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10 Large-Volume Liposuction
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10.19 Large-Volume Liposuction Is Claimed
toHelp [3]
• Decrease pulse rate over 6weeks and 4 months postoperative period.
• Decrease blood glucose levels over 4months postoperative period.
• Decrease serum creatinine and blood urea over 6weeks
and 4months postoperative period.
• Serum total protein and albumin decrease in 6 weeks
postoperative period.
10.20 Liposuction forChronic Medical
Diseases andNoncosmetic
Conditions: Review oftheLiterature
[12]
10.20.1 Liposuction Is aTreatment Option
forSeveral Conditions
1. Multiple systemic lipomatosis
2. Dercum’s disease
3. Subcutaneous lipomas
4. Posttraumatic lipomas
5. Chronic lymphedema
10.21 Summary
Large-volume liposuction procedures are usually ambitious. A
two-stage procedure is much safer. But, given certain advantages the large-volume liposuction has, it cannot be totally
ignored. Large-volume liposuction can be performed if the surgeon is familiar and comfortable with the procedure in a hospital setting and not as a daycare facility. For a novice surgeon, it
should be avoided or done with utmost caution.
10.21.1 Pearls ofWisdom
The maximum amount of lipoaugmentation done by me was
24L in one sitting. This was back in 2005 and had I known
what I know today I probably would not have done it. Today
my lipoaspirate would be 5 L or less and a maximum of
7–8L in a hospital setting with all the precautions in place
including lipoaspirate and infusion versus urine output in the
ratio of 1:1 and a small dose of Furasemide prior to the end
of the case. Experience does matter both for the surgeon and
the anesthesiologist to keep large-volume liposuction safe.
Standard BIG FIVE for better results
• Marking, positioning, and safety of vital structures.
• Sequential inltration as a “Super wet” technique.
• End-point of liposuction is indicated when pinch test less
than 1in. and/or change of feeling from soft to gritty sensation and/or aspirate mixed with blood.
• Limit the number of areas but evacuate completely in the
selected areas.
• Prevent DVT, third spacing, and hypothermia.
References
1. Sood J, Sethi N, Jayaraman L. Liposuction: anaesthesia
challenges. Indian J Anaesth. 2011;55(3):220. https://doi.
org/10.4103/0019- 5049.82652.
2. Kanapathy M, Pacico M, Yassin AM, Bollen E, Mosahebi
A.Safety of large volume liposuction in aesthetic surgery: a systematic review and meta-analysis. Aesthet Surg J. 2021;41(9):1040–53.
https://doi.org/10.1093/asj/sjaa338.
3. Saleh Y, El-Oteify M, Abd-El-Salam A-E-R, Tohamy A, AbdElsayed AA. Safety and benets of large-volume liposuction: a
single center experience. Int Arch Med. 2009;2(1):4. https://doi.
org/10.1186/1755- 7682- 2- 4.
4. Kenkel JM, Brown SA, Love EJ, Waddle JP, Krueger JE,
Noble D, et al. Hemodynamics, electrolytes, and organ histology of larger-volume liposuction in a porcine model. Plast
Reconstr Surg. 2004;113(5):1391–9. https://doi.org/10.1097/01.
prs.0000112748.48243.62.
5. Granados-Tinajero S, Buenrostro-Vásquez C, Cárdenas-Maytorena
C, Contreras-López M.Anesthesia management for large-volume
liposuction. In: Anesthesia topics for plastic and reconstructive surgery. London: IntechOpen; 2019. https://doi.org/10.5772/
intechopen.83630.
6. Kenkel JM, Lipschitz AH, Shepherd G, Armstrong VW, Streit F,
Oellerich M, Luby M, Rohrich RJ, Brown SA.Pharmacokinetics
and safety of lidocaine and monoethylglycinexylidide in liposuction: a microdialysis study. Plast Reconstr Surg. 2004;114(2):516–
24. https://doi.org/10.1097/01.prs.0000128423.84607.61;
discussion 525–6. PMID: 15277825.
7. Slotman GJ, Jed EH, Burchard KW.Adverse effects of hypothermia in postoperative patients. Am J Surg. 1985;149:495.
8. Lang S, Lanigan D, van der Wal M. Trigeminocardiac reexes:
maxillary and mandibular variants of the oculocardiac reex. Can J
Anaesth. 1991;38(6):757–60. https://doi.org/10.1007/BF03008454.
9. Rohrich RJ, Leedy JE, Swamy R, Brown SA, Coleman J.Fluid
resuscitation in liposuction: a retrospective review of 89 consecutive patients. Plast Reconstr Surg. 2006;117(2):431–5. https://doi.
org/10.1097/01.prs.0000201477.30002.ce. PMID: 16462322.
10. Habbema L. Safety of liposuction using exclusively
tumescent local anesthesia in 3,240 consecutive cases.
Dermatol Surg. 2009;35(11):1728–35. https://doi.
org/10.1111/j.1524- 4725.2009.01284.x.
11. Thomas M, etal. Surgical complications of lipoplasty—management and preventive strategies. J Plast Reconstr Aesthet Surg.
2010;63(8):1338–43. https://doi.org/10.1016/j.bjps.2009.06.046.
12. El-Khatib HA.Liposuction for chronic medical diseases and noncosmetic conditions: review of the literature. Plast Aesthet Res.
2015;2:1–6.
Complications inBody Contouring
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GuillermoBlugerman
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11.1 Anesthetic Complications [1–11]
Discussion about complications of general anesthesia is a
very extensive chapter and is beyond the scope of this work.
What is important in this regard is that the anesthesiologist is
accustomed to the technique used by the surgeon primarily if
he is working with large-volume tumescent anesthesia inltrations to avoid over-hydration of the patient and the consequent pulmonary edema that could prove fatal. When general
anesthesia is combined with tumescent liposuction, the infusion of intravascular uids should be restricted to a minimum. Prevention, diagnosis, and treatment of pulmonary
edema belong to the realm of the anesthesiologist and the
clinical team that follows the patient in the immediate postoperative period.
11.2 Lidocaine Toxicity [1–11]
Lidocaine is metabolized in the liver by cytochrome P450
and so it is important that the liver function is normal and this
is preserved. It is essential to rule out the use of drugs by history that could use the same metabolization pathway and
thus cause an elevation of the plasma level of lidocaine by
slowing down or blocking its metabolism. Drugs that interfere with the metabolism of lidocaine are numerous and of
different families. They are attached in a table below and
have to be consulted during the medical consultation.
In countries where prilocaine is available, it is ideal to use
the “Hamburg formula” that reduces the total dose of lidocaine and prilocaine thus reducing the risks of toxicity of
both drugs. Prilocaine is metabolized at the renal level and so
it does not interfere with lidocaine metabolism. Lidocaine
toxicity occurs when the serum levels reach greater than
6 mg/L of blood, and the symptoms go through different
stages. It is very important to be attentive to what the patient
is complaining about as tingling sensations or changes in
mood or taste (metallic taste in the mouth) is one of the rst
symptoms or signs of lidocaine poisoning.
The second most common symptom is the appearance of
delusion or abnormal attitudes with a state that may be
humorous or what the patient may be talking about.
By the use of general anesthesia, doses of lidocaine can
be reduced or eliminated to avoid toxicity, as we do not have
the signs and symptoms that can only be referred to us by an
awake patient.
In the face of the onset of symptomatology for toxicity,
we must resort to the treatment of overdose through the use
of the most appropriate medication. At this point, it is prudent to introduce “the Intralipid 20 protocol” as shown in
Fig.11.1. The protocol in different languages can be downloaded from the website www.lipidrescue.org.
If the poisoning is by prilocaine the rst symptom that is
usually recognized is cyanosis in the nails caused by the production of methemoglobin, the medical treatment of which
consists of the endovenous injection of methylene blue.
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_11].
G. Blugerman (*)
B & S Center of Excellence in Plastic Surgery, Buenos Aires,
Argentina
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_11
193
194
Lipid Rescue
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1.5 mL/kg 20% lipids in fast
injection during 1 minute
Treatment for local anesthetic-induced systemic toxicity and cardiac arrest
In the event of severe toxicity or cardiac arrest, besides de initial measures
and/or cardiopulmonary resuscitation, administer specific treatment
with 20% lipids
Followed immediately
by a 0.25 mL/Kg/min infusión
A rapid injection may be repeated
every 3-5 minutes, maximum
3 mgL/kg total dose in a rapid
injection until spontaneous
circulation return.
achieved (even up to several
circulation return. Infusion may
be increased to 0.5 mL/Kg/min
G. Blugerman
Continue the infusion until
hemodynamic stability is
minutes after spontaneous
if blood pressure drops.
The total maximum recommended dose is 12 mL/Kg (lean weight)
Never exceed a total dose of more than 1000 mL
Fig. 11.1 Intralipid infusion recommendation
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Cytochrome P450-mediated drug interactions affecting lignocaine
Taken from- Improved Predictions of Drug-Drug
Interactions Mediated by Time-Dependent Inhibition of
CYP3A.Jaydeep Yadav, K.Korzekwa, S.Nagar Chemistry,
Medicine Molecular pharmaceutics 2018.
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G. Blugerman
11.3 Dissatisfaction withtheResults [12, 13]
The second most important concern that needs to be discussed
is the patient’s dissatisfaction with the results. It is a very
broad topic that begins at the rst consultation and has to do
with knowing how to assess and manage the expectations of
the patient which he/ she has regarding the results and is it
possible to achieve in this particular case. It is very important
that the patient has realistic expectations based on the information they receive from the professional who is evaluating
it. If we will not be able to achieve patient satisfaction with
non-surgical methods, then one can suggest a surgical option
which should preferably be very conservative. Note that the
discussion should be well balanced and clear and the suggestion should be based on the medical history so as not to have
subsequent legal issues. Muscle tonicity and the presence of
lymphatic drainage pathologies should be evaluated at the
time of consultation. In the abdomen, it is very important to
diagnose the presence of hernias and diastasis of the rectus
muscles following previous pregnancies.
During the physical examination, the skin elasticity,
stretch marks, and folds should be evaluated in order to
achieve the best result. Metabolic and nutritional diseases
related to bulimia, anorexia, and massive weight loss that
modify tissue response to our surgery should also be ruled
out. Body dysmorphophobic disorder should be considered
in patients who resort to multiple body contouring procedures and those who frequently change treating doctors. A
psychological assessment should be recommended to rule
out such a scenario.
Finally, if the treating surgeon is certain that all issues
have been ruled out and that the cause of patient dissatisfaction with the result is valid, then consider referring the patient
to the primary surgeon or advise suitable treatment options.
Please note- “Once you decide to treat this patient, all previous problems will be your responsibility.”
11.4 Contour Irregularities andAsymmetry
[14–19] (Fig.11.2)
Post-liposuction irregularities can be prevented by a thorough assessment of the patient during consultation and making a note of all the irregularities whether they are depressions
or bulges. Examination should include presence of scoliosis
or asymmetry related to difference of length of the lower
limbs and such data should also be recorded in the medical
history. Previous surgeries and scars must also be identied
and recorded, assess whether they are attached to deep structures, and record any details that may lead to the future
appearance of irregularities. The process of marking or mapping the areas to be treated is very important because it will
guide us in our body contouring work.
Once the surgery has been initiated, the preoperative
markings should be respected and modications should be
avoided on the y. Accurate inltration with a peristaltic
pump or syringes is very important as it must be even to
avoid irregularities and asymmetry. Inltration should
always start from the deep planes to the surface planes to
avoid the abandonment of deep tissues in the liposuction process which will then lead to a problem of asymmetry or
irregularity and will add to the dissatisfaction of the patient.
It is alright to make many incisions so as to allow us access
all the areas to be treated symmetrically and appropriately to
avoid some surface irregularities that may occur because we
want to force the entry of the cannula from a distant point
ultimately damaging the shape and surface vascular plexus
of the dermis. One of the useful maneuvers to avoid asymmetry consists of mirror work, which is that whenever symmetrical areas are worked on it is advisable to do them
consecutively in order to keep the memory fresh about the
work that was done in the contralateral area. The pinch test is
very useful for checking the symmetry and assessing whether
it is necessary to remove more tissue from a specic area.
Another useful maneuver is to summon a third party, for
example, the anesthesiologist or some collaborator to
remotely evaluate asymmetry during the surgical process.
Another cause of asymmetry is poor elastic compression
(Fig.11.3). Many times, the patient or the members of the
surgical team has misplaced the elastic compression garment
causing appearance of depressions or rolls or accumulated
deposits of the fat that were left in the tumescent solution.
One of the ways to prevent irregularities is the maneuver
called lipo-disruption or equalization of the remaining fat
volume consisting of continuing movements with the lipocannula or the use of the lipo-shifting cannula in the treated
areas and on the anks, to smoothen out the edges of
Liposuction to have it well contoured.
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a
b
c
Fig. 11.2 (a) 36-year-old patient who underwent liposuction 7years
ago. Came to us for unevenness on the abdomen and thighs. She could
not wear any of the traditional and western clothes and hence was
unhappy with her outcome. (b) Post operative photograph taken
2 months after a complete abdominoplasty and fat grafting of the
depressions (c) at the same time
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G. Blugerman
a
c
b
d
Fig. 11.3 (a, b) Immediate post body-contouring (7days post) photograph of a lady who had prominent depressions because the pressure garment
was not tting well in the inner thigh region. (c and d) Photographs taken 4weeks after the garment was changed and a uniform pressure was used
11.5 Inammation [14–19]
Inammation is a normal process after any traumatic or surgical intervention and should be controlled by providing the
appropriate medication. The patient should be instructed to
avoid self-medication and the use of a proton pump inhibitor
11.6 Residual Edema [14–18] (Fig.11.4)
It should be treated by the use of manual lymphatic drainage
and external ultrasound. Early mobilization and repetitive
physical activity contribute to faster reabsorption of edema.
Correct use of elastic compression should be controlled.
to protect the digestive system.
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Fig. 11.5 Post-liposuction skin discoloration noticed after 5 days.
Please note that all skin discoloration following liposuction happens
due to full thickness injury to the skin ap. If small it heals on its own
with secondary intention. If large requires excision and closure or skin
grafting after debridement
Fig. 11.4 Scrotal edema observed after lipocontouring of the abdomen
and thighs in a male. Similar edema may be observed in the labia of a
female secondary to reduced drainage of uid through the lymphatics.
Release of garment edge at the groin and scrotal support will improve
the condition
11.7 Hyperesthesia [14–18]
Hyperesthesia effect is produced by the loss of natural adipose cell padding from nerves. It is most common in highdenition liposuctions and when using ultrasound, which
acts on the myelin sheath of nerves. In many cases, medication such as pregabalin should be used to reduce discomfort
in this type of patient.
11.8 Skin Necrosis [20–23]
Skin necrosis can occur from devascularization of a skin area
caused by damage to the vascular pedicle that supplies and
drains it, or by excess trauma to the subdermal plexus caused
by the instrument. Another cause may be excess caloric
energy that causes a burn to the skin and subcutaneous tissues. The most important thing is the prevention, early diagnosis of the complication, and the treatment of this
complication (Fig.11.5).
Use of excess energy is prevented by the surgeon being
familiar with the energy to be used and thus avoiding over-
heating and burns. Subdermal plexus injury is avoided with
proper selection of cannulas, the use of low vacuum, the use
of extra incisions that avoid forcing the use of straight cannulae in curved areas. Faulty compression can also cause
skin necrosis. It is also important to evaluate previous scars
before planning body contour surgery to avoid trauma in
areas with a decient blood supply.
11.9 Post-Liposuction Residual Skin Laxity
[21, 22, 24–26]
The patient should be warned about residual skin laxity especially after a large-volume liposuction (Fig.11.6). In many
cases, it is avoidable or predictable, but in other cases, it is
the consequence of the poor response of the skin and collagen of the patient. The presence of previous stretch marks,
pre-existing accidity, ne-skinned areas, hyperelastosisproducing diseases and malnutrition, as well as post-bariatric
surgeries and massive weight loss from diets are common
causes of post-surgical accidity and should be recorded in
patients’ clinical history.
Prevention can be achieved in some cases by ancillary use
of energy during liposuction such as laser, radiofrequency,
ultrasound, and plasma, but the most important thing is to
preserve the septi or partitions that attach from skin to fascia
and which are responsible for the skin to attain a new shape
through their contraction. Once accidity is established, the
treatment involves the use of external energy, such as radiofrequency, focused ultrasound, carboxytherapy, or if it can-
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G. Blugerman
Fig. 11.6 (a, b) Preoperative
photographs of a lady who
wanted lipo-contouring of her
midriff. She underwent
liposuction as well as a lower
abdominoplasty but was
unhappy due to the loose skin
in the peri-umbilical region.
This can be improved by
using radiofrequency
treatment
a
b
not be corrected non-invasively, redundant skin resections
will be required.
Prevention of residual accidity after a body contouring
procedure is primarily based on a good preoperative diagnosis of skin quality and the patient’s clinical and surgical history. The full medical history should investigate frequent
weight changes, post-bariatric surgeries, pregnancies, previous treatments, previous body contouring surgeries, and history of elastic ber collagen diseases. It is important to
evaluate the presence of previous scars in the area to be
treated, their characteristics, and their location. In the abdomen, it is important to evaluate the shape of the navel and the
shape and position of the pubis. In the case of preoperative
accidity, it is important to record in the medical history in
writing that the patient does not want the surgery to remove
the excess skin and prefers a suboptimal result but without
scars. When there is a presence of sagging, it is mandated to
resort to energy use through laser, ultrasound, radiofrequency, or plasma effect that stimulates collagen contraction
and neocollagenesis.
The surgeon may carry out preoperative and postoperative adjuvant treatments available in his practice such as
nutritional medicine, use of cosmeceuticals, ablative and
non-ablative laser equipment, mesotherapy, microneedling,
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chemical peels, kinesiology, microdermabrasion, monopolar, bipolar, or multipolar radiofrequency. In some patients,
physical activity may be helpful in increasing muscle tone as
the way to decrease accidity. If sagging has been diagnosed
as irreversible, the only possibility is the surgical treatment
of it through secondary skin resection using procedures such
as abdominoplasty, thigh lifting, body lift, buttock lift, gluteoplasty with fat transfer, and brachioplasty. Breast or buttock implants may also be necessary. If the presence of a sad
navel is diagnosed, the use of the Borelli thread or our umbilical mobilization technique can be considered.
11.10 Infection [23, 26–29]
Infections in body contouring surgery can become catastrophic. That is why prevention is very important through
the use of antiseptic showers leading up to the surgery date
for the disinfection of the skin surface, performing of procedures in suitable surgical environment, the use of properly
sterilized instruments and disposable supplies, pre- and transoperative antibiotic therapy. Postoperative antibiotic therapy is not evidence-based and it is preferable to avoid it
when possible. Signs and symptoms of the infection are well
known and should be explained to the patient. One symptom
that can sometimes be confused is hyperalgesia, which can
be one of the symptoms of the most dangerous infections
such as gas gangrene and necrotizing fasciitis.
The rst step in the face of an infection is the taking of a
sample for the identication of the microbe and its sensitivity.
This should be done through a needle puncture through healthy
skin. If not much secretion comes out, 5cc of saline solution
can be injected and sucked in. The second step is marking and
photographing the red edges of the suspicious area to evaluate
local spread. Consultation with the infectious disease specialist should also be undertaken and broad- spectrum coverage
established until the laboratory results are obtained. A blood
test and blood culture may be necessary if the infection is in a
more advanced state. The process can manifest itself in the
form of cellulite or in the form of an abscess.
If it occurs in the form of abscess, it is ideal to drain it
through the wound if it is nearby, or by making an incision at
the site of greatest skin uctuation. Once the pus has been
evacuated, cavity lavages should be performed with different
antiseptic solutions depending on the availability and
experience of the surgeon. In our practice, we found that the
so- called “Polish solution” consisting of equal parts peroxide and iodine povidone very useful. The bubbles produced
by peroxide help clean the cavity of the abscess and iodopovidone has a high disinfection capacity. A vacuum drain can
be placed. Depending on the general clinical picture of the
patient, his/her internment at the hospital or monitoring on
an outpatient basis should be undertaken.
Atypical mycobacteria infections may result from the use
of poorly sterilized instruments and are treated with specic
antibiotic schemes that usually last for several months. This
is fully discussed in the volume on breast surgery.
Necrotizing fasciitis is a severe anaerobic infection which
spreads at the fascial plane level and needs emergency
assessment and treatment (Fig.11.7).
Fig. 11.7 Necrotizing fasciitis of the anterior abdominal wall after liposuction and abdominoplasty. She was treated with aggressive debridement
and a delayed skin graft procedure
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