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Is There a Safe Lipoaspirate Volume? a Risk Copyright © 2015 American Society of Plastic Surgeons

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Is There a Safe Lipoaspirate Volume? a Risk Copyright © 2015 American Society of Plastic Surgeons COSMETIC Is There a Safe Lipoaspirate Volume? A Risk Assessment Model of Liposuction Volume as a Function of Body Mass Index Ian Chow, B.A. Background: No concrete data exist to support a specific volume at which lipo- Mohammed S. Alghoul, suction becomes unsafe; surgeons rely on their own estimates, professional or- M.D. ganization advisories, or institutional or government-imposed restrictions. This Nima Khavanin, B.S. 09/23/2019 on BhDMf5ePHKbH4TTImqenVPxW5zIMn7y7iNny6BPwUDEXcBNQnj/5yzs0HGY0kMwEqrR78gp8xtY= by http://journals.lww.com/plasreconsurg from Downloaded study represents the first attempt to quantify the comprehensive risk associated Philip J. Hanwright, M.D. with varying liposuction volumes and its interaction with body mass index. Downloaded Kristen E. Mayer, B.S. Methods: Suction-assisted lipectomies were identified from the Tracking Op- Keith M. Hume, M.A. erations and Outcomes for Plastic Surgeons database. Multivariate regression from Robert X. Murphy, Jr., M.D., models incorporating the interaction between liposuction volume and body http://journals.lww.com/plasreconsurg M.S. mass index were used to assess the influence of liposuction volume on com- Karol A. Gutowski, M.D. plications and to develop a tool that returns a single adjusted odds ratio for John Y. S. Kim, M.D. any combination of body mass index and liposuction volume. Recursive parti- Chicago, Ill.; and Allentown, Pa. tioning was used to determine whether exceeding a threshold in liposuction volume per body mass index unit significantly increased complications. Results: Sixty-nine of 4534 patients (1.5 percent) meeting inclusion criteria by BhDMf5ePHKbH4TTImqenVPxW5zIMn7y7iNny6BPwUDEXcBNQnj/5yzs0HGY0kMwEqrR78gp8xtY= experienced a postoperative complication. Liposuction volume and body mass index were significant independent risk factors for complications. With pro- gressively higher volumes, increasing body mass index reduced risk (OR, 0.99; 95 percent CI, 0.98 to 0.99; p = 0.007). Liposuction volumes in excess of 100 ml per unit of body mass index were an independent predictor of complications (OR, 4.58; 95 percent CI, 2.60 to 8.05; p < 0.001). Conclusions: Liposuction by board-certified plastic surgeons is safe, with a low risk of life-threatening complications. Traditional liposuction volume thresh- olds do not accurately convey individualized risk. The authors’ risk assessment model demonstrates that volumes in excess of 100 ml per unit of body mass index confer an increased risk of complications. (Plast. Reconstr. Surg. 136: 474, 2015.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. iposuction is one of the most commonly removed while minimizing blood loss; however, on 09/23/2019 performed procedures in plastic surgery, large infusion volumes have caused fluid shifts with over 200,000 procedures performed and lidocaine toxicity to become significant safety L 1 2–4 annually. Since its introduction, the procedure has concerns. Substantial perioperative hemo- evolved in both concept and application, becom- dynamic changes have been described in both ing widely practiced by both plastic surgeons and animal and human studies, including increases other physicians. The advent of wetting solutions in cardiac output, mean arterial pressure, cen- has allowed larger volumes of lipoaspirate to be tral venous pressure, heart rate, and pulmonary pressure.5–7 Despite these observations, the clinical From the Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine; the American Society of Plastic Disclosure: Dr. Kim receives research funding from Surgeons; Cosmetic & Reconstructive Specialists of the and is a consultant for the Musculoskeletal Trans- Lehigh Valley, Lehigh Valley Health Network; and the plant Foundation. Mr. Hume is employed by and Division of Plastic Surgery, University of Illinois. Dr. Murphy is the past president of the American Received for publication January 12, 2015; accepted Society of Plastic Surgeons. All other authors have February 26, 2015. no relevant financial relationships to disclose. This Copyright © 2015 by the American Society of Plastic Surgeons particular research received no external funding. DOI: 10.1097/PRS.0000000000001498 474 www.PRSJournal.com Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 136, Number 3 • Liposuction Volume Safety implications remain unclear, as large volumes of such as the Breast Reconstruction Risk Assess- infiltrated solution are generally well tolerated in ment score underlines increased physician and healthy subjects, and several large series have con- patient demand for empiric and patient-centric firmed the overall safety of liposuction.7–12 data in an effort to capture more nuanced and However, with liposuction being performed by quantitative measures of risk than typical popula- untrained professionals, in nonaccredited office tion-based measures.29–32 In this study, we endeav- settings, and with continually increasing lipoaspi- ored to quantify the effect of liposuction volume rate volumes, reports of serious complications on postoperative complication rates and evaluate have surfaced, prompting scrutiny into procedural whether the current 5000-ml large-volume defini- safety.13–17 The reported incidence of death after tion is a valid threshold for procedural risk. Using liposuction varies dramatically between 2.6 and the American Society of Plastic Surgeons Tracking 20.6 per 100,000.10,18–20 In an American Society Operations and Outcomes for Plastic Surgeons for Aesthetic Plastic Surgery survey, thromboem- database, we developed the first risk stratification bolism, abdominal/viscus perforation, fat embo- tool to determine the effect of lipoaspirate vol- lism, and cardiorespiratory failure were the most umes and preoperative body mass index on com- common discernible causes of death. The major- plication rates and to propose a novel cutoff for ity of deaths had no identifiable cause, leading to safety in liposuction using both lipoaspirate vol- speculation that unrecognized volume overload ume and body mass index. and lidocaine toxicity may be more significant pre- cipitants of mortality than previously thought.20,21 Today, significant controversy continues to PATIENTS AND METHODS surround the maximum permissible lipoaspirate Patient Selection volume. There are currently no quantitative data This study is based on the Tracking Opera- to support a specific volume at which point lipo- tions and Outcomes for Plastic Surgeons program, suction is considered unsafe.9,22,23 The current American Society of Plastic Surgeons guidelines which provides Health Insurance Portability and defines 5000 ml of aspirate as large-volume lipo- Accountability Act–compliant, deidentified data- suction that likely portends increased procedural bases to members and candidate members of the risk, despite concluding that “there is no scientific American Society of Plastic Surgeons. The pro- data available to support a specific volume maxi- gram’s registry contains more than 1 million plas- mum at which liposuction is no longer safe.”24,25 tic surgery procedures and has been previously described in detail and validated in several publi- Recently, the utility of lipoaspirate volume as a 33,34 proxy for procedural risk has been questioned, as cations. Patients were identified using Current varying volumes of wetting solution may be infused Procedural Terminology codes for suction-assisted with different amounts of fat removed in the same lipectomy of the head and neck (15876), trunk total lipoaspirate volume, depending on the tech- (15877), upper extremity (15878), and lower nique used, a fact not adequately accounted for extremity (15879). The Procedure Description by simply quantifying liposuction volume.4,9,26 variable was queried to exclude patients who Furthermore, in a prospective study of patients underwent procedures other than suction-assisted undergoing liposuction, Swanson described the lipectomy. Duplicate cases were eliminated based deceptive nature of estimating blood loss based on case identification number. on the negligible levels of hematocrit found in lipoaspirate, which typically accounts for only Preoperative Variables and Outcomes 2 percent of the blood loss experienced during Preoperative demographic variables collected liposuction.27 Nonetheless, current guidelines rec- by the registry include age, body mass index, sex, ommend that large-volume liposuction (>5000 ml American Society of Anesthesiologists physical sta- aspirate) be performed in an acute-care hospital tus class, active smoking, and diabetes. Operative setting for proper monitoring.24,25 details included patient admission status, type of Given limited empirical guidelines, plastic anesthesia, liposuction volume, and operative time. surgeons have relied on subjective estimates of Postoperative complications were catego- the safe lipoaspirate volume based on a patient’s rized as overall complications, surgical complica- medical condition, body mass index, concomi- tions, medical complications, and any return to tant procedures, and the potential physiologic the hospital. Overall complications were defined consequences of liposuction.24,25,28 The introduc- by the presence of either a surgical complica- tion and advent of individualized risk calculators tion, a medical complication, or an unplanned 475 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
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