Guidelines of care for liposuction

Academy guidelines I I i I

This report reflects the best data available at the time the report was prepared, but caution should be exercised in interpreting the data. The results may require alter- ation of the conclusions or recommendations set forth in this report.

Guidelines of care for liposuction* Committee on Guidelines o f Care: Lynn A. Drake, MD, chairman, Roger I. Ceilley, MD, Ray- mond L. Cornelison, MD, William L. Dobes, MD, William Dorner, MD, Robert W. Goltz, MD, Charles W. Lewis, MD, Stuart J. Salasche, MD, and Maria L. Chanco Turner, MD

Task Force on Liposuction: Lynn A. Drake, MD, chairman, Thomas H. Alt, MD, William P. Coleman II[, MD, John W. Skouge, MD, Samuel J. Stegman, MD, and Helen M. Torok, MD

I. Introduction The American Academy of Dermatology's Com-

mittee on Guidelines of Care is developing guidelines of care for our profession. The development of guidelines will promote the continued delivery of quality care and assist those outside our profession in understanding the complexities and boundaries of care provided by dermatologists.

II. Definition Liposuction is the surgical removal of fat deposits with the use of blunt cannulas assisted by suction via small incisions.

III. Rationale A. Scope

The number of liposuction procedures performed in the United States is rapidly increasing. Spe- citic guidelines for liposuction should contain components that identify appropriate care, expectations, side effects, and complications. The following conditions are amenable to liposuction: 1. Disease processes

a) Lipomas, solitary or multiple b) Gynecomastia and pseudogynecomastia c) Lipodystropliy d) AxiUary hyperhidrosis e) Other conditions

2. Cosmetic body contouring a) Face b) Neck c) Extremities d) Abdomen e) Flanks J) Buttocks

Reprint requests: American Academy of Dermatology, Department of Dermatologie Practice, 1567 Maple Ave., P.O. Box 3116, Evanston, ! I 60204-3116.

*Approved April 1989; revised May 1990; approved June 1990. 16/i/26155

3. Assist in flap elevation, subcutaneous debulk- flag, and flap movement for reconstruction of cutaneous defects

B. Issue 1. Physician qualifications

a) General (1) The physician should have completed

residency training or be board certi- fied in an appropriate specialty, such as dermatology, which provides training in cutaneous surgery.

(2) The physician should possess in-depth knowledge of the skin and subcutaneous tissues.

(3) For the type and extent of liposuction surgery performed, the physician should have (a) Knowledge in fluid and electrolyte

balance (b) Knowledge of the management of

potential complications (c) Knowledge of the type of anesthe-

sia selected b) Specific

(1) The physician should have evidence of liposuction surgery training in residency; or

(2) A certificate of attendance at an appropriate liposuction course, which may include videotaped and live surgical presentations.

(3) Physicians performing liposuction should have documented experience at the surgical table conducted by an ap- propriately trained and experienced physician.

IV. Diagnostic criteria A. Clinical

Patient selection and evaluation are critical to determine the feasibility of the operation being

489

490 Drake et aL

considered. Patients undergoing liposuction should have an appropriate history and physical examination. 1. Medical history

a) Special attention should be given to a medical history of bleeding diathesis, infections, emboli, thrombophiebitis, edema, and past operations that may compli- cate the area to be treated with liposuction.

b) Particular attention should be addressed to patients taking systemic medications that affect the clotting mechanisms or platelet functions such as aspirin, nonsteroidal an- ti-inflammatory agents, warfarin, heparin, or other anticoagulants. Drug interaction causing adverse effects, particularly the combined effect of epinephrine and beta blockers, require preoperative identifica- tion and evaluation.

c) The history should also account for any underlying disease process or infection.

2. Physical examination a) Baseline physical examination b) Evaluation should include an examination

of the anatomic site to be treated to account for potential concomitant findings (e.g., hernias, varicose veins, preexisting scars, asymmetry)

c) Evaluation of overall weight, muscle development, and distribution of the adipose tissue

d) Evaluation of the quality of the skin for tone, elasticity, striae, symmetry, and dim- piing

e) Evaluation of the skin for previous areas of normal and abnormal healing, both at rest and with tightening of underlying muscles

)9 Evaluation should also account for any underlying disease process or infection.

3. Mental status Special attention should be paid to ensure that the patient understands the procedure and its limitations and has realistic expectations

4. Laboratory data and surgical preparation a) The need for laboratory data depends on

the volume of fat to be removed and evaluation of conditions revealed in this history and physicaJ examination.

b) Physicians should usually obtain a CBC with differential count, platelet count, pro- thrombin time, partial thromboplastin time, chemistry profile, urinalysis, and other studies as indicated. These may not be necessary in a healthy patient undergoing limited volume removal.

Journal of the American Academy of

Dermatology

c) Laboratory work should be performed in advance to permit further evaluation and correction of conditions that may contrain- dicate surgery

d) I f volumes of fat greater than 3000 cc, exclusive of infranate, need to be aspirated, serial liposuction should be considered. Autotransfusion may be rarely indicated,

B. Diagnostic tests Biopsies, ultrasonography nuclear magnetic res- onance (NMR), or other diagnostic tests may be indicated.

C. Inappropriate diagnostic tests Not applicable

D. Exceptions Not applicable

E. Evolving diagnostic test Not applicable

V, Recommendatiom A. Treatment

1. Nomurgical Not applicable

2. Surgical a) Procedure

(1) Dry technique (a) This involves fat removal by lipo-

suction with the use of general anesthesia without infiltration of dilute epinephrine to the surgical site.

(b) This technique is associated with a higher incidence of intraoperative and postoperative bleeding. Excessive blood loss may result in hypotension, syncope, vascular collapse, and increased likelihood of death. Morbidity may be increased secondary to the blood loss in the aspirate and into the third space compartment.

(c) Because of the availability ofsafer methods, the dry technique is now rarely indicated

(2) Wet technique (a) This technique involves a rela-

tively low volume infiltration of saline containing a concentration of epinephrine between 1:1130,000 and 1:400,000. This is usually combined with the anesthetic lidocaine in dilute concentrate (i.e., 0.2% to 0.5%).

(b) The manufacturer's recommended maximum dose of lidocaine is 7.0 mg/kg of body

Volume 24 Number 3 March 1991

c)

weight. However, the safe maximum dose may be higher and is currently under investigation (see V, A, 3).

(3) Tumescent technique (a) This technique involves high vol-

ume infiltration of saline (may or may not be combined with so- dium bicarbonate) containing a concentration of epinephrine of approximately 1:1,000,000 (one to one million) with lidocaine in 0.05% to 0.1% (1:20 to 1:10) concentration.

(b) With this technique, which is under investigation, the maximum dose of lidocaine has been shown to approach 35 mg/kg of body weight and is usually infil- trated slowly.

Anesthesia The choice of anesthesia is determined by the surgeon, anesthesiologist, or anesthe- fist. (1) Local (2) Local with sedation (may include)

oral intramuscular, or intravenous (3) Cryoanesthesia (4) Regional nerve blocks, spinal blocks (5) General Volume removal The volume of fat aspirated affects the technique, the appropriate anesthesia, the support equipment, the facility, the need for fluid/crystalloid replacement, and the postoperative care. Use of large volumes of dilute local anesthetics and/or epinephrine can aUow the surgeon to remove a larger total volume of aspirate safely. General anesthesia and the dry technique increase bleeding, third space loss, morbidity, and potential death. With these disadvantages and the availability of safer methods, the dry technique is now rarely indicated. (l) Up to 750 cc of fat removed, exclusive

of infranate (a) The need for intraoperative mon-

itoring and intravenous fluid replacement depends on the health and age of the patient. In addition, if intravenous sedation or general anesthesia is used, monitoring with a pulse oximeter, cardiac monitor, and blood pressure device is obligatory.

Guidelines." Liposuction 491

(b) Local anesthesia is usually ade- quate.

{c) Any medications (e.g., sedatives, narcotics, hypnotics, nitrous oxide), which may directly or indi- rectly produce hypoxia, will require careful monitoring of the patient_ When indicated, a pulse oximeter and oxygc'n should be used.

(2) 750 to 2000 cc of fat removal, exclusive of infmnate (a) Local infiltration of dilute epi-

nephrine has been shown to decrease significantly intraopera- five and postoperative blood loss when used with or without intravenous sedation or general anesthesia.

(b) Monitoring and recording of the blood pressure by manual or automatic means is obligatory. Monitoring of the oxygen satu- ration with a pulse oximeter is recommended. In addition, when respiratory depressants such as sedatives, narcotics, hypnotics, or nitrous oxide have been used, monitoring of cardiac function is recommended. If intravenous sedation or general anesthesia is used, monitoring with a pulse oximeter, cardiac momtor, and blood pressure devise is obligatory.

(c) The procedure can be performed in an outpatient or inpatient facility.

(d) Resuscitative equipment and medication must be readily available.

(e) The placement of an intraveno~ line for the possible administra- tion of replacement fluids and/or resuscitative drugs is obligatory. Replacement fluids are indicated when the wet technique is used and are rarely necessary with the tumescent technique.

09 The availability of crystalloids or plasma expanders such as albu- min or Hespan is recommended when the volume of fat removed with the wet technique exceeds 1500 cc.

492 Drake et al.

(3) More than 2000 cc of fat removed, exclusive of infranate (a) Local infiltration of dilate epi-

nephrine has been shown to decrease significantly intraopera- tire and postoperative blood loss when used with or without intravenous sedation or general anesthesia.

(b) Monitoring and recording the blood pressure and pulse by manual or automatic means is obligatory. Monitoring the oxygen sat- uration and cardiac function is obligatory.

(c) The procedure can be performed in an outpatient or inpatient facility and may require overnight inpatient observation.

(d) Resuscitative equipment and medication must be readily available. Personnel trained in ad- vanced cardiac life support or its equivalent must be readily available.

(e) The placement of an intravenous line for the possible administra- tion of replacement fluids and/or resuscitative drugs is obligatory. Replacement fluids are indicated with the wet technique and usually not necessary when the tumescent technique is used.

09 Volumes of fat removed exceed- ing 2000 cc should be performed only by surgeons who are experienced in the successful comple- tion of liposuction on at least 50 patients.

(g) Removal of volumes of fat ex- ceeding 2500 cc with the wet technique is generally not recommended.

(h) Volumes of fat removed exceed- ing 3000 co with any technique should be approached cautiously. Serial procedures are recommended for the removal of large volumes of fat. The use of autologous blood may be rarely indicated.

d) Fluid replacement (1) An intravenous line is necessary for

cases where aspiration of more than 750 cc is anticipated.

(2) A protocol, dependent on the quan-


Dermatology

tity and content of the aspirate, should be predetermined.

e) Surgical setting (1) Liposuction can be performed in a

physician's office, ambulatory surgical center, or hospital operating room.

(2) Office or surgical center settings are most common. (a) They are convenient for patient

and physicians. (b) They decrease the risk of nosoco-

mial infection. (c) They are economical.

(3) Sterile technique (a) Appropriate sterile technique is

recommended for liposuction. (b) It does not require an inpatient

hospital operating room setting, (c) The method of the sterile tech-

nique used will depend on the area, volume of fat aspirated, and the discretion of the physician.

(4) Postoperative monitoring of the patient'svital signs should be performed by qualified medical personnel until the patient is awake, alert, and stable.

(5) Physicians performing liposuction in an office or ambulatory surgical center should have hospital admitting privileges.

39 Adjunctive medications Adjunctive medications are used as indicated by preoperative evaluation.

g) Postoperative care (1) Compression

(a) Binders, girdles, elastic taping, and special garments are appropriate in most cases.

(b) Compression is believed to mini- mize bruising, pain, hernatoma, seroma formation, and third compartment fluid shifts.

(2) Ultrasonography in appropriate patients may reduce postoperative discomfort and increase resolution of ecchymoses.

(3) Antiphlebitis hose may beused post- operatively, especially for larger cases or those involving the lower extremities.

(4) Postoperative activity (a) Most patients are ambulatory

after surgery or after recovery from intravenous sedation or general anesthesia.

(bJ Activities are usually limited

Volume 24 Number 3 March 1991 Guidelines: Liposuct ion 493

from the first through the fourth postoperative day.

(c) Exercise may begin as soon as it is comfortable to do so. Usually 2 to 4 weeks are necessary before the patient can return to unlim- ited activities.

(5) Antibiotics (a) The use of antibiotics preopera-

tively, intraoperatively, or post- operatively in conjunction with lip~uction is at the surgeon's discretion.

(b) The reported infection rate is statistically low.

(c) The role of prophylactic antibiotics is still debatable, but their use is not contraindicated.

3. Other a)

b)

Usual and expected postoperative findings (1) Edema (2) Ecchym~is (3) Dysesthesias (4) Fatigue (5) Discomfort (6) Scarring at the entry sites (7) Minor contour imperfections Occasional postoperative findings (1) Persistent edema (2) Persistent dysesthesia, usually hypes-

thesia (3) Hyperpigmentation (4) Anemia (5) Asymmetry (6) Hematoma (7) Seroma (8) Drug reaction (9) Contour imperfections Postoperative complications (rare) (1) Skin necrosis can be secondary to ne-

crotizing infections or improper technique.

(2) Hypovolemic shock can be related to the volume of fat aspirated or failure to adequately replace crystaUoid, col- loid, or blood.

(3) Large hematoma or seroma (4) Nerve damage other than cutaneous

dysesthesia (5) Infection, localized or generalized (6) Intraperitoneal or intrathoracic per-

foration is an increased risk, which occurs when liposuction is combined with procedures such as tubal ligadon or ventral hernia repair. There is

VI.

VII.

increased risk of these events occur- ring when the patient is under general anesthesia.

(7) Pulmonary and fat emboli have been reported when liposuction is combined with abdominal lipectomy and / or abdominoplasty.

(8) Death (a) Extremely rare (b) Usually secondary to the afore-

mentioned complications. B. Miscellaneous

Not applicable Supporting evidence See Bibliography (Appendix) Disclaimer Adherence to these guidefines will not ensure successful treatment in every situation. Further, there guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances pre- sented by the individual patient.

Appendix, Bibliography

I. Introduction Asken S. Liposuction surgery and autologous fat trans-

plantation. Norwalk, Corm: Appleton & Lange, 1988. Coleman WP. The dermatologist as a liposuction surgeon

[Editorial]. J Dermatol Surg Oncol 1988;14:1057-8. CoLeman WP. Liposuction. In: Coleman WP, Hanke CW,

Alt TH, et al, eds. Cosmetic surgery of the skin, principles and techniques. Philadelphia; B.C. Decker (In press.)

Field LM. The dermatologist and liposuction: a history [Letter]. J Dermatoi Surg Oncot 1987;13:1040-1.

Field LM. Liposuction surgery (surgery-assisted lipectomy). In: Roenigk R J, Roenigk HH, eds. Dermatologic surgery: principles and practice. New York: Marcel De- kker, 1989; 61:1157-77.

Foumier PF. Who should do syringe liposculpturing? [Ed- itorial] J Dermatol Surg Oncol 1988;14:1055-6.

Lillis P J, Coleman WP. Liposuction, Dermatologic Clinics. Philadelphia: WB Saunders 1990;8:3.

Stegman $3, Tromovitch TA, Glogau RG, eds. Liposuc- tion. In: Cosmetic dermatologic surgery. 2nd ed. Chi- cago: Mosby-Year Book, 1990;13:251-75.

II1. Rationale Dolsky RL, Newman J, Fetzek JR, et al. Liposuction: his-

tory, techniques, and complications. Dermatol Clin 1987;5:313-33.

III. Rationale: A. Scope 1. Disease processes Asken S. Refinements in the technique of liposucdon. J

Dermatol Surg Oncol 1988; 14:1165-72. Carlin MC, Ratz JL. Multiple symmetric lipomatosks:

treatment with liposuction. J AM ACAD DEILMATOL 1988;18:359-62.

Coleman WP, III. Noncosmetic applications of liposuction. J Dermatol Surg Oncol 1988;14:1085-90.

4 9 4 Drake et al.

Dolsky RL, Asken S, Nguyen A. Surgical removal of lipomas by lipo-suction surgery. Am J Cosmet Surg 1986;3:27-34.

Field LM. Liposuction surgery (suction-assisted lipectomy) for symmetric lipomatosis [Letter]. J AM ACAD DERMATOL 1988;18:1370.

Field LM. Successful treatment of lipohypertrophic insu- lin lipodystrophy with tiposuction surgery [Letter]. J AM ACAD DER.MATOL 1988;19:570.

Fodor PB. On gynecomastia and suction-assisted lipectomy [Letter]. Plast Reconstr Surg 1988;82:918.

Kanter WR, Wolfort FG. Multiple familial angiolipoma- t~iz: treatment of lip~uction. Ann Plast Surg 1988;20: 277-9.

Lilli.s P J, Coleman WP III. Liposuction for treatment of axillary hyperhidrosis. Dermatol Clin 1990;8:479-82.

Maguire CP. Gynecomastia in the male: correction by liposuction. J SC Med Ass~ 1987;83:430-1.

McEwan CN, Jackson 1T, Stice RC. The application of liposuction for removal of hematomas and fat necrosis. Ann Plast Surg 1987;480-1.

Rubenstein R, Roenigk H H Jr, Garden JM, et al. Lipo- suction for lipomas. J Dermatol Surg Oncol 1985;11: 1070-4.

Scheinberg MA, Diniz R, Diamant J. Improvement of juxtaarticular adiposis dolorosa by fat suction [Letter]. Arthritis Rheum 1987;30:1436-7.

Van Wingerden J J, Erlank JD, Becker JH. Lipotuction for congenital infiltrating lipomatosis of the face [Letter]. Plast Reconstr Surg 1988;81:989.

IIl. Rationale: A. Scope 2. Cosmetic body contouring Asken S. Facial liposuction and microlipoinjection. J Der-

matol Surg Oncol 1988; 14:297-305. Daher JC, Cosac OM, Domingues S. Face-lift: the impor-

tance of redefining facial contours through facial liposuction. Ann Plast Surg 1988;21:1-10.

Dedo DD. Liposuction of the head and neck. Otolaryngol Head Neck Surg 1987;97:591-2.

Guerrerosantos J. Liposuction in the cheek, chin, and neck: a clirtcal study. Facial Plast Surg 1986;4:25-34.

Kennedy BD. Suction assisted lipectomy of the face and neck. J Oral Maxillofac Surg 1988;46:546-58.

Kesselring UK. Facial liposuction. Facial Plast Surg 1986;4:1-4.

Shirakabe Y, Shirakabe T. Liposuction of the neck: a new device of paddler cannula and a paddling technique in an open system. Facial Plast Surg 1986;4:5-10.

Vila Rovira R. Liposuction and facial lifting. Facial Plast Surg 1986;4:19-23.

III. Rationale: A. Scope 3. Flap elevation Cueva R, Thomas JR, Davidson TM. Liposuction to

debulk the peetoralis major myocutaneous flap. Am J Otolaryngol 1988;9:106-10.

Field LM, Novy FG III. Flap elevation and mobilization by blunt liposuction cannula dissection to repair temple defect. J Dermatol Surg Oncol 1987;13:1302-5.

Field LM, Skouge J, Anhalt TS, et al. Blunt liposuction cannula dissection with and without suction assisted lipectomy in reconstructive surgery. J Dermatol Surg Oneol 1988; 14:1116-22.

V. Recommendations: A. Treatment 2. Surgical a) Procedure (1) Dry technique Fournier PF, Otteni FM. Lipodissection in body sculptur-

ing: the dry technique. Plast Reconstr Surg 1983;72:598- 609.


Dermatology

Grazer FM. Discussion of"Quantitative Analysis of Blood and Fat in Suction Lipectomy Aspirates." Plast Recon- str Surg 1986;78:770-2.

Illouz YG. Body contouring by lipolysis: a 5-year experience with over 3,000 cases. Plast Reconstr Surg 1983;72:610-9.

K<~anin R, Riefkohl R. Transfusing plastic surgery patients [Letter]. Plast Reconstr Surg 1985;75:131-2.

V. Recommendations: A. Treatment 2. Surgical a) Procedure (2) Wet technique Mantse L. Liposuction under local anesthesia: a retrospec-

tive analysis of 100 patients. J Dermatol Surg Oncol 1987;13:1333-8.

Piveral K. Systemic lidocaine absorption during lipotuction [Letter]. Plast Reconstr Surg 1987;80:643.

V. Recommendations: A. Treatment 2. Surgical a) Procedure (3) Tumescent technique Gumuncio CA, Beanie JB, Fernando B, et al. Plasma

lidocaine levels during augmentation mammoplasty and suction-assisted lipectomy. Plast Reconstr Surg 1989; 84:624-7.

Klein JA. Anesthesia for liposuction in dermatologic surgery. J Dermatol Surg Oncol 1988;14:1124-32.

Klein JA. The tumescent technique for lipo-sucfion surgery. Am J Cosmet Surg 1987;4:263-7.

Klein JA. Tumescent technique for regional an~thesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatoi Surg Oncol 1990;16:248-63.

Lewis CM, Hepper T. The use of high-dose lidocaine in wetting solutions for lipoplasty. Ann Plast Surg 1989;22:307-9.

Lillis P J, Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption. J Der- matol Surg Oncol 1988;14:1145-8.

V. Recommendations: A. Treatment 2. Surgical e) Surgical setting

Bemstein G, Hanke CW. Safety ofliposuction: a review of 9,478 cases performed by dermatologists. J Dermatol Surg Oncol 1988;14:1112-4.

Chrisman BB, Cd~man WP III. Determining safe limits for untransfused outpatient liposuction: personal experience and review of the literature. J Dermatol Surg On- col 1988;14:1095-102.

Coleman WP III. Liposuction and anesthesia [Editorial]. J Dermatol Surg Oncol 1987;13:1295-6.

Pierce HE. Liposuction surgery: an office procedure. J Nat Med Assoc 1985;77:33-8.

V. Recommendations: A. Treatment 3. Other Alexander J, Takeda D, Sanders G, et al. Fatal necrotiz-

ing fasciitis following suction assisted lipectomy. Ann Plast Surg 1988;20:562-5.

Bello EF, Posaiski I, Pitchon H, et al. Fasciitis and abscesses complicating liposuction. West J Med 1988; 148:703-6.

Dillerud E. Complications after liposuction [Letter]. Pla,st Reconstr Surg 1987;79:844-5.

Klein JA. Anesthesia for liposuction in dermatologic surgery. J Dermatol Surg Oncol 1988;14:1124-32.

Liebman EP, Webster RC, Gaul JR, et al. The marginal mandibular nerve in rhytidectomy and liposuction surgery. Arch Otolaryngol Head Neck Surg 1988; 114:179- 81.

Ross RM, Johnson GW. Fat embolism after liposuction. Chest 1988;93:1294-5.

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Guidelines of care for liposuction