Wednesday, July 16, 2008

Major and Lethal Complications of Liposuction -- An Article Review

I would like to begin this post by saying that I think liposuction is safe when done under the proper conditions by a trained surgeon and for the correct patient. So for all you non-medical types, if you continue to read this, please keep that in mind. I also feel that it is important for anyone who tries to improve their skills/knowledge to be willing to look at outcomes (good and bad) and assess them critically.

The first article referenced below was written by German surgeons and is the article I am reviewing here. Apparently their patients, like the ones in America, feel that liposuction is a minor surgery. Their opening comments could easily apply here in the United States.

The number of aesthetic surgical procedures performed in Germany is increasing rapidly. In 2003, earnings derived from this market totaled more than €1 billion. Suction-assisted lipectomy (liposuction) is the most frequent cosmetic procedure in the United States and Germany. Approximately 200,000 procedures were performed in Germany in 2003. Liposuction is lucrative and, because of the lack of restrictive legal guidelines, the procedure is increasingly performed by nonplastic surgeons and nonphysicians, some of whom have little more experience than a weekend seminar. Thus, liposuction is often performed as an outpatient service in an office setting. The public perception of liposuction as minor cosmetic surgery fails to consider the possibility of major complications with potentially fatal consequences.

And again I would agree with this statement.

Case reports of disastrous complications in the scientific and public media are most often related to the physician's expertise and experience, technical deficiencies, aseptic standards, tumescent anesthesia with or without intravenous sedation, fluid overload, major liposuction, multiple procedures in one setting, embolism, postoperative monitoring, bilateral visual loss, and others. Desrosiers et al. in 2004 reported a case of liposuction performed by an unqualified physician in a kitchen leading to necrotizing fasciitis.

I would commend them on looking at this topic. It is unfortunate that it isn't a prospective, controlled study, but it's a start and a reminder that all procedures have complications. To find the true rate of complication we have to be more forthcoming in reporting them.

As fatalities and major complications from liposuctions in Germany have been reported only as case reports and because of the lack of scientific data, we conducted the first nationwide survey of such incidents.

Two thousand two hundred seventy-five questionnaires were returned (65 percent), which contained 72 severe complications, including 23 fatalities following cosmetic liposuction. Sixty-nine of the 72 cases occurred in Germany, two cases occurred in Austria, and one case occurred in Switzerland. All 72 procedures took place within a 5-year period from 1998 to 2002.

Here is a list of the Collected Complications:

Bacterial Infection--There were 29 cases of bacterial infection (out of 2275 procedures--I will repeated note this number to try to keep things in perspective).

  • Necrotizing fasciitis -- the most frequent with 14 of the 29 cases. Despite the fact that nine of these 14 patients had the liposuction performed in an office setting, there was no evidence of any conspicuous deviation of hygienic standards.
  • Sepsis -- Thirteen patients (out of 2275 cases) experienced various types of sepsis. Five of these 13 patients died.
  1. Streptococci -- six of these 13 cases
  2. Toxic Shock Syndrome -- caused by infection with Staphylococcus aureus was reported in five cases.
  • Gas Gangrene -- Two cases of gas gangrene were found (out of 2275 procedures)

Skin Necrosis (Abdominal Wall) -- There were 10 cases (out of 2275 procedures) of skin necrosis reported. All were located at the abdominal wall region and occurred as a result of a very superficial suction technique.

Perforation of Abdominal Viscera--occurred in nine cases (out of 2275 procedures. Three patients died after developing peritonitis.

Data from a large study showed that one of seven liposuction fatalities was attributable to perforation injuries, which makes intraperitoneal trauma a major risk factor for this procedure. (reference to the 3rd article listed below)

  • Perforation of Small Intestine-- 7 of the 9 cases
  • Perforation of Gallbladder -- 1 of the 9 cases
  • Perforation of Superior Epigastric Artery -- 1 of the 9 cases

Embolism -- All of these cases (8 out of 2275 procedures)demonstrated significantly high suction volumes between 4 and 6 liters in combination with operation times of more than 4 hours. General anesthesia was used in all cases with ensuing embolism. There was no individual or family history indicating a thromboembolic disposition or any evidence of a preexisting bleeding disorder. Two patients in this group died.

  • Pulmonary Embolism-- was evident in seven cases. A deep vein thrombosis was detectable in five cases following liposuction of the lower extremities.

Pulmonary embolism accounts for approximately one of every four liposuction-associated fatalities in different reports. Almost every embolism reported after liposuction occurred after an extensive procedure performed under general anesthesia. The operation time in all six cases with embolism in this study was more than 4 hours.

  • Arterial Embolism --One case of arterial embolism was followed by gangrene of the forefoot.

Hemorrhages -- There were seven (out of 2275 procedures).

A combination of high-volume liposuction (2.5 to 24 liters) with prolonged total operation time (3 to 8 hours) was found in all seven cases with significant hemorrhages. Excessive bleeding was found in four cases. In one case, the surgeon used a combination of tumescent and general anesthesia to perform an 8.5-hour procedure producing a suction volume of 24 liters. Still, the patient survived a disseminated intravascular coagulation, a prolonged intensive care unit stay, and the formation of a massive seroma.

Cardiac Arrest -- Six patients (out of 2275 procedures) sustained a cardiac arrest.

However, because of the incomplete documentation, the exact circumstances remain elusive. Tumescent anesthesia and intravenous sedation was used in four of these six cases. Two patients died secondary to intraoperative cardiac arrest under general anesthesia. Again, the circumstances and causes of this particular case remain obscure. Lidocaine was not used in excessive dosages in any of these six cases.

Fluid Imbalance Issues

  • Hyperhydration (Pulmonary Edema) -- 2 cases (out of 2275 procedures)

Patients with obvious cardiovascular disease are classified as American Society of Anesthesiologists class III or IV, which represents an absolute contraindication for cosmetic liposuction. Nevertheless, in this survey, we found two liposuction patients with documented American Society of Anesthesiologists class III who suffered pulmonary edema following intravenous infusion of more than 3 liters, which required intensive care unit therapy.

  • Hypohydration (Shock, Epilepsy) -- 3 cases (out of 2275 procedures)

In turn, three patients experienced severe consequences from inadequate intraoperative hydration and developed shock, epilepsy, and a stroke, respectively.

Conclusions

1. Liposuction is a surgical procedure and must be performed under aseptic conditions.

Liposuction can create a wound area of up to 1 m2 between skin and muscle fascia that can act as an ideal growth medium for bacteria. Liposuction is not a harmless procedure but a surgical intervention necessitating aseptic standards as in any other elective surgical procedure. Almost all cases of necrotizing fasciitis in this survey had become clinically evident within the first 24 hours after surgery, which should serve as a reminder to reexamine all liposuction patients within this time period.

2. A preoperative medical history and a physical examination of the patient needs to be done before surgery. We surgeons need to make sure the patient is healthy "enough" to have the proposed surgery.

3. Give consideration to seeing liposuction patients for follow-up within 24 hours after discharge to look for early signs of problems. I think this is extremely important if superficial liposuction (for extreme sculpting) is done or large area/volume is done. Remember that:

Liposuction can create a wound area of up to 1 m2 between skin and muscle fascia that can act as an ideal growth medium for bacteria. Liposuction is not a harmless procedure but a surgical intervention necessitating aseptic standards as in any other elective surgical procedure. Almost all cases of necrotizing fasciitis in this survey had become clinically evident within the first 24 hours after surgery, which should serve as a reminder to reexamine all liposuction patients within this time period.

4. Proper training for liposuction, as with any surgical procedure, includes being able to recognize complications and treating them when they occur. Most of the complications listed above (and in other articles) occur when one or more of the following occur

  • High volume liposuction is done (more than 4 Liters removed)
  • Poor technique is used (no excuse in my book for ever perforating an intra-abdominal structure).

The development of skin necrosis following liposuction is almost always a consequence of poor surgical technique. In particular, a very superficial suction technique will regularly result in the destruction of the subcutaneous vascular system.

  • Combination of surgeries done at one time--The surgeon should add up the estimated blood loss and time of each procedure. It is often just safer to do things in stages. Better to "inconvenience" the patient than to have one die.
  • Saying yes to a patient who is not a candidate (see above under the pulmonary edema section). It is the surgeon's duty to say no when the procedure is elective and the patient is not a candidate (for whatever reason--not healthy enough, wrong expectations, etc).

REFERENCE

1. Major and Lethal Complications of Liposuction: A Review of 72 Cases in Germany between 1998 and 2002; Journal of Plastic and Reconstructive Surgery, 121. 396e. 2008; Marcus Lehnhardt, M.D.; Heinz H. Homann, M.D.; Adrien Daigeler, M.D.; Joerg Hauser, M.D.; Patricia Palka, M.D.; Hans U. Steinau, M.D.

2. Don't Try This at Home: Liposuction in the Kitchen by an Unqualified Practitioner Leads to Disastrous Complications. Plast. Reconstr. Surg. 113: 460, 2004; Desrosiers, A. E., III, Grant, R. T., and Breitbart, A. S.

3. Fatal Outcomes from Liposuction: Census Survey of Cosmetic Surgeons; Plast. Reconstr. Surg. 105: 436, 2000; Grazer, F. M., and de Jong, R. H.

4. Physician Profile: Dr. Jeffrey Klein; Pioneer explores tumescent local anesthesia with subcutaneous; Vein Therapy News, Vol 1, No 4, June/July 2008 (a interesting look at Tumescent infiltration)

4 comments:

JC Jones MA RN said...

Very sobering...thanks for sharing the information...jc

Laser clinic MD said...

My niece ran into complications. The doc treating her was something of an ass. When she was admitted to the ER after four days, refused to see her. Perhaps the worst patient care I've ever personally witnessed.

Stefan Nicolau said...

The study says "the authors sent 3500 questionnaires to departments of pathology and forensic medicine, intensive care units, and others." The 72 complications reported are not out of 2275 liposuctions, but out of 2275 centres that were asked to report if they had seen any liposuction-related complications. (1% mortality would have been incredibly high) Nevertheless, this emphasises that liposuction is surgery and can cause severe complications.

Dr. Amy T. Bandy said...
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