Deep vein thrombosis and pulmonary embolism

This is one of the main causes of death in association with cosmetic surgery, although most patients who undergo lipoplasty have low to moderate risk for developing deep vein thrombosis, with proper patient selection and DVT prophylaxis.

Therefore, a mandatory preoperative evaluation to identify factors of risk for thrombosis, as well as the use of elastic stockings, pneumatic systems of intermittent compression, adequate hydration and early mobilization are usually sufficient to prevent venous thrombosis in healthy patients undergoing lipoplasty.

In our procedure, we carry out early mobilization (6–8 hours after the surgery); we always use compressive garments, as well as lymphatic drainage and massage of the lower limbs of the patient one day after the surgery. This work is carried out by physiotherapists on all our patients, and has decreased our rate of thrombosis of the deep veins.

Hypothermia

Mild hypothermia (33 to 36°C) is common in liposuction patients and is the result of a combination of anesthesia-induced impairment, thermoregulation, exposure to a cold environment, and the infiltration of cold solutions. General anesthesia results in vasodilation, an increase in cutaneous heat loss, decreased heat production, and a redistribution of body heat from the core to the periphery. Even mild hypothermia may alter coagulation factors, increase bleeding, increase the incidence of surgical wound infection, prolong recovery time and can lead to increased risk of coagulopathy.

Some preventive measures can be taken to reduce the effects of hypothermia. The patient should be kept in a warm environment preoperatively to minimize the initial temperature drop during induction of anesthesia. Hot air blankets are the most effective noninvasive warming technique available today. Simply covering the patient’s upper extremities and head with a forced air device will help maintain a normal core body temperature and avoid metabolic and blood composition changes. Warming of the intravenous fluids, increased room temperature, and the use of warmed infiltration fluids are some steps that can be performed to prevent hypothermia.

Lidocaine and adrenaline toxicity

The FDA defines 7 mg/kg as the maximum safe dose of lidocaine with epinephrine (and 5 mg/kg for lidocaine only) for regional anesthesia. Literature on liposuction reports the use of lidocaine in doses of up to 33–35 mg/kg,¹ but always in solutions with adrenaline and with low concentration of lidocaine (0.1%) in large volume infiltration. Since the subcutaneous area is able to retain lidocaine, it is be restricted to the infiltration site, and only the exceeding molecules (1 mg of lidocaine for 1 g of tissue) would be available to be submitted to conventional pharmacokinetics. Hepatic function is an important factor that interferes in the concentration of lidocaine. Even drugs which interact with lidocaine in the hepatic cytochromes, such as antidepressants, might raise the serum concentration of lidocaine, causing signs of toxicity in the central nervous and cardiac systems. The hepatic metabolization of lidocaine and adrenaline reaches its serum peak within three hours after infiltration, returning to normal values after 12 hours.⁶

The excessive infiltration of solutions with lidocaine can cause toxicity, cardiotoxicity, convulsions, drug interaction and overdose.

Cardiorespiratory arrest

So far, most cases of death associated with liposuction are from unknown or unidentified causes, but cardiopulmonary arrest is a rare but dreaded complication. Adequate volume resuscitation, electrolyte balance, and proper healthy patient selection are integral to optimizing liposuction cases.

Sepsis

Local infection cases which present with signs of hyperemia, drainage and local pain which do not progressively get better, must be investigated and treated aggressively. The most feared case is necrotizing fasciitis. The cases of systemic infection are sometimes related to inadequate asepsis – for example, contaminants inside the suction cannulas. Cases of perforation of unidentified abdominal viscera and contamination with intestinal contents are known, and care must be taken during even the smallest liposuction cases to prevent this.

Fat emboli

According to Fourme and colleagues fat embolism syndrome is a very rare occurrence that has been reported infrequently after liposuction alone.⁷ Therefore, some authors think that the incidence of this complication after liposuction must be revised, because diagnosis is difficult and the clinical pattern is not specific.

The syndrome generally manifests itself within the first two postsurgical days as a triad of respiratory distress, cerebral dysfunction, and petechial rash. Treatment is largely supportive and managed medically with corticosteroids.

Perforation of abdomen and viscera

This may occur with experienced professionals, but it usually happens with unprepared professionals and is a catastrophic complication, because when it occurs it usually calls for a laparoscopy or even an exploratory laparotomy. Incisions may be made in different places to help the surgeon make the procedure easy and safe. In patients with elevated lower back arches, the authors recommend that liposuction be done on the upper abdomen, through incisions made in the inframammary crease. An adequate physical exam is of great importance to identify hernias of the abdominal wall, or scars which might be incidental entry points for the cannula.

Irregularities and depressions

This kind of complication is best defined as an undesirable consequence of liposuction. They often occur when the basic principles of the technique are not respected. There are areas with low potential for retraction and which are difficult to approach. We have to remember that the disposition and characteristics of the fat cells, the density of the conjunctive septi among them, as much as the structure of the collagen within the superficial and deep layers of the fat tissue are different in each part of the human body, as described by De Souza Pinto.^4,8

The purpose of the procedure is to remove the “reserve” fat, which resists loss of weight, and to model the body; it is not a method of weight loss. Total aspirated volumes are conveniently limited to a total of 6–8% in body weight.

In the treatment of insufficient fat removal or located fat build-up (undercorrection) (Fig. 60.1), careful liposuction must be performed progressively, with thin cannulas (2–3 mm) (Fig. 60.2), to avoid causing an abrupt subcutaneous fault, and to improve local cutaneous retraction (Fig. 60.3).

Fig. 60.1 A, Progressive treatment of insufficient fat removal (undercorrection). B, Result before and after secondary lipoplasty.

Fig. 60.2 Thin probe (VASER).

Fig. 60.3 Skin retraction after secondary lipoplasty.

To treat irregularities and depression, we break the adherences with a ring cannula (Fig. 60.4) and then perform fat injections to improve the skin (Fig. 60.5).

Fig. 60.4 A, Ring cannulae to correct irregularities. B, Preoperative and postoperative views of irregularities correction.

Fig. 60.5 A, Preoperative and postoperative of depression correction (back view). B, Preoperative and postoperative of depression correction (oblique view). C, Preoperative and postoperative of irregularities correction (lateral view).

Folds in the compressive garment can also cause irregularities, and the use of foam under the mesh and adequate postural positioning is recommended.

In our procedure, we perform VASER® and “lipomioplasty” techniques that respect the anatomy of the body muscles by moving the cannulas in the same direction of the muscle fibers (Fig. 60.6). This achieves better body contouring with enhanced skin retraction. The sum of these two procedures promotes high quality results with decreased areas of irregularities.

Fig. 60.6 Lipomioplasty – following the muscle fibers.

Skin excess

The evaluation of the amount of fat to be aspirated and the skin excess that can be treated by postsurgical cutaneous retraction is done subjectively, based on physical exam data and the surgeon’s experience (Fig. 60.7). If the patient has dramatic skin excess, we prefer to perform the procedure with skin resection.

Fig. 60.7 Skin excess.

Unaesthetic scars

As in any other kind of surgery, the incisions of liposuction can evolve in an undesirable manner and become unaesthetic. These incisions can display depigmentation, enlargement, dehiscence, hypertrophy and even evolve into keloids.

The incisions must always be placed where they can be hidden and allow easy access and passage of the cannulas. Very small incisions can increase the rubbing of the cannula against the skin and this may cause low-quality scars.

To avoid this kind of complication, it is recommended the edges be lubricated with physiologic saline or another kind of solution. In our procedure, we use neomycin sulphate with bacitracin (Nebacetin®) to lubricate the edges.

In addition to this precaution, we may also protect the skin with plastic dressing (Tegaderm®) or specific rigid protectors. The dressing must be fixed with micropore tape directly onto the skin.

Seromas

Potential spaces created where adipose tissue has been removed by cannulas occur in response to trauma, liquid from the infiltration, local exudation, and bruises.

We minimize seromas by using drains in the subcutaneous areas, which present high volumes on the first day after surgery, for the first 24 h on average, and providing manual lymphatic drainage. Compressive garments (with a stable compression rate less than the central venous pressure) immediately after surgery can help to prevent seromas and minimize pain by reducing the mobility of all aspirated tissue.

Cutaneous hyperpigmentation

This usually occurs in aspirated areas due to deposition and fixation by the ultraviolet light of the hemosiderin, derived from the degradation of hemoglobin present in superficial ecchymoses. It is generally connected with vasculopathy caused by trauma from the cannula, and can provoke skin sloughs.

It can be prevented by avoiding exposure of the aspirated area to the sun until the ecchymoses disappear. The use of Vaser (UAL) has resulted in a significant decrease of ecchymoses and less chance of hyperpigmentation.

Infection

Infection is extremely serious, because the detachment scheme makes for a fast and sweeping progression, the most fearful evolution being necrotizing fasciitis. This is usually caused by Streptococcus pyogenes, or synergistic infection by anaerobes. The diagnosis must be made as quickly as possible, with broad-spectrum antimicrobial therapy taken until the infectious agent has been defined. Only surgical debridement can improve the survival chances of the patient with necrotizing fasciitis. Adequate antiseptic measures (especially liposuction cannulas), trans-surgical care, and prophylactic antibiotic therapy for at least 7 days is our recommendation.

Necrosis

This may occur due to trauma of the subdermal plexus and skin during superficial liposuction. In Vaser, the tip of the cannula can cause burning of the skin, so we should always have appropriate entry protection on the skin. The compressive garment can also be a cause of necrosis, due to the ischemia caused by excessive compression, mainly in fold regions.

Anesthesia, hyperesthesia and dysesthesia

These are rare post-liposuction complications. This kind of manifestation may be associated with injury or demyelination of the superficial branches of the sensory nerves (more common in ultrasonic liposuction).

The burning and deep pain which worsens with effort are the most common manifestations, and usually are self-limited, ending within three months.

Cutis marmorata

Several authors believe that the contact of the liposuction cannula with the deep dermis over large areas can be the main factor causing local lesions of the subdermal plexus, resulting in a skin pattern resembling cutis marmorata. It remains rare, affecting a few cases. This skin pattern involves rosy-purplish stains intermingled with other whitish stains on the skin in the areas subjected to surgery. The stains may persist up to one year after the operation.

To avoid this rare complication, it is important during superficial liposuction to maintain a strip about 1–2 cm thick under the deep dermis to preserve the arterial plexus of the skin. This will prevent the formation of a marbled appearance of the skin (Figs 60.8, 60.9).

Fig. 60.8 Cutis marmorata 1 week after lipoplasty.

Fig. 60.9 Cutis marmorata 1 year after lipoplasty.

Various reports in the literature have referred to the presence of long-lasting vasomotor syndromes. In all of these reports, coloration is described varying from the bluish-purple of cyanosis (acrocyanosis) to the rosy-purple of the stains appeared in “net,” “tree branches” or “marbled” skin patterns of livedo reticularis, livedo racemosa and cutis marmorata, respectively. However, there is no consensus among the authors regarding some descriptions.