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Liposuction has become one of the most popular cosmetic procedures performed by board-certified plastic surgeons in the United States.
Liposuction has evolved over the last several decades, with the introduction of tumescent and superwet techniques, ultrasonic liposuction, power-assisted liposuction, and, more recently, laser-assisted liposuction (see the images below). Highly emulsified fat with high fat-to-fluid ratio with VASER ultrasonic-assisted liposuction and standard tumescent suction-assisted liposuction . Unfortunately, the increasing number of potential patients makes it relatively easy for inadequately trained or inexperienced physicians to encounter disastrous complications or even death when performing large volume liposuction. To minimize the risk of death and disastrous complication during large volume liposuction, 5 pillars of safety must be strictly adhered to. The surgeon must be properly trained and educated in liposuction techniques and have a thorough understanding of the physiologic changes that occur with regular and large volume liposuction.
The anesthesiologist working with the surgeon also must be well trained and have a complete understanding of the physiology associated with infusion and removal of large volumes of fluids. The facility where the procedure is performed must be completely equipped to deal with any problem or complication that may occur during or after the procedure. The support staff working in the operating room and recovery room should be thoroughly trained and familiar with the procedure, care, and recovery of the patient. Deviation from any one of these pillars can lead to serious complications or death of the patient. In evaluating each patient, careful patient selection is extremely critical in large volume liposuction.
Failure to detect underlying cardiovascular, pulmonary, renal, hepatic, or thyroid disease can lead to fatal complications. Candidates for large volume liposuction should be in a healthy state both physically and mentally. General endotracheal anesthesia administered by a board-certified anesthesiologist is the preferred method of anesthesia for large volume liposuction. Healthy patients within this range postoperatively do not exhibit signs of intravascular volume depletion or overload. Positive-pressure ventilation during anesthesia and increased circulating levels of epinephrine may alter renal blood flow and cause oliguria, which can persist postoperatively.
Patients may be admitted for overnight nurse observation and care for a number of reasons, including a history of underlying medical problems (eg, asthma, sleep apnea, cardiovascular or pulmonary problems), lack of competent adult supervision, patient convenience, multiple surgical procedures, or extensive surgical operating room time. Pneumatic compression devices are used for all patients undergoing large volume liposuction. Attention to body temperature is crucial during large volume liposuction for a number of reasons. Admit patients undergoing large volume liposuction to the recovery room for approximately 1.5-2 hours for close monitoring of hemodynamics, pulmonary function, and fluid balance. Patients usually are seen in the office 24-48 hours later for instruction on how to change the garments. Complications in large volume liposuction are the same as with smaller volume liposuctions and other surgical procedures. Major complications following large volume liposuction tend to be rare and can be minimized by adhering to the 5 pillars of safety (ie, safe surgeon, safe anesthesiologist, safe facility, safe coworkers, properly selected patient). Apply ultrasonic energy only in a wet environment, and always keep the ultrasound probe moving. Large volume liposuction can be performed safely if certain guidelines are followed.[11] Properly selected patients who have a good understanding of the expectations and limitations of the procedure tend to be very satisfied with the results. A retrospective series evaluated 631 consecutive patients who underwent liposuction procedures of at least 3000 mL total aspirate.[12] Average follow-up was 1 year.
The results show that large volume liposuction can be a safe and effective procedure when patients are carefully selected and when anesthetic and surgical techniques are properly performed. In addition to these basic pillars, several other issues are worth repeating to ensure a safe outcome. Compressive postoperative garments always are worn to minimize postoperative bleeding, swelling, and third spacing of fluid. Ultimately, the long-term results following large volume liposuction depend on the preoperative condition of the patient's skin, the patient's overall health and expectations, and the ability of the patient to maintain a healthy weight and lifestyle postoperatively.
Recently, authors presented a preliminary study investigating the effects of large volume liposuction on the parameters that determine type 2 diabetes. The data reveal a trend of improvement in blood glucose levels associated with weight loss that helps the patients.
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author M Dean Vistnes, MD, FACS, to the development and writing of this article. Medscape's clinical reference is the most authoritative and accessible point-of-care medical reference for physicians and healthcare professionals, available online and via all major mobile devices. The clinical information represents the expertise and practical knowledge of top physicians and pharmacists from leading academic medical centers in the United States and worldwide.
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Access health plan drug formulary information when looking up a particular drug, and save time and effort for you and your patient. Medscape Reference features 129 medical calculators covering formulas, scales, and classifications. Hundreds of image-rich slideshow presentations visually engage and challenge readers while expanding their knowledge of both common and uncommon diseases, case presentations, and current controversies in medicine. Click on citations within drug and disease topics in our clinical reference to review the clinical evidence on MEDLINE. Medscape is the leading online destination for healthcare professionals seeking clinical information. All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. Safe technique of liposuction under local anesthesia that can be performed in an office based setting. Physicians need to be aware there are safer and more practical anesthesia methods for office-based procedures. Select appropriate surgery candidates; perform tumescent anesthesia, liposuction and post-op care. Evaluate and assess the various types of surgical procedures for which tumescent anesthesia can be used as a more effective and safer method of anesthesia and decrease complications.
In compliance with the Americans With Disabilities Act, we will make every reasonable effort to accommodate your needs. Tumescent liposuction totally by local anesthesia is about safety, finesse, gentleness, and optimal cosmetic results.

Although liposuction is not a technically difficult procedure, it requires thoughtful planning and an artistic eye to achieve aesthetically pleasing postoperative results.
These advances have made the removal of larger volumes of fat with less blood loss easier and safer. Conversely, experience has shown that when properly trained surgeons perform large volume liposuction under ideal conditions, it is a safe and effective procedure for removing excess fat with low complication and morbidity rates. The facility should be certified and accredited by a nationally recognized surgery accreditation body. In the authors' practice, patients are admitted overnight for observation if more than 5 L of lipoaspirate have been removed. Many overweight patients may actually be poor candidates for the procedure for physiologic or psychological reasons. Patients should be in either American Society of Anesthesiologists (ASA) class I (healthy with no medical problems) or ASA class II (medical problems well controlled on medications). A patient with a history of sleep apnea is at increased risk of fatal complications during the postoperative period. A balanced anesthetic consisting of narcotic, midazolam, propofol, and an inhalational agent is used for most patients.
The residual volume is the difference between all fluids received by the patient and the total saline and urine output of the patient. For this theory to be valid, using appropriate compression garments is essential to minimize fluid sequestration into the tissues, as is closing access incisions to prevent wound drainage. Exercise caution in the healthy oliguric patient with normal hemodynamics and a normal-to-high residual volume in the recovery room.
Furthermore, overnight care and registered nurse observation facilities should be available for all patients, although these are not necessary for everyone.
Postoperative monitoring during overnight stays should include pulse oximetry, hemodynamic monitoring, and fluid volume status in addition to control of postoperative pain and nausea.
If prone positioning is anticipated, the patient undergoes induction of general anesthesia on the gurney and then is turned to the prone position. Patients are at increased risk of hypothermia due to exposure of large body surface areas, infusion of large volumes of wetting solutions, and long operative procedures. These can be divided into minor and major complications and are medical or aesthetic in nature. The incidence of pulmonary embolus, deep venous thrombosis, major infection, penetration injuries, skin or soft tissue necrosis, bleeding, pulmonary edema, hypovolemic shock, fat emboli, drug toxicity (epinephrine or lidocaine), unplanned blood transfusion, and mortality is uniformly low or absent in almost every large series of patients who have undergone large volume liposuction.
These include minor aesthetic contour irregularities, prolonged swelling, scar tissue formation, minor wound healing problems, seromas, sensory changes and discomfort, hyperchromia, and blistering of the skin from garment irritation or ultrasonic liposuction. Importantly, physicians who are considering performing large volume liposuction must understand the physiology and differences from smaller volume liposuction.
Meticulous fluid balance calculations are necessary to avoid volume abnormalities, and experience is mandatory when performing the largest aspirations. The surgeon first must be well trained in smaller volume liposuction and have a thorough understanding of the physiologic implications of infusing and suctioning large amounts of fluids from the body. Finally, attention must be paid to maintaining the patient's core body temperature using heating blankets on the table, minimizing body exposure, using Bair Hugger-type warming blankets, and using warmed wetting solution. Whenever in doubt, consider staging procedures in terms of multiple liposuction procedures or combining the liposuction with other procedures. The average blood glucose level dropped 18% in the return patients, and the average weight loss was 9.2%. The importance of preoperative hemoglobin evaluation in large volume liposuction: lessons learned from our 15-year experience. Extending the role of liposuction in body contouring with ultrasound- assisted liposuction.
Hemodynamic Changes and Fluid Shifts After Large-Volume Fluid Infiltration: Results From a Porcine Model. Metabolic effects of large-volume liposuction for obese healthy women: a meta-analysis of fasting insulin levels. Topics are richly illustrated with more than 40,000 clinical photos, videos, diagrams, and radiographic images. The articles assist in the understanding of the anatomy involved in treating specific conditions and performing procedures. Check mild interactions to serious contraindications for up to 30 drugs, herbals, and supplements at a time. Plus, more than 600 drug monographs in our drug reference include integrated dosing calculators. Liposuction is a medium of artistic expression that displays itself in the." practical application of scientific knowledge, the production of what is beautiful, the perfection of workmanship, and the continuing improvement in technique. The goal of the liposuction surgeon is to remove "target" fat, leaving the desired body contour and smooth transitions between suctioned and nonsuctioned areas. However, large volume liposuction is a more complex and physiologically different procedure than traditional liposuction, in which small volumes of fat are removed.
The most common definitions refer to either total fat removed during the procedure (eg, 4 L of fat removal) or total volume removed during the procedure (fat plus wetting solution, eg, 5 L of total volume removal).
Failure to exclude these patients can lead to clinical and aesthetic disasters and unhappy patients. Patients with uncontrolled medical problems are not candidates for large volume liposuction.
Patients must have an adequate cardiopulmonary reserve to handle the large volumes of wetting solution that are typical with large volume liposuction. Patients who are experiencing rapid or persistent weight gain should be started on a program of exercise and nutritional modification before being accepted as surgical candidates.
Offering elective aesthetic surgery to patients with body dysmorphic disorder or eating disorders should be avoided.
Intraoperative monitoring includes noninvasive blood pressure monitoring, ECG, pulse oximetry, temperature, end-tidal carbon dioxide measurements, and monitoring of urine output with Foley catheter in all patients. The authors' experience and research support the use of room-temperature tumescent fluid to minimize the risk of ultrasound-induced subcutaneous tissue elevation while maintaining stable core body temperature. Fluid received includes IV fluid, crystalloid wetting solution, and any infused posttreatment bupivacaine solution.
A small dose of IV furosemide (Lasix; 5 mg) often can stimulate a brisk diuresis in these patients. Young healthy patients with no underlying medical problems should recover uneventfully as long as intelligent and competent adult help is available during the entire first 24 hours following surgery.
The ankle compression devices are equally as effective as the longer calf compression devices and are particularly useful when the patient is undergoing knee or calf liposuction.
A well-trained and competent recovery room staff of registered nurses is essential when providing postoperative care to a patient who has undergone large volume liposuction.
Because patients who have undergone large volume liposuction may have more problems with skin elasticity and redundancy at the start, a higher incidence of aesthetic contour-related problems may exist.
Physicians who have little or no experience with large volume liposuction or those who do not adhere to the 5 pillars of safety are at significantly higher risk of a patient experiencing a major complication or death following this type of procedure. Applying the same standards and treatment parameters as with small volume liposuction may result in death and disaster.

Cases should be scheduled and performed such that incrementally larger volumes of fat are removed as the physician gains experience. Patients should be psychologically stable with good diet and exercise habits or evidence of motivation toward these habits. The tumescent technique of injecting very large volumes of wetting solution must be avoided in large volume liposuction, as this invariably leads to fluid overload and its associated problems.
Customize your Medscape account with the health plans you accept, so that the information you need is saved and ready every time you look up a drug on our site or in the Medscape app. Norma Kassardjian’s education, training, publications and more, please refer to their Curriculum Vitae. Careful selection of patients and proper surgical technique help avoid contour irregularity, and diligent perioperative care of the patient helps avoid postoperative complications. Because many of the complications associated with large volume liposuction are related to fluid shifts and fluid balance, classifying the procedure as large volume based on the total volume removed from the patient, including fat, wetting solution, and blood, makes more sense.
Do not offer noncompliant or poorly motivated patients large volume liposuction as a sole means of reducing their weight.
If the patient has reasonable expectations that agree with technically achievable results, the patient undergoing large volume liposuction tends to be very happy.
Continuous communication between the surgeon and anesthesiologist is essential to avoid problems.
The authors recommend infiltration of wetting solution at a 1:1 ratio, ie, the superwet technique. Add these together and then subtract the urine output and the saline portion of the aspirate (do not include the fat). As with any situation, careful clinical evaluation of the patient and all the available data should be made before embarking on a course of treatment.
Animal studies have shown that hemodynamic parameters return to baseline 20 hours following tumescent fluid infiltration. This helps minimize heat loss and protects sensitive pressure points (eg, occiput, knees, elbows, heels, iliac crest, breasts, genitals).
Low molecular weight dextran or heparin typically is not used or required during these procedures. Numerous problems that may occur during surgery (eg, cardiac dysrhythmias, coagulopathies, oliguria, electrolyte imbalances) can be intensified or worsened by hypothermia. The Foley catheter usually is left indwelling overnight for patient convenience and to monitor diuresis.
Generalized postsurgical edema often can be treated in healthy patients with a mild diuretic 48 hours postoperatively. Good preoperative patient counseling and declining to operate on poor candidates can minimize these types of complications. The anesthesiologist, present on every case, likewise must have a complete understanding of the procedure and be well trained to handle preoperative, perioperative, or postoperative problems. Instead, the superwet technique of fluid infiltration, in which volume infused is roughly equal to total volume removed (1:1 ratio), should be practiced.
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To resolve this conflict of interest, he will refrain from making recommendations regarding products that HK Surgical sells during his teaching, and will support his presentation and clinical recommendations with the best available evidence from the medical literature. Over-the-counter and prescription diet medications should be discontinued at least 2-3 weeks prior to surgery.
The key is to address preexisting skin contour irregularities, asymmetries, skin laxities, and redundancies in helping the patient understand what kind of result will be obtained.
The difference is the residual crystalloid volume that remains in the patient, which acts as the fluid resuscitation source for the patient during the postoperative period. In one porcine model, animals were able to tolerate large fluid challenges delivered by clysis with statistically significant but only modest increases in hemodynamic parameters, which gradually returned to baseline within 20 h.[8] Therefore, 24-h observation is important in large volume liposuction patients.
Take care to avoid traction or pressure on the brachial plexus, ulnar nerve, or other large nerves. Use of the compression devices is continued through the recovery room phase and overnight if the patient is admitted.
If questions arise concerning the patient's fluid status while in the recovery room, use the residual volume theory and the patient's clinical status to determine whether the patient is hypervolemic or hypovolemic. The facility where the procedure is performed should be accredited, properly equipped, and have experience with large volume liposuction procedures. With this in mind, remember that enough wetting solution with epinephrine should be infused to maintain an essentially bloodless aspirate.
The authors hypothesize that large volume liposuction in their series may have motivated some to diet, which could be explored in a larger series with control groups. In these cases, the possibility of secondary procedures and touch-up procedures should also be emphasized. The anesthesiologist should be provided with a running balance of wetting solution infused, fat and saline aspirated, blood loss, and urine output. Tape the eyes shut after placement of ophthalmic lubrication and place the head on a gel horseshoe headrest to take pressure off the eyes and stabilize the head against liposuction-induced motion. Otherwise, encourage patients to begin ambulation as soon as possible and instruct them in lower extremity muscle-contracting exercises while they are in bed to minimize the risk of deep venous thrombosis and pulmonary embolus.
In addition to a heating blanket on the bed, a hot air blanket (eg, Bair Hugger type) is used to cover nonsurgical areas during the procedure. Overnight care facilities must be available with registered nursing care and the appropriate monitoring equipment.
Liposuction alone did not improve obesity but helped to motivate some of the patients to lose weight.
Klein further discloses that he will be discussing the use of an unlabeled drug: Lidocaine. Careful monitoring of these variables and of intravenous (IV) fluid gives the anesthesiologist an accurate idea of the patient's fluid balance and should avoid the problem of fluid overload or hypovolemia. Protection against corneal abrasion is important when the patient is in the prone position and during long procedures. Support staff at every level of the procedure, from the preoperative phase through recovery, must be competent and experienced.
In such cases, either the procedure should be terminated or more wetting solution should be infused for added hemostatic effect from the epinephrine. Use gel chest rolls for positioning and immobilization of the patient when in the prone position.
The majority of the complications consisted of minor skin injuries and burns, allergic reactions to garments, and postoperative seromas. The more serious complications included 4 patients who developed mild pulmonary edema and 1 patient who developed pneumonia postoperatively.

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