Orlando, Fla. — When carried out with careful precautions to mitigate potential risks, large volume liposuction can be a safe and important option for achieving contour correction in obese patients and motivating them toward positive lifestyle changes, according to Mohan Thomas, M.D., D.D.S., speaking at the 24th annual scientific meeting of the American Academy of Cosmetic Surgery.
"With obesity on the rise and bariatric surgery associated with potential significant morbidity, alternative methods for promoting weight loss have an important role," explains Dr. Thomas, who is medical director, the Cosmetic Surgery Institute, Mumbai, India. "Large volume liposuction is not a substitute for dieting and exercise and is not appropriate for all overweight individuals. However, performed under the proper conditions, its safety profile is acceptable and it can yield predictable results that can be a powerful stimulus for patients to institute and adhere to behavioral modifications."
Dr. Thomas defined large volume liposuction as a procedure involving removal of more than 5 L of supernatant lipoaspirate. He reports results from a study of 25 cases of large volume liposuction performed over a two-year period. All were done under general anesthesia and with tumescent infiltration using a lidocaine 0.05 percent solution.The patients ranged in age from 16 to 54 years old, but most were in their 20s or 30s, and the ratio of females to males was 3-to-1. The average volume of lipoaspirate was 7.5 L, and the maximum volume aspirated was 10.5 L. The only serious complication encountered was a case of pulmonary edema due to fluid overload. However, it resolved with timely and appropriate medical management.
"This patient received 1 unit of albumin for every 4 L of lipoaspirate, but analysis of our laboratory monitoring results from patients undergoing large volume liposuction showed that while changes in hemoglobin and hematocrit were predictable based on volume of lipoaspirate, the serum protein change was not. It is unclear whether this patient developed pulmonary edema as a result of too-rapid fluid administration, or if the albumin played a role in creating a hyperosmolar solution. However, most healthy patients are able to recover serum protein levels fairly quickly without receiving albumin, and we are no longer administering it," Dr. Thomas says.
The only other complication encountered was a suture line dehiscence in a 16-year-old male who had 7 L of fat aspirated during a combined liposuction and tummy tuck procedure. The wound healed secondarily without problems.
Proper patient selection is the first issue to consider for optimizing the risk/benefit profile of large volume liposuction. The procedure is not applicable to persons who are morbidly obese, but may be performed in those weighing up to twice their ideal body weight. Health status is also important in choosing appropriate candidates.
"Prior to undertaking the procedure, patients need to have a complete history and physical exam, because only persons who are generally healthy with no medical problems or who have certain chronic disorders, such as hypertension, diabetes or hyperthyroidism, that are well-controlled on medication are candidates," Dr. Thomas says.
Large volume liposuction is always performed using tumescent technique under general anesthesia with the assistance of a competent anesthesiologist, and as an inpatient procedure that includes a postoperative overnight stay. Proper fluid replacement is another key safety measure for avoiding pulmonary edema or complications involving fluid and electrolyte imbalance. With the goal being for output (aspirate + urine output) to equal input (infiltration + IV fluids), the volume of tumescent anesthesia to be delivered is calculated as slightly greater than the estimated amount of lipoaspirate that will be removed. In addition, fluid balance is carefully monitored during the procedure.
Dr. Thomas uses lidocaine in the tumescent anesthesia solution. To guard against lidocaine toxicity, he calculates the maximum dose the patient should receive as 50 mg/kg body weight, and divides the dose equally among the number of liter bags of tumescent anesthesia solution.
"Lidocaine toxicity is a very real issue, and to avoid any mistakes in preparing the tumescent solution, there should be a signed written order for the lidocaine dose, and the solution should be mixed on the day of surgery with a medically qualified onlooker to double-check that everything is correct," Dr. Thomas says.