25 Prevention and Treatment of Liposuction Complications

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25 Prevention and Treatment of Liposuction

Complications

Melvin A. Shiffman

25.1 Introduction

Liposuction of the abdomen may be associated with a variety of complications most of which can be avoided.

The more aggressive the liposuction, especially in the superficial subcutaneous tissues and with large amounts of fat removal, the more likely a complication will occur. “It is not so much what is removed that is important, but what is left behind” [1].

25.2 Complications

25.2.1 Asymmetry

If the patient has asymmetry of the abdominal wall preoperatively, this should be pointed out to the patient and recorded with adequate photos. More fat may have to be removed from one side or one area of the abdominal wall because of the asymmetric accumulation.

Asymmetry can be avoided by being aware of the amounts of fat and fluid removed from each side of the abdomen so that there is no large discrepancy. Observ- ing the results carefully at the end of liposuction may disclose further areas that need correction.

Asymmetry that is present postoperatively may need revision liposuction for removal of excess fat from those areas affected. If there is a deficit in any area that needs correction, injection of autologous fat may be considered.

25.2.2

Depressions (Grooves, Waviness)

Excessive or superficial liposuction too close to the skin may result in depressions. Superficial liposuction should not get closer than 1 cm below the skin of the abdominal wall, and smaller cannulas (< 3.5 mm) should be utilized in comparison to the deep liposuction that can be performed with cannulas over 3.5 mm (3.5 – 6.0 mm depending on the thickness of the fat layer).

Depressions can be corrected by selectively liposuctioning the areas around the depression and filling the indented area with autologous fat [2]. If the indentation is noted while performing the liposuction, autologous fat can be injected at that time. It is possible to fill defects with the “liposhifting” technique by tumescing the areas around the depression, loosening the fat with multiple criss-crossing tunnels, and molding the fat into the defect by rolling a large cannula (6 – 10 mm) across the prepared areas toward the depression [3].

The skin scar may become depressed and is usually due to the suction staying on when the cannula is removed and reinserted multiple times. This can be prevented by turning off the suction before removing the cannula or by having a finger vent in the handle of the cannula.

25.2.3 Chronic Edema

An infrequent occurrence, persistent edema in the area of liposuction, can be distressing to the patient. This may be due to excessive trauma to the tissues but liposuction is a traumatic procedure causing so-called “in- ternal burn-like injury.” Proper compression is usually the key to prevention. Remember that excessive compression of an extremity can result in venous thrombosis and possible embolic disorder.

Repeat liposuction (in an amount to break up the edematous tissues and flatten the region) of the area with tumescent technique is usually helpful but must be followed by adequate compression dressings.

25.2.4

Bleeding, Hematoma

Tumescent technique in liposuction has reduced the amount of bleeding to a degree that is usually minimal.

Preoperatively, the patient must be forewarned to stop all aspirin containing products, ibuprofen, and herbs at least 2 weeks before and for 2 weeks after surgery. Ex- cessive liposuctioning in a single area may cause bloody fluid to appear in the tubing and this should forewarn the surgeon not to continue surgery in that

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area unless further tumescent solution is used. The use of low vacuum pressures (250 – 300 mm) on the liposuction machine or venting the liposuction syringe will reduce bleeding.

Bleeding following liposuction may appear as bright red blood coming from the incision site or may be hid- den and appear as orthostatic hypotension when the patient tries to sit up or stand. Postoperative dizziness and feeling faint should not be considered a drug reaction or dehydration until after the Hgb or Hct is checked. Intra- venous fluid resuscitation may be enough if the bleeding is not over 15 % of the blood volume but some patients with more blood loss may require Hespan, dex- tran, albumin, or blood to restore the blood volume.

Hematoma in the tissues can be treated conserva- tively with aspiration. This should be distinguished from bruising that requires no treatment. A hematoma that becomes a persistent untreated mass will form a seroma and then a chronic pseudocyst.

25.2.5 Seroma

The collection of serous fluid in the liposuction area may be due to irritation of the tissues by the traumatic procedure but is more frequently the result of concomitant oversuctioning of a single area with undermining of a flap allowing a cavity to form. Sometimes a hematoma may appear first and be replaced over time with serosanguineous fluid and then serous fluid.

A persistent collection of fluid following liposuction may be treated with needle aspiration followed by adequate compression dressings. This may need to be re- peated every few days. If the collection can be reached through one of the liposuction incisions, a drain can be inserted to reduce the fluid and kept in place with compression dressings that need to be changed every cou- ple of days. Prophylactic antibiotics may be used during the time the drain is in place. If the collection becomes chronic (over 4 weeks), the fluid should be aspi- rated and air may be injected into the cavity to cause irritation (Fig. 25.1). Compression dressings are necessary after each such treatment. Another method that is available but requires adequate anesthesia is curetting the lining of the cavity through a small incision or through one of the liposuction incisions. If the liposuction is combined with abdominoplasty and a chronic seroma occurs, the pseudocyst may be excised through the abdominal scar (Fig. 25.2).

25.2.6 Infection

The occurrence of infection in a clean surgery case is approximately 1 % in outpatient surgery and 3 % in hospital surgery. The tendency to consider liposuction

as minor surgery with minimal care about sterility in the surgery suite can be detrimental to the patient. Se- rious infections have been documented following liposuction [4, 5]. Necrotizing fasciitis [6, 7] and toxic shock syndrome [8, 9] have been reported.

Postsurgical infection should be diagnosed as early as possible in order to prevent more serious manifesta- tions of the infection such as necrosis, septicemia, or toxic shock. Blisters may presage the appearance of necrosis and should be treated and observed closely.

There are various dressings that may cause blisters such as tape on the skin and Reston foam. Any erythe- ma is an indication of inflammation or infection and should be treated as such with antibiotics and close fol- low-up.

25.2.7

Perforation of Intra-abdominal Vessel or Viscus [10 – 12]

Perforation of the abdominal wall is most likely to occur in the presence of hernia or abdominal wall scar, which can divert the direction of the cannula. The non- dominant hand should always feel the end of the cannula. When the cannula is not palpable, the surgeon should reassess his technique and consider perforation of the abdominal wall. Under local tumescent anesthesia, perforation can be detected at the time of surgery by the presence of abdominal pain. Liposuction over the ribs can be aided by the use of pressure on the lower ribs with the flat portion of the non-dominant hand, which will result in the cannula easily going over the ribs instead of under with perforation into the chest.

If there is unusual abdominal pain postoperatively such as increasing pain or severe pain, perforation must be considered. It may be difficult to examine the abdomen directly by pressure because liposuction alone will cause pain in the area. The presence of rebound tender- ness usually indicates peritonitis. Flat plate and upright abdominal X-rays may show free air if the bowel is per- forated. The patient may have to be observed in the hospital if there is the possibility of viscus perforation. Vas- cular perforation that causes significant blood loss will result in abdominal pain, orthostatic hypotension, and shock. Insertion of a small catheter (Angiocath) into the abdominal cavity and the instillation of some sterile sa- line can produce bloody drainage consistent with vas- cular injury. If the blood is totally retroperitoneal, CT scan may be necessary. Emergency exploratory laparot- omy is usually indicated.

25.2.8

Thromboembolism [10]

Medium- and high-risk patients for thromboembolism should have the necessary precautions taken in the pe- rioperative period (see Chapter 27). These include 216 25 Prevention and Treatment of Liposuction Complications

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a Fig. 25.1. a Left Preoperative 43-year-old female with history of liposuction of inner and outer thighs 6 years previously.

Right one week postoperative- ly with swelling of thighs

b1 b2 b3

c d

b Five months postoperatively with chronic seromas outlined following multiple needle aspirations and compression as well as open drainage with a drain. c Ultrasound of seroma in right thigh at 5 months postoperatively (arrow seroma). d Ultrasound of right thigh seroma 6 ½ months postoperatively following one injection of room air into the seroma (arrow seroma). This shows a marked decrease in the size of the cavity. The left thigh was injected once with room air and had complete closure of the seroma

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a

b

Fig. 25.2. a Postoperative li- posuction and mini-abdominoplasty with bulging chronic seroma (pseudocyst) 3 months postoperatively.

b Pseudocyst following exci- sion

compression stockings (TEDS) or intermittent compression garments. Failure to warn female patients to stop estrogens at least 2 weeks prior to surgery may increase the risk of thromboembolism [13].

Thromboembolism has to be diagnosed early if death is to be prevented. Any postoperative patient who develops shortness of breath or chest pain must be considered to have possible pulmonary embolism and a ventilation-perfusion lung scan obtained. The use of intravenous heparin can be life-saving and, at times, may be started even before the confirmed diagnosis.

25.2.9 Scars

Significant scars following liposuction are not fre- quent. It is rare to see hypertrophic scars or keloids.

Poor placement of incisions may result in easily visible scars. Some scars may become depressed if the suction on the cannula is maintained each time the cannula is withdrawn from the incision. If using a machine for vacuum, either stop the machine before withdrawal or use cannulas with a hole vent in the thumb portion of the handle for easy release.

Incision sites may be irritated by the multiple fast passes of the cannula, resulting in a reddening around or in the scar. Steroid creams will resolve the problem.

The incision performed should always be slightly larger than the cannula. Some surgeons use a plastic plug in the incision while performing liposuction that will prevent the cannula from rubbing on the skin.

The use of large incisions is not indicated since most cannulas are 6 mm or less and more often than not are 4 mm or less. Some surgeons use microcannulas (under 2 mm), but this requires many more skin incisions and the liposuction takes longer to perform.

The treatment of hypertrophic or keloid scars in- cludes steroid injection, radiation, reexcision, silicone gel sheeting, pressure therapy, or a combination of these [14]. None of the treatments is effective in a large percentage of patients; however, hypertrophic scars have a tendency to resolve on their own over a period of time.

Skin necrosis will usually result in a significant scar.

Treatment may require excision and careful closure.

25.2.10

Neurologic Problems

Decreased sensation or sensory loss may occur but is almost always temporary.

Chronic pain may be due to a small neuroma but is more often due to injury to the underlying fascia or muscle. Injection of local anesthetic into the area of pain will usually relieve the complaint for a short period of time. Multiple injections may be necessary to relieve the pain permanently. A neuroma can be surgical- ly resected. If a scar in the tissues (subcutaneous fat, fascia, or muscle) is tethered to the skin, there may be chronic unrelieved pain. The pain may have to be treated by release of the scar.

25.2.11

Lidocaine Toxicity

There is very little treatment for lidocaine toxicity ex- cept for supportive methods. This problem can easily be avoided by keeping the lidocaine at a safe level through the use of less than 35 mg/kg or, when abso- lutely necessary, a maximum of 55 mg/kg in the total tumescent fluid. However, “just because a surgeon has infiltrated, without mishap, 50 – 60 mg/kg lidocaine in hundreds of cases does not necessarily imply either that such a large dose of lidocaine can be given with impu- nity, or that this dose recommendation is ’safe’” [15]. If general anesthesia is used, the lidocaine total can be much less.

A careful history must be taken to make sure the patient has not been taking cytochrome P450 inhibitors, which may result in lidocaine toxicity even with the total lidocaine dosage within the usually accepted maximum [16]. Lidocaine occurs in the body as unbound pharmacologically active lidocaine and protein bound inactive lidocaine. Factors affecting the protein binding of lidocaine include age, stress, obesity, hepatic function, renal function, cardiac disease, cigarette smoking, use of oral contraceptives, beta blockers, tricyclic de- 218 25 Prevention and Treatment of Liposuction Complications

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pressants, histamine-2-blockers, inhalation anesthet- ics, and anorexants [17]. The injection of lidocaine in small amounts as a local anesthetic has been associated with death from allergic reaction to the preservative, methylparaben.

25.2.12 Necrosis

There may be skin necrosis after liposuction if the cannula comes too close to the skin and disrupts the sub- dermal plexus of vessels (Fig. 25.3). This is more likely to occur with the use of cannulas with sharp edges and turning the openings toward the skin surface. Combin- ing excessive liposuction of the mid upper abdomen and full abdominoplasty increases the risk of necrosis of the abdominoplasty flap.

Necrotizing fasciitis has been reported following liposuction [18]. This disorder is a fulminant streptococcal group A infection or mixed bacterial infection frequently with anaerobes that involves the superficial and deep fascia, producing thrombosis of the subcutaneous vessels and gangrene of the underlying tissues.

Treatment requires surgical debridement, antibiotics, and hyperbaric therapy [19].

25.2.13

Toxic Shock Syndrome

There have been reports of toxic shock syndrome, which is a potentially fatal disorder [20, 21]. The syndrome is caused by the exotoxins (superantigens) se- creted with infection from Staphylococcus aureus and group A streptococci [22]. Knowledge of the criteria for diagnosis is important in order to treat this potentially fatal disease. These include [22]:

a b

Fig. 25.3. a Extensive necrosis of the upper abdominal wall following liposuction. b Indented scarring of the upper abdominal wall following complete healing by secondary intention

1. Fever (> 102°)

2. Rash (diffuse, macular erythroderma)

3. Desquamation (1 – 2 weeks after onset, especially of palms and sole)

4. Hypotension

5. Involvement of three or more organ systems:

a) Gastrointestinal (vomiting, diarrhea at onset) b) Muscular (myalgia, elevated CPK)

c) Mucous membrane (conjunctiva, oropharynx) d) Renal (BUN or creatinine > 2 times normal) e) Hepatic (bilirubin, SGOT, SGPT > 2 times normal) f) Hematologic (platelets < 100,000)

6. Negative results on the following studies (if obtained)

a) Blood, throat or cerebral spinal fluid (CSF) cultures

b) Serologic tests for Rocky Mountain spotted fever, leptospirosis, measles

Treatment consists of surgical debridement for necrosis, antibiotics, circulatory and respiratory care, antico- agulant therapy for disseminated intravascular coagu- lation, and immunoglobulin [23]. Experimental approaches have included use of anti-tumor necrosis fac- tor monoclonal antibodies and plasmapheresis.

25.3 Conclusions

Complications of liposuction are best avoided when possible. The surgeon should be aware of the available treatments for the various complications. It is prefera- ble not to combine large abdominal liposuction with concomitant abdominoplasty since this will increase the possibility of a variety of complications.

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References

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Ann Plast Surg 29:562 – 565

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Annu Rev Microbiol 55:77 – 104

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220 25 Prevention and Treatment of Liposuction Complications