H/T to Jeff Frentzen, PSP Blog, for the link to this article “Large Volume Liposuction - Nip/Tuck Gets It Very Wrong” by Natalie Kita (December 22, 2009)
I am not so silly as to miss seeing FX Network's plastic surgery-based drama Nip / Tuck for what it truly is: entertainment. I don't expect pinpoint scientific accuracy. However, when doing any sort of medical-based drama, doing it well requires that you must at least attempt to be somewhere in the realm of reality where the medical facts are concerned.
Last week's episode broke that rule ten times over when it portrayed a large volume liposuction case in which 150 lbs of the patient's body weight were removed during a lipo/tummy tuck combo surgery. We won't even get into the ethical considerations of sucking the fat out of a prisoner so he can be legally slim enough to receive his scheduled lethal injection. That's a blog for another day.
I have not been a fan of Nip/Tuck for several years now. This just adds to my disdain for the show. Be that as it may, lets look at liposuction.
Liposuction is a surgical procedure done for shaping, not weight loss. It is considered to be one of the most frequently performed plastic surgery procedures in the United States. Large-volume liposuction is defined as the removal of 5000 cc or greater of total aspirate during a single procedure.
A recent Aesthetic Surgery Journal article (full reference below) looked at 25 years of liposuction experience. Their experience mirrors the history of liposuction during their study period: July 1983 to January 2008. The liposuction techniques studied included dry liposuction, tumescent liposuction, tumescent UAL, and tumescent LAL. Note how the technique and safety issues evolved over time.
1983-1985 Dry liposuction with 10-, 12-, and 15–mm diameter cannulas.
1985-1987 Dry liposuction with cannula diameters reduced to 5, 6, and 8 mm. The submental area was at all times treated with a 3–mm cannula.
Liposuction was always performed in the deep plane; aspiration ceased once mostly blood was being obtained. For the first six months in which liposuction was performed, there were no parameters defining when to stop the aspiration and volumes as high as 8000 mL were obtained.
After those six months, in collaboration with the anesthesiologists, a calculation of volume reposition was made according to the aspiration obtained. For every 1000 mL extracted, there was a reposition of 1000 mL of isotonic saline solution and 1000 mL of polygeline solution (Haemaccel 3.5% colloidal intravenous infusion; Aventis, Strasbourg, France).
All patients had blood tests before surgery and 24 hours after surgery to measure hemoglobin and hematocrit values. Aspiration volumes were reduced after six months, ranging from 2000 to 4000 mL. Patients with hemoglobin values less than 8 and who experienced the symptoms of anemia (ie, increased heartbeat, low blood pressure, constant headache, dizziness, and weakness) were transfused.
1987 – present Tumescent liposuction was performed in all patients, technique evolved over time.
At first, only isotonic saline solution was administered before aspirations.
Beginning in 1989, the infiltration solution was prepared using two adrenaline ampoules (1 mg of adrenaline per each 1 mL ampoule) per 1 L isotonic saline solution. No lidocaine was added. The solution was administered in a 1:1 ratio (the amount of solution being infiltrated was approximately the same as the aspiration obtained).
Cannula diameters were reduced to 3, 4, and 5 mm. The amount of fat extraction was limited to 5000 mL.
1998 – 1999 Ultrasound-assisted liposuction (UAL) (16000 Hz) was performed.
2007 – 2008 Laser-assisted liposuction (LAL) was performed with an internal diode laser (wavelength, 660 nm; power, 130 mW).
There were no changes in infiltration solution, volume extraction, or operating time when using either tumescent solution alone versus suction-assisted-liposuction (SAL) or LAL. Both of the latter techniques were performed using an internal cannula after the tumescent solution was applied, followed by performance of SAL.
The authors state that time frame was the main criteria for which technique was used.
Most significantly, the use of tumescent liposuction reduced the incidence of anemia, but increased the incidence of seroma. The incidence of postoperative pain and fibrosis in our patients was similar regardless of the technique used. Aesthetic results using assisted liposuction devices in UAL and LAL procedures were similar to those achieved in tumescent liposuction.
The second reference article is from the ASPS Patient Safety Committee. It is a great review of liposuction and it’s risks/safety. Here is their assessment of liposuction for obesity:
Large-volume liposuction has become a technique for addressing contour irregularities, but preliminary studies also suggest improvement in cardiovascular risks, blood pressure reduction, and reduced levels of fasting insulin after liposuction. Although liposuction may provide some physiologic benefit to the obese patient, there are inherent risks in these patients that must be considered, such as poor wound healing, increased risk of infection, deep vein thrombosis, and sleep apnea. …….. Liposuction is not considered a standard treatment for obesity.
Also from the same Safety Committee Advisory:
When referring to liposuction volume, total aspirate should be the volume recorded. Some states have imposed restrictions pertaining to the aspirate volume and surgical facility; these limits range from 1000 to 5000 cc (e.g., California, Florida, Kentucky, New York, Ohio, and Tennessee). Surgeons should consult their individual state regulations; however, it is the position of American Society of Plastic Surgeons that, regardless of the anesthetic method, large-volume liposuction (>5000 cc of total aspirate) should be performed in an acute-care hospital or in a facility that is either accredited or licensed. Postoperative vital signs and urinary output should be monitored overnight in an appropriate facility by qualified and competent staff members who are familiar with the perioperative care of the liposuction.
It must be remembered that liposuction is surgery. As with all surgeries, complications can occur. Minor complications that resolve on their own or with little additional treatment include small hematomas, seromas, and minor contour irregularities. More severe complications are rare, but include skin perforation, major contour defects, skin necrosis, thermal injury, vital organ injury, adverse anesthesia reaction, major hemorrhage, ischemic optic neuropathy, deep vein thrombosis, pulmonary embolism, and fat embolism.
Liposuction: 25 Years of Experience in 26,259 Patients Using Different Devices; Aesthetic Surgery Journal, Vol 29 (6), pp 509-512; Lina Triana, Carlos Triana, Carlos Barbato, Marco Zambrano
Evidence-Based Patient Safety Advisory: Liposuction; Plastic and Reconstructive Surgery. 124(4S):28S-44S, October 2009; Haeck, Phillip C.; Swanson, Jennifer A.; Gutowski, Karol A.; Basu, C Bob; Wandel, Amy G.; Damitz, Lynn A.; Reisman, Neal R.; Baker, Stephen B.; the ASPS Patient Safety Committee