- Email: [email protected]
Patient satisfaction after high-volume lipoplasty
Scientific Forum
Patient Satisfaction After High-volume Lipoplasty: Outcomes Survey and Thoughts on Safety Mark E. Richards, MD Dr. Richards is in private practice in Bethesda, MD.
Background: The technique of high-volume lipoplasty (HVL) remains controversial despite several reports of its safety and benefits. Objectives: An outcomes survey was conducted to determine patient satisfaction with the results of HVL in a series of 92 consecutive cases. The literature concerning safety issues related to HVL is summarized, and suggestions for future guidelines and investigation are proposed. Methods: Ninety-two patients underwent HVL between January 1, 1999, and December 31, 2001. Aspiration ranged from 5 to 15.7 L, with an average of 8.2 L per patient. No unplanned hospitalizations or transfusions were required, and no deaths occurred. Patients were questioned by telephone 13 to 49 months after HVL and asked to evaluate the benefits of surgery using a 4-point scale on which the lowest rating represented no long-term benefit and the highest rating indicated dramatic improvement. They were also asked to evaluate change in clothing size since surgery, with 0 indicating no size change and 4 indicating a size reduction of more than 6 sizes. Results: The response rate for the survey was 47% (43 of 92 patients). Patient satisfaction was high, averaging 3.4 on the 1-to-4 scale. On average, patients experienced a decrease of 3 to 4 clothing sizes. Conclusions: With careful patient selection and attention to key safety issues, HVL can provide a high level of longterm satisfaction to patients. (Aesthetic Surg J 2003;23:345-352.)
S
everal excellent articles have been published on the safety and benefits of high-volume lipoplasty (HVL).1–4 Nevertheless, in my opinion the controversy surrounding this procedure has adversely affected the exchange of information so vital to our ability to improve the safety of HVL and enhance our skills regarding this procedure. Although HVL is a small part of my aesthetic surgery practice, I find it a valuable tool in the aesthetic surgery armamentarium. This report on a 36month “slice” of my HVL experience is an attempt to encourage an objective and scientific discussion of the benefits and safety of HVL by its practitioners. Only by sharing our collective experiences with HVL can we develop “collective good judgment” in this unique procedure.
Patients and Methods Patient selection
This study included 92 HVL procedures (aspiration ≥ 5 L) performed consecutively from January 1, 1999, through December 31, 2001 (Table 1). The patients who underwent HVL were in good health (American Society of Anesthesiologists [ASA] level 1 or 2) and had 2 AESTHETIC
lengthy preoperative consultations regarding the risks and recovery associated with HVL. Although advanced age is not an absolute contraindication for HVL, I discourage elderly patients from undergoing the procedure because of their decreased cardiac reserves. Obesity is not an absolute contraindication, as long as the goal of the patient and doctor is to achieve body-shape contouring and not merely fat reduction. All patients were informed of the hospital’s requirement for an overnight hospital stay if lipoplasty aspirate volume exceeded 10 L. Surgical procedure
All procedures were performed in a hospital setting with the patient under general anesthesia. Attempts were made to keep the operating-room temperature well above 21°C (70°F). All patients received 500 mg of methylprednisolone after the induction of anesthesia but before the procedure. The wetting solution consisted of 1-L bags of intravenous normal saline solution to which had been added 2 mL of 1:1000 epinephrine, 10 mL of 8.4% sodium bicarbonate, and 50 mL of 1% lidocaine. Lidocaine was only added to the first 5 L of wetting solution. Patients were prepped while standing with poviSURGERY
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Table 1. Lipoplasty volumes aspirated No. of patients Liters removed
2001
5–6.0 6–6.9 7–7.9 8–8.9 9–9.9 10–10.9 11–11.9 12–12.9 13–13.9 14–14.9 15–15.9 No. of patients
4 5 8 5 5 3 0 4 3 0 1 38
done-iodine solution, before the induction of anesthesia. Antibiotic prophylaxis for skin flora (usually a cephalosporin) was given intravenously before surgery. The operating table was covered in sterile drapes. Sterile stockings were placed on the patient’s feet and lower legs. Manual (and, later, power-assisted) lipoplasty was performed with the patient in the supine and lateral decubitus positions only. No prone positioning was used, and no ultrasonic lipoplasty was performed. The wetting solution was instilled so as to achieve the approximate ratio of 1 mL of wetting fluid for every 1 mL of aspirate removed, up to 5 L. After 5 L of aspirate had been removed, 0.5mL of wetting solution was instilled per additional milliliter of aspirate removed. The amount of aspirate removed ranged from 5 to 15.7 L, with an average of 8.2 L per patient. Early in the series, an intravenous fluid–warming system was used. However, it is doubtful that any significant warming resulted, in light of the high flow rate of the wetting solution and the low heat transfer rate of the warming system available at the time. Intravenous fluid administered during surgery was limited to “maintenance” volume (no replacement was given for amount of aspirate removed), as determined by the anesthesiologist. The patient was fitted with a compression girdle after surgery, while still in the operating room, and encouraged to drink enough fluids at home to maintain clear urine. Recovery room discharge criteria included a body temperature above 36.7°C (98°F).
Patients were questioned by telephone during the first 2 months of 2003, 13 to 49 months after surgery. This delay between the surgery date and the patient survey was incorporated into the study to allow time for the iniAesthetic
Surgery
1999
3 9 2 2 3 1 1 0 2 0 0 23
10 3 7 5 1 0 3 0 2 0 0 31
Total patients 17 17 17 12 9 4 4 4 7 0 1 92
tial postprocedure enthusiasm to fade and for the patients’ normal lifestyle habits to be reestablished before they were asked to evaluate their satisfaction levels. Multiple attempts were made to contact each patient by last known home address, e-mail address, and home and work telephone numbers. One person (the office nurse) talked to all respondents, using a set script as follows: “Dr. Richards is writing a scientific paper on the longterm follow-up of liposuction patients. Very little is written about the long-term results. He hoped that you would be willing to answer a couple questions to give plastic surgeons a better understanding of how patients feel about the procedure years after liposuction.” Patients were asked the following 2 questions: Question 1: Satisfaction
I felt liposuction gave me: 1. No long-term benefit 2. Improvement, but it was not worth the time, money, or recovery 3. Worthwhile improvement 4. Dramatic improvement that changed my quality of life Question 2: Size Change
My change in clothing size when comparing today to before surgery is: 0. No change 1. Down 1 or 2 sizes 2. Down 3 or 4 sizes 3. Down 5 or 6 sizes
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4. Down more than 6 sizes
Results Typical results are illustrated in Figures 1 and 2. Of the
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Discussion 92 HVL patients from the study period, we were able to get responses from 43 (47%) (Table 2). Although a higher response rate would have been desirable, the 47% rate exceeded our expectations, given the highly transient nature of the population in the Washington, DC, suburbs where I practice. In response to question 1, all patients reported some level of improvement as a result of surgery, with 98% evaluating their improvement as either “worthwhile” or “dramatic” (Table 3). In response to question 2, 68% of patients reported a decrease of at least 2 clothing sizes, with 30% reporting a decrease of 5 sizes or more. The average level of patient satisfaction was 3.4 on the 4point scale, in which 1 represented the lowest and 4 the highest level of satisfaction (Table 4). The highest level of satisfaction (3.6) was reported by the 30% of patients who experienced a clothing-size decrease of 5 to 6 sizes, and the lowest level of satisfaction (3.0) was reported by the 5% of patients who reported a clothing-size decrease of more than 6 sizes. It is worth noting that even patients who experienced no long-term change in clothing size were satisfied with the results of surgery because their body shape and contours were much improved. Complications
No patients required blood transfusions, intensive-care monitoring, or hospitalization for complications or physiologic instability. Three intraoperative complications occurred. Early in this series, a flexible, thinner-gauge infusion needle replaced the stiffer, heavier-gauge needles that had been used. Shortly after this equipment change, 2 patients treated several weeks apart each experienced a pneumothorax that was suspected after extubation because of oxygen saturations lower than those recorded before surgery. The patients remained physiologically stable and well oxygenated. After the pneumothoraxes were confirmed on chest radiography, an interventional radiologist treated them using a 10F pigtail catheter attached to a Heimlich valve, similar to the treatment of radiology patients with needle-biopsy pneumothoraxes. This resulted in immediate reexpansion of the lungs with no perceptible air leakage, allowing discharge home on the day of surgery. The patients returned to the hospital several days later for uneventful catheter removal. After these two cases, the larger, stiffer-gauge infusion needles were used exclusively. The third and final pneumothorax complication occurred near the end of this series, in a patient with moderate scoliosis, significant flank lipodystrophy, and a costal-margin deformity that was not appreciated before surgery. The same interventional radiology treatment was successfully used. Patient Satisfaction After High-volume Lipoplasty: Outcomes Survey and Thoughts on Safety
AESTHETIC
Lipoplasty, unlike many of the other procedures we perform, rarely causes concern over possible injury to major blood vessels, nerves, and surrounding structures vital to function, or with regard to skin viability. Instead, our attention centers on potential complications related to fluid balance, blood loss, drug toxicities, hemostasis, and circulating fatty acid effects on the tissues. The following discussion reviews the medical literature pertaining to these issues and proposes some suggestions for further research. Blood loss
When a wetting solution containing 2 mL of 1:1000 epinephrine per liter is used, operative blood loss has been shown in several studies to be less than 20 mL/L. 5–7 Additionally, Karmo7 found the decrease in hemoglobin 7 days after surgery to be 0.93 g/dL, with an SD of 0.92 g/dL. It is interesting that the volume of aspirate in this valuable study correlates neither with the level of postoperative hemoglobin drop 1 week after surgery nor with total operative blood loss as measured in the aspirate. Even more interesting, the measured blood loss in the aspirate did not correlate with the measured decrease in circulating hemoglobin 1 week after surgery. Although Dr. Karmo’s patients each underwent an extensive hematologic laboratory workup revealing normal results before surgery, some patients’ hemoglobin decreased by more than 4 g/dL, whereas others’ dropped by less than 0.5 g/dL. His data suggest that preoperative hematology tests are worthless predictors of risk for significant postoperative anemia from lipoplasty. This study also demonstrates that the volume of aspirate in lipoplasty procedures does not correlate with the level of postoperative anemia. Hypothermia and blood loss
I suspect that a factor not addressed in Karmo’s paper — hypothermic coagulopathy — plays a crucial role in determining the level of perioperative blood loss in HVL. I also hypothesize that because of hypothermic coagulopathy, those patients with the lowest intraoperative core body temperatures during lipoplasty will also have the largest postoperative decrease in hemoglobin level. Hypothermic coagulopathy is a serious but poorly understood problem8–11 that is receiving serious attention in the cardiac, trauma, and orthopedic surgery literature but has only begun to be discussed in the plastic surgery literature.12 Good evidence suggests that hypothermia, even mild hypothermia, can predispose patients to excessive blood loss and cardiac dysfunction.13–16 SURGERY
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A
B
C
D
E
F
G
H
Figure 1. A, C, E, G, Preoperative views of a 43-year-old woman. B, D, F, H, Postoperative views 6 months after removal of 8.8 L of aspirate through HVL. 348
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A
B
C
D
E
F
G
H
Figure 2. A, C, E, G, Preoperative views of a 33-year-old woman. B, D, F, H, Postoperative views 14 months after removal of 13.1 L of aspirate through HVL. Patient Satisfaction After High-volume Lipoplasty: Outcomes Survey and Thoughts on Safety
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Table 2. Survey response rate Year of surgery
Respondents
2001 2000 1999 Total
Response rate (%)
22 of 38 11 of 23 10 of 31 43 of 92
58 48 32 47
Table 3. Patient satisfaction with HVL Self-assessment
No. of patients
No long-term benefit Improvement, but not worth it Worthwhile improvement Dramatic improvement, life-changing
% of respondents
0 1 25 17
0 2 58 40
Table 4. Long-term clothing size decrease after HVL Long-term change in clothing size
No. of patients
None 1–2–size decrease 2–4–size decrease 5–size decrease Over 6–size decrease
% of respondents*
6 8 14 13 2
Average level of satisfaction (1–4)
14 19 33 30 5
3.2 3.1 3.4 3.6 3.0
*Total percent adds up to 101% as a result of rounding.
When a patient’s risk factors for intraoperative hypothermia are being evaluated, low ambient operatingroom temperature is second only to being a neonate.13 At operating-room temperatures below 21°C (70°F), exposed anesthetized patients frequently experience hypothermia, defined as a core body temperature below 36°C (96.8°F).13 Once human core temperature is at or below 35°C (95°F), significant coagulopathy occurs.15 For these reasons, I keep the operating room uncomfortably warm, 21°C to 23°C (70°F–74°F), and ask the anesthesiologist to monitor core temperature using an esophageal thermometer probe. Although upper-body hot-air blankets should theoretically help maintain body temperature, I have noted that they usually fail to do so in a cold room when most of the patient’s body surface is exposed and often moist with wetting solution. Surgeons typically keep operating rooms cold for their own comfort, yet lipoplasty involves exposing patients to ambient room temperatures over a large portion of their 350
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body surfaces. A controlled study examining the relationship between operating room temperature and core body temperature in exposed anesthetized patients is needed to advance our knowledge of the effect of room temperature on patient safety. Fat embolism
The term “fat embolism” has been used to explain a patient’s sudden physiologic decline during the lipoplasty perioperative period that is unrelated to drugs, fluid shifts, blood loss, or physical obstruction of the pulmonary artery (ie, not a thromboembolic phenomenon).17–21 This poorly understood phenomenon has occurred in lipoplasty procedures with aspirate volumes of less than 2 L. Although fat embolism is not conducive to human research, excellent animal studies point clearly to the deleterious effects of circulating fat.22, 23 It is clear that “liquefied” fat can make its way into circulation during the traumatization of both fat cells and vessels during lipoplasty, although it is not clear
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how often and to what degree this occurs. The measurement of circulating fat during lipoplasty would be an excellent subject for future study. A discussion of the biochemical basis of how circulating fat can lead to pulmonary artery constriction (resulting in decreased cardiac output, acidosis, and potential cardiovascular collapse) and increased pulmonary capillary permeability (potentially leading to hypoxia, acidosis, and acute respiratory distress syndrome) is far beyond the scope of this article. However, multiple animal studies have shown that the significant life-threatening effects of fat in the pulmonary circulation are mediated by thromboxane A2 released from platelets and leukocytes, which in turn cause pulmonary endothelium–dependent factors to be released. This in turn results in decreased pulmonary (and cardiac) function, caused by pulmonary-artery contracture as well as by increased pulmonary-vasculature permeability. 24–27 Fortunately, the administration of aspirin, indomethacin, or a glucocorticoid blocks many of the deleterious effects of thromboxane A2 (presumably by blocking the function of cyclooxygenase). 21,22,26–29 I administer intravenous methylprednisolone (500 mg) at the time of anesthesia induction as prophylactic treatment for the fat-embolism phenomenon. In light of these factors, I suggest that the following recommendations deserve serious consideration: 1. Monitoring of the patient’s core body temperature and maintenance of an operating-room temperature warm enough to keep the patient’s core temperature close to 36°C (97°F) — or higher, if possible. 2. Pretreatment of the patient with a cyclooxygenase (or thromboxane A2 synthesis) inhibitor that does not interfere with platelet aggregation or clotting, such as a glucocorticoid steroid. (More specific thromboxane A2–synthesis inhibitors will be available in the future.) 3. Maintenance of patients in the recovery room until body temperature is more than 36.7°C (98°F) to minimize the risk of postoperative bleeding (and unmonitored hypotension) caused by persistent mild hypothermia-related coagulopathy.
Conclusion For properly selected patients, HVL is a safe procedure with a very high patient satisfaction rate, provided that the surgeon performing the procedure uses good judgment in intraoperative fluid management, maintenance of adequate core body temperature during and immediately after surgery, and prophylactic measures to Patient Satisfaction After High-volume Lipoplasty: Outcomes Survey and Thoughts on Safety
AESTHETIC
help avoid circulating fat-induced cardiopulmonary problems.■
References 1. Commons G, Halperin B, Chang CC. Large volume liposuction: a review of 631 consecutive cases over 12 years. Plast Reconstr Surg 2001;108:1753-1763. 2. Giese S, Neborsky R. Improvements in cardiovascular risk profile after large volume lipoplasty: a 1-year follow-up study. Aesthetic Surg J 2001;21:527-531. 3. Baxter R. Serum lipid changes following large volume suction lipectomy. Aesthetic Surg J 1997;17:213-215. 4. Albin R, de Campo T. Large-volume liposuction in 181 patients. Aesthetic Plast Surg 1999;23:5:15. 5. Klein J. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg 1993;62:1085-1098. 6. Samdal F, Amland F, Bugge J. Blood loss during liposuction using the tumescent technique. Aesthetic Plast Surg 1994;18:157-160. 7. Karmo F, Milan M,Stein S, Heinsimer JA. Blood loss in major lipodystrophy procedures with the tumescent technique. Aesthetic Surg J 1998;18:30-35. 8. Watts DD, Trask A, Soeken K, et al. Hypothermic coagulopathy in trauma: effect of varying levels of hypothermia on enzyme speed, platelet function, and fibrinolytic activity. J Trauma 1998;44:846-854. 9. Krause KR, Howells GA, Buh CL,et al. Hypothermia-induced coagulopathy during hemorrhagic shock. Am Surg 2000;66:348-354. 10. Eddy VA, Morris JA, Cullinane DC. Hypothermia, coagulopathy, and acidosis. Surg Clin North Am 2000;80:845-854. 11. Danks RR. Triangle of death: how hypothermia, acidosis, and coagulopathy can adversely affect trauma patients. JEMS 2002;27:61-6, 68-70. 12. Toledo LS, Regatieri LF, Carneiro JDA. The effect of hypothermia on coagulation and its implications for infiltration in lipoplasty: a review. Aesthetic Surg J 2001;21:40-44. 13. Macario A, Dexter F. What are the most important risk factors for a patient’s developing intraoperative hypothermia? Anesth Analg 2002;94:215-220. 14. Winkler M, Akca O, Birkenberg B, et al. Aggressive warming reduces blood loss during hip arthroplasty. Anesth Analg 2000;91:978-984. 15. Schmied H, Kurz A, Sessler DI, et al. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Lancet 1996;347:289-292. 16. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events: a randomized trial. JAMA 1997;277:1127-1134. 17. Ross RM, Johnson GW. Fat embolism after liposuction. Chest 1988;93:1294-1295. 18. Laub DR. Fat embolism syndrome after liposuction: a case report and review of the literature. Ann Plast Surg 1990;25:48-52. 19. Samdal F, Aasen AO, Mollnes TE, et al. Effect of syringe-assisted liposuction on activation of cascade systems and circulating cells when using the superwet or tumescent technique. Ann Plast Surg 1995;35:242-248. 20. Scroggins C, Barson PK. Fat embolism syndrome in a case of abdominal lipectomy with liposuction. Md Med J 1999;48:116-118. 21. Platt MS, Kohler U, Ruiz R, et al. Deaths associated with liposuction: case reports and review of the literature. J Forensic Sci 2002;47:205207.
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22. Nakata Y, Tanaka H, Kuwagata Y, et al. Triolein-induced pulmonary embolization and increased microvascular permeability in isolated perfused rat lungs. J Trauma 1999;47:111-119.
rabbit isolated pulmonary artery and the involvement of endotheliumderived thromboxane A2 Br J Pharmacol 1997;122:199-208.
23. Rostagno C, Gensini GF, Bonsinelli S, et al. The prominent role of thromboxane A2 formation on early pulmonary hypertension induced by oleic acid administration in sheep. Thromb Res 1990;58:35-45.
28. Gao Y, Tolsa JF, Shen H, Raj JU. A single dose of antenatal betamethasone enhances isoprenaline and prostaglandin E2–induced relation of preterm ovine pulmonary arteries. Biol Neonate 1998;73:182-189.
24. Buzzard CJ, Pfister SL, Campbell WB. Endothelium-dependent contractions in rabbit pulmonary artery are mediated by thromboxane A2. Circ Res 1993;72:1023-1034.
29. Henry CL, Ogletree ML, Brigham KL, Hammon JW Jr. Attenuation of the pulmonary vascular response to endotoxin by a thromboxane synthesis inhibitor in un anesthetized sheep. J Surg Res 1991;50:77-81.
25. Pierson RN, Parker RE. Thromboxane mediates pulmonary vasoconstriction and contributes to cytotoxicity in pig lungs perfused with fresh human blood. Transplant Proc 1996;28:625.
Accepted for publication May 28, 2003.
26. Cave AC, Manchu A, Derius NW, Hearse DJ. Thromboxane A2 mediates pulmonary hypertension after cardiopulmonary bypass in the rabbit. J Thorac Cardiovascular Surg 1993;106:959-976.
Copyright © 2003 by The American Society for Aesthetic Plastic Surgery, Inc.
Reprint requests: Mark E. Richards, MD, 11300 Rockville Pike, Suite 912, North Bethesda, MD 20852; [email protected].
1090-820X/2003/$30.00 + 0 doi:10.1067/maj.2003.73
27. Nakayama K, Ueta K, Tanaka Y, et al. Stretch-induced contraction of
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Patient Satisfaction After High-volume Lipoplasty: Outcomes Survey and Thoughts on Safety Mark E. Richards, MD Dr. Richards is in private practice in Bethesda, MD.
Background: The technique of high-volume lipoplasty (HVL) remains controversial despite several reports of its safety and benefits. Objectives: An outcomes survey was conducted to determine patient satisfaction with the results of HVL in a series of 92 consecutive cases. The literature concerning safety issues related to HVL is summarized, and suggestions for future guidelines and investigation are proposed. Methods: Ninety-two patients underwent HVL between January 1, 1999, and December 31, 2001. Aspiration ranged from 5 to 15.7 L, with an average of 8.2 L per patient. No unplanned hospitalizations or transfusions were required, and no deaths occurred. Patients were questioned by telephone 13 to 49 months after HVL and asked to evaluate the benefits of surgery using a 4-point scale on which the lowest rating represented no long-term benefit and the highest rating indicated dramatic improvement. They were also asked to evaluate change in clothing size since surgery, with 0 indicating no size change and 4 indicating a size reduction of more than 6 sizes. Results: The response rate for the survey was 47% (43 of 92 patients). Patient satisfaction was high, averaging 3.4 on the 1-to-4 scale. On average, patients experienced a decrease of 3 to 4 clothing sizes. Conclusions: With careful patient selection and attention to key safety issues, HVL can provide a high level of longterm satisfaction to patients. (Aesthetic Surg J 2003;23:345-352.)
S
everal excellent articles have been published on the safety and benefits of high-volume lipoplasty (HVL).1–4 Nevertheless, in my opinion the controversy surrounding this procedure has adversely affected the exchange of information so vital to our ability to improve the safety of HVL and enhance our skills regarding this procedure. Although HVL is a small part of my aesthetic surgery practice, I find it a valuable tool in the aesthetic surgery armamentarium. This report on a 36month “slice” of my HVL experience is an attempt to encourage an objective and scientific discussion of the benefits and safety of HVL by its practitioners. Only by sharing our collective experiences with HVL can we develop “collective good judgment” in this unique procedure.
Patients and Methods Patient selection
This study included 92 HVL procedures (aspiration ≥ 5 L) performed consecutively from January 1, 1999, through December 31, 2001 (Table 1). The patients who underwent HVL were in good health (American Society of Anesthesiologists [ASA] level 1 or 2) and had 2 AESTHETIC
lengthy preoperative consultations regarding the risks and recovery associated with HVL. Although advanced age is not an absolute contraindication for HVL, I discourage elderly patients from undergoing the procedure because of their decreased cardiac reserves. Obesity is not an absolute contraindication, as long as the goal of the patient and doctor is to achieve body-shape contouring and not merely fat reduction. All patients were informed of the hospital’s requirement for an overnight hospital stay if lipoplasty aspirate volume exceeded 10 L. Surgical procedure
All procedures were performed in a hospital setting with the patient under general anesthesia. Attempts were made to keep the operating-room temperature well above 21°C (70°F). All patients received 500 mg of methylprednisolone after the induction of anesthesia but before the procedure. The wetting solution consisted of 1-L bags of intravenous normal saline solution to which had been added 2 mL of 1:1000 epinephrine, 10 mL of 8.4% sodium bicarbonate, and 50 mL of 1% lidocaine. Lidocaine was only added to the first 5 L of wetting solution. Patients were prepped while standing with poviSURGERY
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Table 1. Lipoplasty volumes aspirated No. of patients Liters removed
2001
5–6.0 6–6.9 7–7.9 8–8.9 9–9.9 10–10.9 11–11.9 12–12.9 13–13.9 14–14.9 15–15.9 No. of patients
4 5 8 5 5 3 0 4 3 0 1 38
done-iodine solution, before the induction of anesthesia. Antibiotic prophylaxis for skin flora (usually a cephalosporin) was given intravenously before surgery. The operating table was covered in sterile drapes. Sterile stockings were placed on the patient’s feet and lower legs. Manual (and, later, power-assisted) lipoplasty was performed with the patient in the supine and lateral decubitus positions only. No prone positioning was used, and no ultrasonic lipoplasty was performed. The wetting solution was instilled so as to achieve the approximate ratio of 1 mL of wetting fluid for every 1 mL of aspirate removed, up to 5 L. After 5 L of aspirate had been removed, 0.5mL of wetting solution was instilled per additional milliliter of aspirate removed. The amount of aspirate removed ranged from 5 to 15.7 L, with an average of 8.2 L per patient. Early in the series, an intravenous fluid–warming system was used. However, it is doubtful that any significant warming resulted, in light of the high flow rate of the wetting solution and the low heat transfer rate of the warming system available at the time. Intravenous fluid administered during surgery was limited to “maintenance” volume (no replacement was given for amount of aspirate removed), as determined by the anesthesiologist. The patient was fitted with a compression girdle after surgery, while still in the operating room, and encouraged to drink enough fluids at home to maintain clear urine. Recovery room discharge criteria included a body temperature above 36.7°C (98°F).
Patients were questioned by telephone during the first 2 months of 2003, 13 to 49 months after surgery. This delay between the surgery date and the patient survey was incorporated into the study to allow time for the iniAesthetic
Surgery
1999
3 9 2 2 3 1 1 0 2 0 0 23
10 3 7 5 1 0 3 0 2 0 0 31
Total patients 17 17 17 12 9 4 4 4 7 0 1 92
tial postprocedure enthusiasm to fade and for the patients’ normal lifestyle habits to be reestablished before they were asked to evaluate their satisfaction levels. Multiple attempts were made to contact each patient by last known home address, e-mail address, and home and work telephone numbers. One person (the office nurse) talked to all respondents, using a set script as follows: “Dr. Richards is writing a scientific paper on the longterm follow-up of liposuction patients. Very little is written about the long-term results. He hoped that you would be willing to answer a couple questions to give plastic surgeons a better understanding of how patients feel about the procedure years after liposuction.” Patients were asked the following 2 questions: Question 1: Satisfaction
I felt liposuction gave me: 1. No long-term benefit 2. Improvement, but it was not worth the time, money, or recovery 3. Worthwhile improvement 4. Dramatic improvement that changed my quality of life Question 2: Size Change
My change in clothing size when comparing today to before surgery is: 0. No change 1. Down 1 or 2 sizes 2. Down 3 or 4 sizes 3. Down 5 or 6 sizes
Patient outcomes study
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2000
Journal
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4. Down more than 6 sizes
Results Typical results are illustrated in Figures 1 and 2. Of the
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Discussion 92 HVL patients from the study period, we were able to get responses from 43 (47%) (Table 2). Although a higher response rate would have been desirable, the 47% rate exceeded our expectations, given the highly transient nature of the population in the Washington, DC, suburbs where I practice. In response to question 1, all patients reported some level of improvement as a result of surgery, with 98% evaluating their improvement as either “worthwhile” or “dramatic” (Table 3). In response to question 2, 68% of patients reported a decrease of at least 2 clothing sizes, with 30% reporting a decrease of 5 sizes or more. The average level of patient satisfaction was 3.4 on the 4point scale, in which 1 represented the lowest and 4 the highest level of satisfaction (Table 4). The highest level of satisfaction (3.6) was reported by the 30% of patients who experienced a clothing-size decrease of 5 to 6 sizes, and the lowest level of satisfaction (3.0) was reported by the 5% of patients who reported a clothing-size decrease of more than 6 sizes. It is worth noting that even patients who experienced no long-term change in clothing size were satisfied with the results of surgery because their body shape and contours were much improved. Complications
No patients required blood transfusions, intensive-care monitoring, or hospitalization for complications or physiologic instability. Three intraoperative complications occurred. Early in this series, a flexible, thinner-gauge infusion needle replaced the stiffer, heavier-gauge needles that had been used. Shortly after this equipment change, 2 patients treated several weeks apart each experienced a pneumothorax that was suspected after extubation because of oxygen saturations lower than those recorded before surgery. The patients remained physiologically stable and well oxygenated. After the pneumothoraxes were confirmed on chest radiography, an interventional radiologist treated them using a 10F pigtail catheter attached to a Heimlich valve, similar to the treatment of radiology patients with needle-biopsy pneumothoraxes. This resulted in immediate reexpansion of the lungs with no perceptible air leakage, allowing discharge home on the day of surgery. The patients returned to the hospital several days later for uneventful catheter removal. After these two cases, the larger, stiffer-gauge infusion needles were used exclusively. The third and final pneumothorax complication occurred near the end of this series, in a patient with moderate scoliosis, significant flank lipodystrophy, and a costal-margin deformity that was not appreciated before surgery. The same interventional radiology treatment was successfully used. Patient Satisfaction After High-volume Lipoplasty: Outcomes Survey and Thoughts on Safety
AESTHETIC
Lipoplasty, unlike many of the other procedures we perform, rarely causes concern over possible injury to major blood vessels, nerves, and surrounding structures vital to function, or with regard to skin viability. Instead, our attention centers on potential complications related to fluid balance, blood loss, drug toxicities, hemostasis, and circulating fatty acid effects on the tissues. The following discussion reviews the medical literature pertaining to these issues and proposes some suggestions for further research. Blood loss
When a wetting solution containing 2 mL of 1:1000 epinephrine per liter is used, operative blood loss has been shown in several studies to be less than 20 mL/L. 5–7 Additionally, Karmo7 found the decrease in hemoglobin 7 days after surgery to be 0.93 g/dL, with an SD of 0.92 g/dL. It is interesting that the volume of aspirate in this valuable study correlates neither with the level of postoperative hemoglobin drop 1 week after surgery nor with total operative blood loss as measured in the aspirate. Even more interesting, the measured blood loss in the aspirate did not correlate with the measured decrease in circulating hemoglobin 1 week after surgery. Although Dr. Karmo’s patients each underwent an extensive hematologic laboratory workup revealing normal results before surgery, some patients’ hemoglobin decreased by more than 4 g/dL, whereas others’ dropped by less than 0.5 g/dL. His data suggest that preoperative hematology tests are worthless predictors of risk for significant postoperative anemia from lipoplasty. This study also demonstrates that the volume of aspirate in lipoplasty procedures does not correlate with the level of postoperative anemia. Hypothermia and blood loss
I suspect that a factor not addressed in Karmo’s paper — hypothermic coagulopathy — plays a crucial role in determining the level of perioperative blood loss in HVL. I also hypothesize that because of hypothermic coagulopathy, those patients with the lowest intraoperative core body temperatures during lipoplasty will also have the largest postoperative decrease in hemoglobin level. Hypothermic coagulopathy is a serious but poorly understood problem8–11 that is receiving serious attention in the cardiac, trauma, and orthopedic surgery literature but has only begun to be discussed in the plastic surgery literature.12 Good evidence suggests that hypothermia, even mild hypothermia, can predispose patients to excessive blood loss and cardiac dysfunction.13–16 SURGERY
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Figure 1. A, C, E, G, Preoperative views of a 43-year-old woman. B, D, F, H, Postoperative views 6 months after removal of 8.8 L of aspirate through HVL. 348
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Figure 2. A, C, E, G, Preoperative views of a 33-year-old woman. B, D, F, H, Postoperative views 14 months after removal of 13.1 L of aspirate through HVL. Patient Satisfaction After High-volume Lipoplasty: Outcomes Survey and Thoughts on Safety
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Table 2. Survey response rate Year of surgery
Respondents
2001 2000 1999 Total
Response rate (%)
22 of 38 11 of 23 10 of 31 43 of 92
58 48 32 47
Table 3. Patient satisfaction with HVL Self-assessment
No. of patients
No long-term benefit Improvement, but not worth it Worthwhile improvement Dramatic improvement, life-changing
% of respondents
0 1 25 17
0 2 58 40
Table 4. Long-term clothing size decrease after HVL Long-term change in clothing size
No. of patients
None 1–2–size decrease 2–4–size decrease 5–size decrease Over 6–size decrease
% of respondents*
6 8 14 13 2
Average level of satisfaction (1–4)
14 19 33 30 5
3.2 3.1 3.4 3.6 3.0
*Total percent adds up to 101% as a result of rounding.
When a patient’s risk factors for intraoperative hypothermia are being evaluated, low ambient operatingroom temperature is second only to being a neonate.13 At operating-room temperatures below 21°C (70°F), exposed anesthetized patients frequently experience hypothermia, defined as a core body temperature below 36°C (96.8°F).13 Once human core temperature is at or below 35°C (95°F), significant coagulopathy occurs.15 For these reasons, I keep the operating room uncomfortably warm, 21°C to 23°C (70°F–74°F), and ask the anesthesiologist to monitor core temperature using an esophageal thermometer probe. Although upper-body hot-air blankets should theoretically help maintain body temperature, I have noted that they usually fail to do so in a cold room when most of the patient’s body surface is exposed and often moist with wetting solution. Surgeons typically keep operating rooms cold for their own comfort, yet lipoplasty involves exposing patients to ambient room temperatures over a large portion of their 350
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body surfaces. A controlled study examining the relationship between operating room temperature and core body temperature in exposed anesthetized patients is needed to advance our knowledge of the effect of room temperature on patient safety. Fat embolism
The term “fat embolism” has been used to explain a patient’s sudden physiologic decline during the lipoplasty perioperative period that is unrelated to drugs, fluid shifts, blood loss, or physical obstruction of the pulmonary artery (ie, not a thromboembolic phenomenon).17–21 This poorly understood phenomenon has occurred in lipoplasty procedures with aspirate volumes of less than 2 L. Although fat embolism is not conducive to human research, excellent animal studies point clearly to the deleterious effects of circulating fat.22, 23 It is clear that “liquefied” fat can make its way into circulation during the traumatization of both fat cells and vessels during lipoplasty, although it is not clear
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how often and to what degree this occurs. The measurement of circulating fat during lipoplasty would be an excellent subject for future study. A discussion of the biochemical basis of how circulating fat can lead to pulmonary artery constriction (resulting in decreased cardiac output, acidosis, and potential cardiovascular collapse) and increased pulmonary capillary permeability (potentially leading to hypoxia, acidosis, and acute respiratory distress syndrome) is far beyond the scope of this article. However, multiple animal studies have shown that the significant life-threatening effects of fat in the pulmonary circulation are mediated by thromboxane A2 released from platelets and leukocytes, which in turn cause pulmonary endothelium–dependent factors to be released. This in turn results in decreased pulmonary (and cardiac) function, caused by pulmonary-artery contracture as well as by increased pulmonary-vasculature permeability. 24–27 Fortunately, the administration of aspirin, indomethacin, or a glucocorticoid blocks many of the deleterious effects of thromboxane A2 (presumably by blocking the function of cyclooxygenase). 21,22,26–29 I administer intravenous methylprednisolone (500 mg) at the time of anesthesia induction as prophylactic treatment for the fat-embolism phenomenon. In light of these factors, I suggest that the following recommendations deserve serious consideration: 1. Monitoring of the patient’s core body temperature and maintenance of an operating-room temperature warm enough to keep the patient’s core temperature close to 36°C (97°F) — or higher, if possible. 2. Pretreatment of the patient with a cyclooxygenase (or thromboxane A2 synthesis) inhibitor that does not interfere with platelet aggregation or clotting, such as a glucocorticoid steroid. (More specific thromboxane A2–synthesis inhibitors will be available in the future.) 3. Maintenance of patients in the recovery room until body temperature is more than 36.7°C (98°F) to minimize the risk of postoperative bleeding (and unmonitored hypotension) caused by persistent mild hypothermia-related coagulopathy.
Conclusion For properly selected patients, HVL is a safe procedure with a very high patient satisfaction rate, provided that the surgeon performing the procedure uses good judgment in intraoperative fluid management, maintenance of adequate core body temperature during and immediately after surgery, and prophylactic measures to Patient Satisfaction After High-volume Lipoplasty: Outcomes Survey and Thoughts on Safety
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help avoid circulating fat-induced cardiopulmonary problems.■
References 1. Commons G, Halperin B, Chang CC. Large volume liposuction: a review of 631 consecutive cases over 12 years. Plast Reconstr Surg 2001;108:1753-1763. 2. Giese S, Neborsky R. Improvements in cardiovascular risk profile after large volume lipoplasty: a 1-year follow-up study. Aesthetic Surg J 2001;21:527-531. 3. Baxter R. Serum lipid changes following large volume suction lipectomy. Aesthetic Surg J 1997;17:213-215. 4. Albin R, de Campo T. Large-volume liposuction in 181 patients. Aesthetic Plast Surg 1999;23:5:15. 5. Klein J. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg 1993;62:1085-1098. 6. Samdal F, Amland F, Bugge J. Blood loss during liposuction using the tumescent technique. Aesthetic Plast Surg 1994;18:157-160. 7. Karmo F, Milan M,Stein S, Heinsimer JA. Blood loss in major lipodystrophy procedures with the tumescent technique. Aesthetic Surg J 1998;18:30-35. 8. Watts DD, Trask A, Soeken K, et al. Hypothermic coagulopathy in trauma: effect of varying levels of hypothermia on enzyme speed, platelet function, and fibrinolytic activity. J Trauma 1998;44:846-854. 9. Krause KR, Howells GA, Buh CL,et al. Hypothermia-induced coagulopathy during hemorrhagic shock. Am Surg 2000;66:348-354. 10. Eddy VA, Morris JA, Cullinane DC. Hypothermia, coagulopathy, and acidosis. Surg Clin North Am 2000;80:845-854. 11. Danks RR. Triangle of death: how hypothermia, acidosis, and coagulopathy can adversely affect trauma patients. JEMS 2002;27:61-6, 68-70. 12. Toledo LS, Regatieri LF, Carneiro JDA. The effect of hypothermia on coagulation and its implications for infiltration in lipoplasty: a review. Aesthetic Surg J 2001;21:40-44. 13. Macario A, Dexter F. What are the most important risk factors for a patient’s developing intraoperative hypothermia? Anesth Analg 2002;94:215-220. 14. Winkler M, Akca O, Birkenberg B, et al. Aggressive warming reduces blood loss during hip arthroplasty. Anesth Analg 2000;91:978-984. 15. Schmied H, Kurz A, Sessler DI, et al. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Lancet 1996;347:289-292. 16. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events: a randomized trial. JAMA 1997;277:1127-1134. 17. Ross RM, Johnson GW. Fat embolism after liposuction. Chest 1988;93:1294-1295. 18. Laub DR. Fat embolism syndrome after liposuction: a case report and review of the literature. Ann Plast Surg 1990;25:48-52. 19. Samdal F, Aasen AO, Mollnes TE, et al. Effect of syringe-assisted liposuction on activation of cascade systems and circulating cells when using the superwet or tumescent technique. Ann Plast Surg 1995;35:242-248. 20. Scroggins C, Barson PK. Fat embolism syndrome in a case of abdominal lipectomy with liposuction. Md Med J 1999;48:116-118. 21. Platt MS, Kohler U, Ruiz R, et al. Deaths associated with liposuction: case reports and review of the literature. J Forensic Sci 2002;47:205207.
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22. Nakata Y, Tanaka H, Kuwagata Y, et al. Triolein-induced pulmonary embolization and increased microvascular permeability in isolated perfused rat lungs. J Trauma 1999;47:111-119.
rabbit isolated pulmonary artery and the involvement of endotheliumderived thromboxane A2 Br J Pharmacol 1997;122:199-208.
23. Rostagno C, Gensini GF, Bonsinelli S, et al. The prominent role of thromboxane A2 formation on early pulmonary hypertension induced by oleic acid administration in sheep. Thromb Res 1990;58:35-45.
28. Gao Y, Tolsa JF, Shen H, Raj JU. A single dose of antenatal betamethasone enhances isoprenaline and prostaglandin E2–induced relation of preterm ovine pulmonary arteries. Biol Neonate 1998;73:182-189.
24. Buzzard CJ, Pfister SL, Campbell WB. Endothelium-dependent contractions in rabbit pulmonary artery are mediated by thromboxane A2. Circ Res 1993;72:1023-1034.
29. Henry CL, Ogletree ML, Brigham KL, Hammon JW Jr. Attenuation of the pulmonary vascular response to endotoxin by a thromboxane synthesis inhibitor in un anesthetized sheep. J Surg Res 1991;50:77-81.
25. Pierson RN, Parker RE. Thromboxane mediates pulmonary vasoconstriction and contributes to cytotoxicity in pig lungs perfused with fresh human blood. Transplant Proc 1996;28:625.
Accepted for publication May 28, 2003.
26. Cave AC, Manchu A, Derius NW, Hearse DJ. Thromboxane A2 mediates pulmonary hypertension after cardiopulmonary bypass in the rabbit. J Thorac Cardiovascular Surg 1993;106:959-976.
Copyright © 2003 by The American Society for Aesthetic Plastic Surgery, Inc.
Reprint requests: Mark E. Richards, MD, 11300 Rockville Pike, Suite 912, North Bethesda, MD 20852; [email protected].
1090-820X/2003/$30.00 + 0 doi:10.1067/maj.2003.73
27. Nakayama K, Ueta K, Tanaka Y, et al. Stretch-induced contraction of
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