Thomas Wright, MD FACP FACPh RVT
Laser Lipo and Vein Center
Introduction
In September of 2017, Dr. Adam Ali published an article, “Fat Attacks!” A Case of Fat Embolism Syndrome Post Liposuction” in the British Medical Journal (Adam A., 2017).
This is a case report of a serious complication that occurred after liposuction of the knees and lower legs on a patient with lipedema.
While Fat Embolism Syndrome is a very rare complication of liposuction, this report is an important reminder that liposuction surgery has potentially serious risks and everything possible should be done to reduce those risks.
My talk today focuses on lowering the risk of Lymph Sparing Liposuction and the safety factors that must be taken into consideration when performing the procedure and what patients should know before choosing to have the procedure.
Reference: Adam A., T.G. (2017, September 25). Fat Attacks! A Case of Fat Embolism Syndrome Post Liposuction. British Medical Journal. doi: 10.1136/bcr-2017-220789
Objectives
- Identify the risk factors for lymph sparing liposuction in patients with Lipedema.
- Explain how risk factors in patients with Lipedema can be reduced pre-operatively, during the procedure, and post-operatively.
- Describe how lymph sparing liposuction can be performed safely to reduce risks of complications in patients with Lipedema.
Risk of Complications
There are risks for any patient having liposuction surgery; however, Lipedema patients are generally at a higher risk for complications for several reasons – including Lipedema patients often have other comorbidities or health issues that make having any surgery a higher risk.
FACTORS THAT INCREASE RISK OF COMPLICATIONS WITH LIPOSUCTION
Risk Factors
- Lipedema patients are generally heavier than most other patients having liposuction. Increased weight or high BMI is a risk for any surgery. (Gupta, 2016)
- Lipedema patients have higher than average subcutaneous fat. The risk of complications increases significantly (3x) for liposuction procedures that remove more than 5 liters of fat in a single procedure. (Chow, 2015), (Gilliland MD, 1997), (Gilliland MD, C. G., 1999)
- The use of general anesthesia (GA) increases the risk of complications in all surgeries including liposuction. General anesthesia by itself can lead to life-threatening complications – even death. GA increases the risk of Post Operative Cognitive Dysfunction (POCD). (Gottschalk, 2011) (Perouansky, 2010)
- The presence of varicose veins increases the risk of bleeding and the risk of DVT and embolism. Lipedema patients have an increased risk of varicose veins and venous insufficiency. (Clavijo-Alvarez, 2011)
Risk Factors – Lymphatic Injury
The larger the diameter suction cannula – the more traumatic the liposuction. (Venkatram J., 2008), (Skouge, 1990), (Lawrence N., 1996)
REDUCING RISK FACTORS AND COMPLICATIONS OF SURGERY
- Before and after liposuction is performed, complete decongestion of the lipedema tissue must occur. This is achieved through the following:
- Complete Decongestive Therapy (CDT) with Manual Lymph Drainage (MLD)
- Wraps
- Compression stockings, leggings, or pants
- Intermittent compression pump
- Complete decongestion of the tissues is important because it not only reduces swelling, which temporarily worsens after surgery, it also reduces inflammation, tenderness, fatigue, and heaviness.
- Patients also come to realize the significant benefits of compression, which increases the likelihood of compliance through the post-operative period, which significantly improves results.
- Patients with varicose veins and underlying venous reflux should be treated before undertaking liposuction.
- Large varicose veins increase the risk of bleeding, DVT, and/or fat embolization during the liposuction procedure.
- Treat spider veins / small vein networks?
- Since Lipedema patients frequently have varicose veins, this is especially important for lipedema patients. (Clavijo-Alvarez, 2011), (Gilliland C.G., 1997)
LYMPH SPARING LIPOSUCTION TECHNIQUE
- Liposuction with a generous tumescent technique that avoids general anesthesia significantly reduces operative and peri-operative complications, which even with modern techniques is often as high as 0.3%, 3 in 10,000, in lipedema patients with comorbidities. (Gottschalk, A.H., 2011), (Gupta, V.W., 2016)
- Reliance on generous tumescent anesthesia alone also helps protect delicate lymphatic structures from injury.
Safety
- Limits on the amount of fat removed in one liposuction. On average there is an increased risk (3X) > 5.0 liters of total volume aspirate is removed. (Gilliland, C.G., 1999)
- Some states, including Florida and California, have laws regulating the amount of total volume aspirate that can be removed.
- Limits of 5 – 8% of total body surface area also increased risk. Lipedema patients have more subcutaneous fat per surface area treated. (Chow, I.H., 2015)
- Although more liposuction at one time may be requested and performed, our current medical literature shows an increased risk.
- Studies have shown larger diameter liposuction suction cannulas are more traumatic and more likely to disrupt lymphatic vessels and small venules.
- Tumescent delivery water jet or pump does not cause trauma.
- Large cannulas remove fat more quickly reducing the time required to remove fat and complete surgery.
- Smaller cannulas increase the surgical time, but significantly reduces the risk of trauma to the lymphatic vessels. (Venkataram, 2008), (Skouge, 1990), (Lawrence, 1996)
Intimate knowledge of the locations and anatomic variations of the lymphatic drainage in the limb or body area that is going to be treated is crucial. Great care should be taken to orient the suction cannulas in a longitudinal manner parallel to the lymphatic collecting ducts in the epi facial areas. Knowledge of the location and orientation of pseudo-fascial lymphatic pathways and the afferent lymph vessels is also important to avoid transecting this pathway during the liposuction procedure.
Summary
Medical literature gives us useful guidance on how best to reduce the risk of complications from liposuction. Lipedema patients are especially susceptible to injury of the lymphatics and other complications from liposuction. While Liposuction is generally a safe and effective treatment for Lipedema, great care should be taken to reduce any risk of adverse outcomes when possible.
References
Adam, A., T. G. (2017, September 25). Fat Attacks! A Case of Fat Embolization syndrome Post Liposuction.
British Medical Journal. doi: 10.1136/bcr-2017-220789
Chow, I. H. (2015). Is There a Limit? A Risk Assessment Model of Liposuction Volume on complications in Lipoabdominoplasty. Plastic Reconstructive Surgery, 10-01
Clavijo-Alvarez, J. M. (2011). Prevention of Venous Thromboembolism in Body Contouring Surgery. Plastic Surgery, 228-32.
Gilliland MD, C. G. (1999). Safety Issues in Ultrasound Assisted Large-Volume Lipoplasty. Clinical Plastic Surgery, 317-35.
Gilliland MD, C. G. (1997). Tumescent Liposuction Complicated by Pulmonary Edema. Plastic Reconstructive Surgery, 215-19.
Gottschalk, A. H. (2011). Is Anesthesia Dangerous? Dtsch Arztebl International, 469-74.
Gupta, V. W. (2016, June). Safety of Aesthetic Surgery in the Overweight Patient: Analysis of 127,961 Patients. Aesthetic Surgery, 36(6), 718-29.
Lawrence N., C. W. (1996). Liposuction. Advanced Dermatology, 11, 19-49.
Skouge, J. (1990). The Biochemistry and Development of Adipose Tissue and Pathophysiology of Obesity as it Relates to Liposuction Surgery. Dermatology Clin, 8, 385-93.
Venkatram J., C. J. (2008, Jul-Dec). Tumescent Liposuction: A Review. Aesthetic Surgery, 49-57.
doi: 10.4103/0974-2077.44159
Perouansky M., Hemmings, H. (2010, December). Neurotoxicity of General Anesthetics: Cause for Concern? Anesthesiology, 111(6) 1365-1271. doi: 10097/ALN.0b013e3181bf1d61
