I work in a private practice setting in Palo Alto, California, and liposuction is one of the most common plastic surgery procedures performed. The accepted definition of a “large-volume” liposuction is a total aspirate of greater than 4 liters. Seventy percent of the total aspirate is fat, so if a total volume of 4 liters is harvested, the total volume of fat is 0.7 X 4, or 2.8 liters. Each liter of liposuction fat weighs approximately 2 pounds, so the weight removed in a 4-liter total-aspirate liposuction is 2.8 liters X 2 pounds/liter = 5.6 pounds.
The current accepted upper limit for fat removed in an outpatient liposuction is 5 liters, so the maximum weight of fat removed would be 5 liters X 2 pounds/liter = 10 pounds.
Early in my career, in the late 1980’s, liposuction was a bloody procedure. Prior to surgery healthy outpatients donated their own autologous blood, which they received intraoperatively to treat the expected hemorrhage which accompanied liposuction.
In the late 1980’s, American dermatologist Jeffery Klein introduced the tumescent technique for liposuction, in which dilute solutions of epinephrine and lidocaine were injected into the subcutaneous tissues prior to liposuction. This technique induced vasoconstriction and resulted in decreased blood loss, and made transfusion and post-operative anemia rare.
The volume of tumescent solution injected by the surgeon is roughly equivalent to the total volume expected to be aspirated from the patient. For a large-volume liposuction, 4 – 7 liters of tumescent solution may be injected into the body areas to be suctioned. The tumescent solution includes 1 mg of epinephrine and 20 ml of 1% lidocaine (200 mg lidocaine) per one liter of Lactated Ringers. The complication of local anesthetic toxicity from lidocaine is rare. The maximum dose of lidocaine should be kept < 35 mg/kg, or < 2450 mg for a 70 kg (154 pound) patient. If the surgeon injects six liters, this will total only 1200 mg of lidocaine. Symptoms of epinephrine toxicity are also rare.
Preanesthetic assessment and patient selection are key for safe large-volume liposuction procedures. All patients are ASA I or II, and have stable medical histories. Our facility requires each patient to weigh less than 250 pounds, or to have a BMI < 36. Preoperative labs and ECGs are done only as needed, per standard Ambulatory Surgery Center policies. The procedures are done under general endotracheal anesthesia, and can last from 3 to 8 hours. Our facility, the Plastic Surgery Center in Palo Alto, has two operating rooms. At times the second room is not occupied, and a solo anesthesiologist is the only anesthesia professional present on site and must be prepared to handle any and all emergencies.
A protocol for large-volume liposuction at our facility is as follows:
- General anesthesia is induced. An endotracheal tube rather than a supraglottic airway is used. Many procedures involve both supine and prone positioning because anterior and posterior parts of the body are liposuctioned. A Foley catheter is inserted into the bladder.
- After prepping and draping, the surgeon injects the tumescent solution into the areas to be liposuctioned. The total volume of the injectate must not exceed 10 liters. In most cases, the total volume of the injectate does not exceed 6 liters.
- The liposuction proceeds. The typical aspirate is a mixture of fat and tumescent fluid, with minimal bloody or reddish tinge. The total volume of fat aspirated is not to exceed 5 liters. The ratio of fat/total aspirate in each container is 0.7. If a total of 7 liters of liposuction aspirate is harvested, the total volume of fat is 7 X 0.7, or 4.9 liters.
- Fluid intake and output must be balanced. The total intake includes 6 liters of tumescent Lactated Ringers, plus intravenous fluids. Usually the volume of intravenous fluid is kept to less than 1 liter. The output equals the total aspirate volume of 7 liters in this case, plus the urine output. If the urine output is less than 0.5 ml/kg/hour, the diuretic furosemide 10 mg can be administered IV.
- Maintaining normothermia is challenging. Large-volume liposuction usually requires exposure of the patient’s body surface from the lower thorax to the knees to room air temperature. Twin Bair Huggers are used to warm both the lower and upper non-operative fields of the patient’s body.
- At the conclusion of surgery, constricting garments are applied to the patient’s body to reduce edema and bleeding. General anesthesia is continued until these garments are applied.
- Patients are discharged home after a typical PACU time of 75-120 minutes.
How safe is large-volume liposuction?
Palo Alto plastic surgeon George Commons and anesthesiologist Bruce Halperin published a retrospective review on 631 consecutive patients from 1986–1998 who underwent liposuction procedures of at least 3 liters total aspirate.(1) Total aspirate volumes ranged from 3 to 17 liters. Complications consisted of minor skin injuries and burns, allergic reactions to garments, and postoperative seromas. Only four patients of 631 (0.6%) developed serious complications, including four patients with mild pulmonary edema and one patient who developed pneumonia postoperatively. These patients were treated appropriately and had uneventful recoveries.
A retrospective study from Germany reported on 2275 large-volume liposuction patients from 1998-2002 in which there were 72 cases of severe complications (3.1%), including 23 deaths.(2) The most frequent complications were bacterial infections (necrotizing fasciitis, gas gangrene, and sepsis), hemorrhage, perforation of abdominal viscera, and pulmonary embolism. Fifty-seven of the 72 complications were clinically evident within the first 24 postoperative hours. Risk factors for the development of severe complications were insufficient standards of hygiene, infiltration of multiple liters of tumescent solution, permissive postoperative discharge, selection of unfit patients, and lack of surgical experience, especially regarding the identification of complications. The striking 1% mortality rate of this series documents that liposuction was dangerous in Germany between 1998 and 2002.
A review of 127,961 cosmetic surgery cases in the U.S. in 2016 showed a 0.9% complication rate in liposuction patients. Overweight patients (BMI = 25-29.9) and obese patients (BMI ≥ 30) were both independent risk factors for post-operative infection and venous thromboembolism.
In a series from Illinois, 69 of 4534 (1.5 percent) of liposuction patients in experienced a postoperative complication.(4) Both the liposuction volume and the patient’s BMI were significant independent risk factors. Liposuction volumes in excess of 100 ml per unit of body mass index were an independent predictor of complications (p < 0.001).
In experienced hands, the major morbidity of large-volume liposuction should be low—no more than the complication rates of 0.6 – 1.5% reported from the United States above. As long as there are patients who desire less fat in their thighs, hips, buttocks, abdomen, knees, arms, or necks, there will be a demand for liposuction. Large-volume liposuction requires an anesthesia professional who’s comfortable managing the perioperative medicine. If you’re considering this surgical procedure, my recommendation is to seek both a surgeon and an anesthesia team who are well trained and experienced.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
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