anesthesia with the superwet technique, the lidocaine component may be eliminated with out an increase in post-operative pain³⁴.

Epinephrine

Epinephrine causes vasoconstriction resulting in hemostasis and delayed absorption of the anesthetic agent. This prolongs its effect, decreases the amount of anesthetic needed, and reduces the risk of lidocaine toxicity³⁵. It is recommended that epinephrine doses not exceed 0.07 mg/kg, although doses as high as 10 mg/kg have been used safely³⁶. The detection of peak levels between 2 and 4 hours after infusion has been found in multiple studies^37,38. It has been shown that the time when the lowest cutaneous hemoglobin concentration after 1% lidocaine with 1:100,000 epinephrine is injected subcutaneously is 25.9 minutes³⁹. This is considerably longer than the frequently quoted 7 to 10 minutes for maximal cutaneous vasoconstriction⁴⁰.

Bupivacaine

Bupivacaine is a long acting amide local anesthetic, which, unlike lidocaine, does not have an active metabolite Of all the amide local anesthetics, bupivacaine is said to be the most cardiotoxic. This toxicity is seen mostly when there is a sudden increase in the plasma concentration of bupivacaine⁴¹. However, full recovery has been reported using an intravenous injection of a lipid emulsion, Intralipid 20% (Baxter Healthcare Corp., Deerfield, Ill.). It has been suggested that lipid emulsion may reverse local anesthetic toxicity by extracting lipophilic local anesthetics from aqueous plasma or tissues or by counteracting local anesthetic inhibition of myocardial fatty acid oxygenation⁴². In a prospective study, Swanson³⁸ found plasma levels were slower to rise than lidocaine, peaking at 20 hours compared to 8 to 18 hours after infusion. That study also went on to show safety with 550 mg administered and 3.33 mcg/ml peak plasma concentrations.  An online survey to members of the American Society of Plastic Surgeons revealed that 7% of respondents are using bupivacaine in their tumescent solutions with no reported cases of toxicity⁴³.

Sodium Bicarbonate

When lidocaine is used for local, subcutaneous injections patients often complain of pain thought to be related to the pH of most commercial lidocaine solutions, which are between 3.5 and 7.0^44,45. Some data suggest that alkalization of lidocaine does in fact reduce the level of pain associated with its injection.

Wetting Solutions

The current options for wetting solutions are dry, wet, superwet, and tumescent. The essential differences between these techniques focus on the amount of infiltrating solution injected into the tissues and the resultant blood loss as a percentage of aspirated fluid. The dry technique involves no infused fluid and results in approximately 25-40% blood loss of the volume removed. Blood loss has been estimated to represent approximately 1 percent of the liposuction aspirate volume for both tumescent and superwet techniques⁴⁶. Swanson³⁸ felt that this was a gross underestimation and has shown that there is substantial extravascular “third-space” blood loss into the interstitial tissues correlating to an approximate 2-point percentage decrease in hemoglobin for every 2500 cc of aspirate. “True” tumescent anesthesia is considered a 3:1 infiltrate to aspirate under pure local anesthesia. Most plastic surgeons report using a wetting solution that is a variation of superwet anesthesia (1:1 infiltrate to aspirate).Tissue blanching and moderate tension are considered clinical endpoints of infiltrate⁴⁷.

OPERATIVE CONSIDERATIONS

Cannulas

In general, blunt tipped cannulas are used to minimize perforation risk and smaller diameter cannulas are used to minimize contour irregularities. Non-blunt cannulas are typically used for breaking up scar or discontinuous undermining.   Aspiration has been found to be directly proportional to cannula and suction-tubing diameter and inversely proportional to cannula and suction-tubing length⁴⁸. Beck⁴⁹ with a proprietary manufacturing process found multiport and dual port cannulas to be significantly more efficient at aspiration compared to the standard Mercedes tip cannula.

Operative Techniques

Specific depths of subcutaneous fat should be suctioned, which vary from different body locations and patient specific goals. For example, the deep and/or intermediate fat layer should be primarily suctioned²² but, in rare cases, superficial or subdermal liposuction may be appropriate⁵⁰. Anatomic “zones of adherence,” present in both men and women, are important to identify preoperatively. These are areas with relatively dense fibrous attachments running to the underlying deep fascia where they help define the natural shape and curve of the body. These areas are not to be suctioned⁵¹ because of the high potential for contour deformities. Small volume procedures or procedures primarily for harvesting fat can be performed with syringe liposuction. The syringe technique employs blunt-tipped suction cannulae connected to a syringe. Drawing back the syringe plunger generates the negative pressures needed to remove fat during liposuction and replaces the electric vacuum pump and connecting tubing traditionally used for this procedure⁵². See surgical videos

ADJUNCTIVE LIPOSUCTION TECHNOLOGY/TECHNIQUES

Power Assisted Liposuction (PAL)

Power-assisted liposuction (PAL) is a commonly used technology that uses a variable-speed motor to provide reciprocating motion to the cannula, which in combination with the reciprocating action of the surgeon’s arm, facilitates removal of adipose tissue. The principal advantages of PAL is treatment speed, economy of motion, and reduced operator fatigue⁵³.

Laser Assisted Liposuction (LAL)

Goldman and colleagues showed histological evidence of coagulation of small blood vessels, rupture of adipocytes, reorganization of the reticular dermis, and coagulation of collagen in fat tissue with an updated 1064nm wavelength Nd:YAG laser⁵⁴. In a prospective, randomized, double-blind, controlled clinical trial comparing outcomes between suction-assisted lipoplasty and laser- assisted lipoplasty in patients where the authors randomly allocated half a body part for each modality, no major clinical differences for suction-assisted lipoplasty versus laser-assisted lipoplasty was seen⁵⁵. Although there is no conclusive evidence for the use of lasers in liposuction the recent adoption of the 1440nm laser may prove to be efficacious for emulsification. The longer wavelength has twenty times more absorption in adipose tissue than the 1064- nm/1320-nm and forty times more absorption than 924-nm/980-nm wavelengths⁵⁶.

Ultrasound Assisted Liposuction (UAL)

Vibration amplification of sound energy at resonance (VASER; Solta Medical, Inc., Hayward, CA) is another modality that was introduced to the United States with great fanfare after early utilization with mixed results of hollow probe ultrasonic liposuction in the 1990s⁵⁷. Nagy and Vanek⁵⁸ compared VASER-assisted lipoplasty and suction-assisted liposuction. They evaluated 2 objective end points: skin retraction in which VASER showed a 6% increase and blood loss, which also showed a minimal benefit of 3cc per 100cc of aspirate. Both surgeons and patients were unable to tell the difference between sides treated with either system⁵⁹. With the growth of autologous fat transfer, the use of ultrasound to selectively target and dislodge fat cells from the fatty tissue matrix may help improve fat viability and retention⁶⁰.

Radiofrequency Assisted Liposuction (RFAL)

Paul and Mulholland introduced radio frequency assisted liposuction and soft tissue contraction technology showing that energy could be delivered to the dermis while heating the deep adipose and subcutaneous tissue to much higher temperatures without compromising skin safety⁶¹. Using the BodyTiteTM (Invasix Ltd., Israel)  device in an industry sponsored in-vivo study linear contraction observed at 6 months follow-up was much more significant than reported with any other technology and varied from 12.7 up to 47% depending on patient and treatment variables⁶². Chia and Theodorou⁶³ in a study on arm contouring with RFAL used 3 independent plastic surgeons’ evaluations of the preoperative and postoperative photographs and showed improvement in arm contouring be 8% excellent, 72% good, 18% moderate, and 2% poor. They determined the degree of skin tightening to be 11% excellent, 46% good, 38% moderate, and 5% poor.

Water Assisted Liposuction (WAL)

WAL utilizes a dual- purpose cannula that emits pulsating, fan-shaped jets of tumescent solution, followed by simultaneous suctioning of the fatty tissue and the instilled fluid . In a single surgeon study using the Body-Jet (Human Med, Eclipse Ltd., Dallas, Texas) the amount of blood loss was negligible, with lipocrits estimated at less than 1.0% in both small and large volume liposuction cases⁶⁴. There was no comparison to other modalities and since no thermal energy was applied there was no discussion of skin tightening or emulsification. In a study comparing grafted lipoaspirates from WAL compared to SAL the water-based group had better weight retention, less apoptosis, and greater angiogenesis⁶⁵.

Separation, Aspiration, and Fat Equalization  (SAFE Lipo)

Created by Dr. Simeon Wall Jr. this three-step process has been proposed to reduce irregularities, bruising, and increase skin retraction. Fat separation is performed without suction, using an angled 5-mm exploded tip (basket) cannula (Microaire, Charlottesville, VA, USA). Aspiration of the separated fat is performed with an angled 3-mm or 4-mm Mercedes cannula, to be used in areas with thinner or thicker areas of fat, respectively. Fat equalization (post-tunneling) of the previously treated areas is performed with the angled 5-mm exploded tip cannula, without suction. The contour of the areas is assessed by a rolling pinch test while passing the cannula, with the end point of a completely smooth rolling pinch test without thick or thin areas of contour. This process leaves behind a layer of separated fat that can be considered as local fat grafts⁶⁶.

Markings

Areas to be suctioned are typically marked with a circle in a topographical pattern. Zones of adherence and areas to avoid are marked with hash marks⁶⁷. Some authors advocate grid markings to standardize resection and reduce contour irregularities⁶⁸. Incisions should be placed in natural creases to minimize visibility and some recommend placing bilateral access incisions asymmetrically to avoid scars that appear planned. It is important to review all markings and access incision locations with patients in front of a mirror before they are medicated.

Fluid Management

Under or over fluid resuscitation remains a critical issue with regard to liposuction. Empiric formulas have been suggested. Rohrich et al. suggest intraoperative fluid ratios near 1.8 for small-volume reductions and 1.2 for large-volume aspirations⁶⁹.  Pitman et al. recommend that the total volume of fluid administered should equal twice the volume of total aspirate⁷⁰. Matarasso recommends the total intake of injected, intravenous, and postoperative fluid is 2 to 3 mL/mL aspirate over the course of the two days after surgery⁷¹. The aim of intravenous fluid administration is to replace the preoperative deficit and provide maintenance fluid. With awake tumescent liposuction the patient is able to drink normally the night before and the day of surgery eliminating the need to replace deficits minimizing the risks of over or under hydration.

Post-Operative Care

Traditionally, prolonged use of elastic compression garments was advocated. The general rule of thumb was for patients to wear the garment for one week for every decade of life (40 year old patients would wear garments for 4 weeks). Prolonged compression can cause skin creases, hyperpigmentation, pain, and swelling. Some ways to minimize swelling and post-operative compression included minimally traumatic surgical technique, not suturing the incisions as recommended by Toledo and Mauad and applying bulky absorbent dressings for the 1st 24-48 hours to allow the excess remnant fluid and serous reaction to flow out⁷². Klein⁷³ advocates for bimodal compression. During the first stage of bimodal compression, a high degree of compression is maintained for as long as drainage persists. The second stage of bimodal compression begins 24 hours after all drainage has ceased, and employs either moderate compression or no compression.

COMPLICATIONS

Local

With appropriate patient selection and minimally traumatic techniques many complications can be avoided. Overly aggressive liposuction can lead to seromas. The collection of serous fluid in a treated area may lead to extensive breaking of the fibrous tissue network leading to a single cavity formation⁷⁴. The lower abdomen in patients with high BMI is a common area for seromas. Infection is extremely uncommon (less than 1% incidence)⁷⁵. This may be due to a combination of sterile technique, small incisions, and the anti-bacterial effects of lidocaine. The most common post-operative complication is contour irregularities with an incidence of 2.7%⁷⁶.  Illouz recommends that as a rule the contour should be slightly under-corrected to allow for post-operative fat lysis, which will amplify the result⁷⁷. Using small cannulas, not performing superficial liposuction, turning the suction off when exiting incisions, crisscrossing areas, constantly analyzing areas(visual and tactile), proper positioning, can all help reduce the chance of contour irregularities. Autologous fat transfer at the time of surgery or 6 months post-operatively can be used to help correct deformities. Toledo and Mauad recommends routine harvesting of a few syringes of fat prior to SAL so that it may be re-injected in cases of inadvertent over-liposuctioning in any area⁷². Relatively infrequent skin conditions such as hyperpigmentation, necrosis, and erythema abigne can be seen. Underlying connective tissue disease, smoking, along with superficial aggressive liposuction may contribute to these complications⁷⁸.

Systemic Complications

The most frequent potentially lethal complications associated with liposuction are pulmonary embolism, fat embolism, sepsis, necrotizing fasciitis, and perforation of abdominal organs. Grazer and de Jong⁴ in a North American survey of American Society of Aesthetic Plastic Surgery (ASAPS) members found a fatality rate of 19.1 per 100,000 liposuction procedures. The major cause of death was pulmonary thromboembolism. Even though dermatological studies of true tumescent liposuction have reported the risk of death from liposuction procedures to be zero in a series 66,000⁷⁹ cases there are reports of deaths in true awake tumescent liposuction⁷⁵. Major risk factors for the development of severe complications are poor standards of sterility, the infiltration of multiple liters of wetting solution, permissive postoperative discharge, and selection of unfit patients⁷⁵.

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