Low-risk lipo

The overall complication rate for liposuction is low, occurring in 1.02 percent of all procedures, with the risk of death 2.4 per 10,000 performed. But one expert reminds practitioners that lipo's major risk factor, thromboembolism, stands at a not trivial 23.1 percent — whether due to blood or fat emboli. However, he states, if the proper precautions are taken, this adverse event can be kept to a minimum.

RISK FACTORS "Thromboembolism is often difficult to prevent and every precaution must be taken as the complications may be catastrophic," Claude Garde, M.D., tells Cosmetic Surgery Times . Common risk factors for thromboembolism, he notes, include vein injury, increasing interaction of the fat and blood circulation, the amount of fat removed in a single procedure, the length of a procedure and the type of anesthesia used.

"As the surgeon introduces the cannula through the skin, the veins will invariably break and this can result in embolism," says Dr. Garde, a plastic surgeon from La Varenne, France.

As the veins break, Dr. Garde explains, there is an interaction between the fat and the blood. If there is a modification of the pressure under the skin resulting in a decreased pressure in the veins compared to the fat — during tumescent anesthesia for instance — embolism becomes a very real risk. The larger the diameter of the veins traumatized, the higher the risk of thromboembolism.

According to Dr. Garde, this risk is correlated to the volume of fat extracted during the liposuction procedure. The more fat removed, the greater the subcutaneous trauma and therefore the higher the risk that the veins will break and more pressure will be exerted on the subcutaneous tissues.

"When you perform the tumescent anesthesia at the beginning of the liposuction procedure, the vessels are completely collapsed due to the surrounding compression by the fat tissue," he says. "When you remove volumes of fat, you decrease the pressure on these vessels and they subsequently open up again, filling with blood and 'opening the doors' for a thromboembolic event."

According to Dr. Garde, the risk of embolism is increased the more protracted the liposuction procedure is. The longer the procedure, the more venous stasis occurs and therefore the higher the risk of clot formation within the veins. This is especially important given the type of sedation employed. If a general anesthesia is performed, the tonus of the muscle is released, upping the risk of embolism.

"There is no standard duration of liposuction procedures, as different patients have different volumes of fat to be removed," observes Dr. Garde. "However, the risk of embolism significantly increases in procedures that are longer than two-and-a-half hours."

POST-OP GARMENT Among the five preventive measures Dr. Garde recommends, the first is that, post-operatively, patients wear a special lipo-panty that does not excessively constrict the body.

"There are different panties for different body types," he notes, and cautions that if an ideally formed panty is used on a patient who does not have an ideal form, the panty will constrict some areas but not others. The stiffness of a panty should provide a level of high pressure but at the same time impart a certain tonicity, he advises — very similar to the compression stockings used after vein stripping.

"The best lipo-panty will have a compression of the calf beginning distally, and an elective compression at the level at which the liposuction surgery was performed," Dr. Garde says. "The ideal panty can act as an important preventive measure for thromboembolism."

DUPLEX SONOGRAPHY According to Dr. Garde, venous diseases are very common in obese patients, yet are not always immediately apparent upon first observation. For this reason, he says, it is imperative not to operate on the patient before having assessed the venous status via duplex sonography.

Dr. Garde performs this sonography in all his patients, especially those with varicose veins. He then removes all veins larger than 9 mm in diameter prior to liposuction because, he says, upon insertion of the liposuction cannula under the skin, these friable veins will invariably be broken.