Liposuction deaths hit the headlines
Liposuction deaths hit the headlines
The number of liposuction procedures has grown, according to statistics from both the American Society of Plastic and Reconstructive Surgeons (ASPRS) in Arlington Heights, IL, and the American Academy of Cosmetic Surgery (AACS) in Chicago. Between 1992 and 1998, the number of liposuctions performed by members of ASPRS grew 216% to a total of 172,079 procedures in 1998. The AACS reports an increase of more than 300% between 1990 and 1996, with a total of 292,942 procedures performed in 1996.
Because there are so many more patients undergoing liposuction in a variety of surgical settings that range from hospital-based outpatient surgery centers to physicians’ offices, the medical community is taking a look at the safety of the procedure.
The article "Deaths related to liposuction" in the May 13 issue of the New England Journal of Medicine outlined the cases of five patient deaths in New York that have been attributed to liposuction. All five cases involved tumescent liposuction, with the subcutaneous infusion of a solution that contains lidocaine, epinephrine, sodium bicarbonate, and normal saline. Causes for the deaths were attributed to lidocaine toxicity or lidocaine-related drug interaction.
"The [NEJM] article brings up some good points, but it is based on incomplete data," says Jack G. Bruner, MD, of The Plastic Surgery Center, in Sacramento, CA. Bruner heads up a task force on lipoplasty for the ASPRS.
"The ASPRS set up a committee to study liposuction in the summer of 1997 because we began to see reports of liposuction complication rates that were higher than we would expect to see in plastic surgery," explains Bruner. "The number of complications were not alarming, but we want to discover the reasons for these complications."
Because no one fully understands what happens throughout the body during and after liposuction, the task force members set up a $150,000 grant to underwrite research that studies the physiology of liposuction. Effects of the anesthetics, infusion of fluid and removal of fat on the entire body will be studied, says Bruner.
Articles such as the one in the May NEJM and the subsequent coverage in the consumer press are of great concern to plastic surgeons because they don’t contain complete data, says Rod J. Rohrich, MD, chief of plastic surgery at Southwest Medical Center in Dallas. "Liposuction is one of the safest, most commonly performed plastic surgery procedures in the country, but this article pointed to five cases for which there was no data on one case and cause of death was not known in two of the cases."
Lack of scientific data makes the evaluation of liposuction complications difficult, admits Bruner. "Unfortunately, when there is a liposuction death to investigate the medical records are located in an attorney’s safe and not accessible for scientific study in a timely manner." Because liposuction does not have to be performed in an accredited surgery center or hospital, there is no mandatory reporting or review process that will capture information on all adverse events, he adds.
To address this problem, the ASPRS is starting an outcomes study in which physicians will agree to keep accurate records and submit information on all liposuction patients. "This study will help us identify medical practices that result in the best patient outcomes and identify medical practices that increase risk to patients," says Bruner. The study should be complete near the end of 2000, he adds.
Three types of liposuction
Tumescent liposuction is a cause of concern to ASPRS members, says Bruner. There are three types of liposuction that use a liquid infusion to replace some or all of the fat removed, he explains:
• Wet liposuction involves infusing 200 or 300 cc of the lidocaine, epinephrine, and saline solution when removing 1,000 cc of fat.
• Super-wet liposuction means infusing 1,000 cc of solution for 1,000 cc of fat removed.
• Tumescent liposuction involves the infusion of two to three times the volume of fat removed, for example, 2,000 to 3,000 cc of solution for 1,000 cc of fat.
"Our concern is the amount of lidocaine and epinephrine that is absorbed by the patient," explains Bruner.
"We also question how much fat a surgeon should remove at one time," he adds. If a surgeon is removing more than 5,000 cc of fat, the patient should be admitted overnight to be observed for potential complications, recommends Bruner.
Rohrich agrees with Bruner and adds, "If less than 5 liters is removed, the surgery staff should have warming fluids and blankets available to handle the potential of hypothermia."
Another reason to admit a patient overnight is the length of surgery, says Rohrich. "If a patient undergoes more than six hours of surgery, that patient should be admitted overnight," he explains.
Day-surgery program managers can help avoid liposuction complications by making sure the surgeon has hospital privileges to perform liposuction, adds Bruner. "Not only does this ensure that the physician can continue caring for the patient if complications develop but it demonstrates the physician’s commitment to training and gaining the experience needed to perform liposuction safely."
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