Complications and corrections of lipoplasty

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CHAPTER 60 Complications and corrections of lipoplasty

Ewaldo Bolivar de Souza Pinto, Rodrigo Federico, Andrey van Ass Malheiros

Introduction

Lipoplasty or liposuction is a surgical procedure used to treat and reshape the body. It is an elective procedure that is typically performed on healthy patients who wish to improve their contour. Liposuction is becoming the most common procedure performed by plastic surgeons in the entire world, and is a very safe procedure today. However, it carries with it certain risks and complications, including a death rate of 1/5000 procedures.1 Risks can be minimized or avoided by a well-trained surgeon and surgical team.

History

Since the beginning of the 20th century many surgeons have tried to model body contouring to fit the current concept of beauty of the time. Historically, many approaches have been used to evacuate fat deposits during lipoplasty, and some of these procedures had complications.

Dujarrier first attempted to remove subcutaneous fat with a uterine curette, but tragic complications eventually evolved to necrosis and amputation, possibly due to vascular injury or infection.2 It was the first complication described for a lipoplasty attempt.

No technical innovations were achieved until 1982, when Joseph Schrudde used a delicate curette to correct lipodystrophy, significantly reducing blood loss.3

The senior author was one of the pioneers of the careful approach of the superficial layer of the abdomen which was, before this, responsible for many contour irregularities, as a consequence of treatment of the deeper layer. The same author included the back region and, progressively, included other areas, noting significant retraction of the skin and a better contour. He also observed that, with no superficial approach, it was difficult to obtain good results in the presence of scars or depressions.4 It was Gasparotti5 who named this technique “superficial liposuction” and promoted it internationally. The development of new techniques, new cannulas, better anesthesia and the better training of the surgeon are helping to ensure patients’ safety and the efficacy of the procedure.

Complications

See Table 60.1.

Table 60.1 Factors that increase risk in lipoplasty

1. Injecting too much fluid and local anesthesia
2. Removing too much fat
3. Performing too many procedures in the same surgical act
4. Wrong indication for the procedure
5. Inadequate monitoring

*Grazer FM, de Jong RH. Fatal Outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg 2000;105:436–446.

The complications of lipoplasty can be local (aesthetic complications) or systemic (life-threatening complications).

The local complications can be irregularities, depressions, seromas, hematomas, alterations of skin color and sensitivity, infections, excess skin and cutaneous necrosis, cutis marmorata. The systemic issues are deep venous thrombosis, pulmonary embolism, fat emboli, hypovolemia, edema, toxicity or medication interaction, perforation of viscera, sepsis and other complications associated with any surgical procedure.

Unsatisfactory results in cases where ideal contour is not achieved, may be either due to undercorrection, asymmetrical correction or failure in communication between the patient and surgeon.

Liposuction is a very common procedure, and is performed by dermatologists, gynecologists, otolaryngologists and others. The practice of lipoplasty by non-trained professionals who perform this procedure in a place without necessary hospital support, predisposes patients to complications with potentially fatal outcomes.

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.

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