Safety Guidelines of Liposuction
‘Better safe than sorry’
In the zeal of creating epoch milestones, surgeons often cross the threshold of safety. Surgical magic not collaborated with the basic principles or ignoring it can cause catastrophes. Before jumping into the bandwagon of innovation, it is better to outweigh the risks and refrain from them. Cosmetic Surgery should be undertaken in a minimal risk environ. As much as the set-up, the staff involved must be adequately trained, so must the indications and pitfalls carefully weighed before embarking on the procedure. Pointless jumping in the wrong track, when confronted with complications, morbidity and mortality and sighing ‘I didn’t know this would happen’. Better know the limitations than regret later.
However easy the procedure might seem, sticking a cannula into a lump of fat, liquefying and extracting it out, it can give rise to complications.
In addition to the risks of anaesthesia, be it local or general, other known complications are:
Bruising: This occurs when infiltration is less than adequate. Correct dose of vasoconstrictors in the tumescent solution is vital to prevent bruising. Liposuction in less fat-laden areas can cause bruising. Though bruising settles over time, occasionally it can leave pigmentation difficult to eradicate.
Sensation & Deep Structure Damage: Paraesthesia is not uncommon with the procedure. So is damage to deeper structures such as nerves, blood vessels, muscles and abdominal organs. While performing it is better to remember liposuction is not a heavyweight challenge. A gentle approach may reduce chances of them.
Cardio-pulmonary Problems: Deep Vein Thrombosis, cardiac and pulmonary complications can occur. Prevention of deep vein thrombosis by anticoagulants, intermittent calf pressure can avoid the dreaded disaster.
Fluid Accumulation: Abnormal fluid shifts can occur with it. Close monitoring is mandatory and appropriate replacement, if need be being called for.
Infection: Rare in the procedure, unless the surgeon embarks on it after a rectal case. Haematoma is a potential source of infection. If suspected, antibiotic cover is mandatory.
Contour Defects: It happens with lack of expertise, not being in correct plane, leaving loose or rippled skin to ‘settle over time’. Sometimes cellulites are worsened. Swelling may persist. If skin tightening is essential, it should be carried out simultaneously. Swelling can be minimised by ensuring use of pressure garments.
Burns: Burns have been reported with earlier ultrasound machines when Zuki first used it. Recent machines do not cause them.
These are recognised complications of liposuction and how to avoid them. As I mentioned earlier overzealous use of the procedure is a dangerous entity. With the rat race of publications all trying to make a mark in the evolution of liposuction, it is essential to follow the safety guidelines before being swept away by claims of success. It is good to remember, that no matter what the recent development, the safety of the patient is prime. It cannot be put at risk by over enthusiasm, trailing the path of doubtful recent developments, even if they claim success in selected cases.
This is especially relevant to some people advocating large volume liposuction. It is a more complex, physiologically dissimilar procedure than the traditional one, whose basic principles are described in my other chapter and complications at the beginning of this treatise. Though it is advocated in presence of a trained surgical team, I have my reservations regarding its safety. It can lead to severe morbidity and death. This raises the question how one would differentiate between a ‘trained’ and an ‘untrained’ surgeon who would be capable of performing this mammoth procedure. I feel there is a thin line between the two. Understanding the ambiguity between the two, the question arises, whether anyone should at all embark in the procedure?
Liposuction is for the correction of centrifugal obesity (localised collection of fat) and not for centripetal obesity (weight reduction). Other alternatives are available as dieting, exercise, anti-obesity drugs and in morbid obesity, bariatric surgery. If these alternatives constitute the treatment of obesity, I do not find any reason for the so-called ‘large volume liposuction’. The definitions by people advocating it, varies from 4 litres to 5 litres or even more. In my practice, I have set the upper limit of liposuction as 3 litres, which is safe. If it be so, what benefit would be obtained by the extra litres subjecting the patient to risk? This can give rise to great amounts of fluid shifts. Even if these shifts are managed competently, is it worth the risk when liposuction is a cosmetic procedure?
In cosmetic surgery, the safety of the patient is prime than an overzealous surgeon subjecting the patient to the risk of morbidity and mortality. In no circumstances can it be compensated for doubtful benefits. Those advocating this extensive volume removal highlight conditions for carrying it as properly trained surgeon, anaesthetist, other staff educated in liposuction techniques with thorough understanding of the fluid shifts. Aren’t all performing the procedure adequately trained? That throws their argument in the bin as they failed to define any other additional expertise. They also advise optimal operating conditions and post-operative recovery care. All modern surgical techniques are carried out in these conditions. So, this argument is again ambiguous. And above all, careful selection of patient. If larger volumes are required to be aspirated the procedure can be staged thereby minimising the risk. I emphasise, compromising the safety of the patient in a cosmetic procedure is no alternative to safe surgery. There is an old surgical saying ‘What you can do tomorrow, don’t do it today’.
Overweight patients are poor candidates for liposuction. They would invariably pose fluid shift problems and increased risk of embolism. The patients with controlled medical problems can be operated. However, those with uncontrolled problems should be refused surgery. After all, this is not a life threatening or essential surgery. Like any other surgical procedure haematological (specially ascertaining coagulopathies), cardiovascular, pulmonary, renal, hepatic, endocrine and metabolic disorders. Patients with sleep apnoea can cause problems during post-operative recovery period especially if they have compensated cardiopulmonary reserve to handle the tumescent procedure. Patients who have a tendency of over-eating or weight gain must should be carefully monitored and controlled by dieting before the procedure. Non-compliant or poorly motivated patients should be refused surgery. Expectations of the patients must be realistic. Those with body dysmorphic disorder or eating disorder should be avoided. Other assessments include the contour irregularities and asymmetries, skin laxity and redundancy, whether a lift is simultaneously warranted.
I routinely use general anaesthesia, unless it is a particular local area. In addition to the routine anaesthetic monitoring, the solution I use for infiltration is
1 litre of Normal Saline
2 ml of Adrenaline
50 ml of Sodium Bicarbonate
Since I do not use local anaesthesia, there is no problem in monitoring the dose of lidocaine (Xylocaine) whose maximal permissible limit is 35mg/kg. The other problem with lidocaine is its uncontrollable and potentially serious toxicity which can cause disastrous consequences. I have not seen any renal hypovolemia and oliguria due to the dose of adrenaline used. However, it is not advisable to cross 2.5 ml. In the rare event of oliguria, diuretics may be used if the oliguria is due to adrenaline and not hypovolemia.
- I do not operate as a day case. Usually an overnight stay with monitoring ensues safety of the patient. Animal studies have shown that haemodynamic parameters stabilize to baseline in 20 hours.
- Patients need to be marked before surgery in standing position. Often these change in supine and prone position and may lead to false assessment.
- In addition to usual operating room precautions, as avoiding the arms to drop which may lead to nerve traction injury, eyes protected with ophthalmic antibiotic and taped, adequate headrest, pneumatic compression devices for lower limbs and heparinising (I use 40mg of Clexane) to prevent deep vein thrombosis which reduces the chance of pulmonary embolism. Often maintenance of operating room temperature is essential as tumescent technique can occasionally cause hypothermia.
- Pressure garments is a must to remove the dead space.
- Sometimes post-surgical oedema can be treated with mild diuretics, though it is better to wait. It should clear-out in 4-5 days’ time.
The key to basic safety lies in carefully assessing the patient in standing position, marking out the asymmetries pre-operatively, carrying out the procedure in wet milieu.
As I mentioned earlier at the beginning of the chapter, safety is prime than heroism. The body cannot tolerate excessive trauma. Excessive liposuction can cause progressive capillary endothelial damage. Beyond a certain threshold it increases hypercoagulability, like Disseminated Intravascular Coagulation (DIC) or thromboembolism due to decreased levels of free protein S. A dangerous procedure in a well-equipped hospital set-up with adequately trained staff is still dangerous, no matter even if certain surgeons claim its safety.
Echoing the words of Oliver Goldsmith ‘Handsome is he that handsome does, in surgical terms ‘A good surgeon is one what he does for patient’s safety’ than his uncalled-for itch to cross benchmarks. While absolute parameters remain undocumented and proved, many patient-dependent and surgeon-dependent variables make it unpredictable. The caprices of realistic cosmetic surgery result in a vague edge for safety. Nevertheless, it is safer to work within established protocols. I believe ‘large volume liposuction’ is a misguided extension of tumescent technique. Its safety has not been established by controlled study in literature. No data has established its long-term safety, except certain surgical group claiming its effectiveness without the data backup.
Finally, if the safety guidelines are adhered then liposuction is a safe procedure.
‘Give me the wisdom to understand the limits without gimmicks’