The Perils of Modern Liposuction Surgery

TASA ID: 3797

In 1987, Jeffrey Klein, MD, evolved the principles of the tumescent technique of anesthesia and tumescent liposuction. As an innovation for safe and effective liposuction, the concept of tumescent liposuction vaulted liposuction into the number one spot for cosmetic procedures performed in the United States, with cosmetic breast surgery its only competitor in popularity. The concept of inflating fatty tissue with fluid prior to exposing it to a vacuum, delivered through a narrow cylinder, converted a dangerous procedure full of morbidity due to blood loss into a safe and reproducible procedure capable of sculpting the shape of the human body. Key to the success of inflating fatty tissue with anesthetic solution was the idea of minimizing blood loss, minimizing pain during surgery, eliminating the need for unconscious anesthesia, and promoting minimally traumatic lipolysis.

Lipolysis is the splintering of fat cells (adipocytes), allowing fatty contents to flow out of the cell to be subsequently suctioned with a vacuum. Lypolysis using the tumescent technique of liposuction appears to be a physical phenomenon describing fat cells bloated with fluid splitting open and releasing fatty contents when exposed to a vacuum. Other terms for this phenomenon include the wet technique of liposuction and the super-wet technique of liposuction.

Since its initial description in 1987, industry has sought to profit from this procedure by adding physical modalities which purport to produce or augment lipolysis. Hence, the last 20 years have witnessed the introduction of mechanically-assisted liposuction, ultrasonic-assisted liposuction, cold laser-assisted liposuction, and laser-assisted liposuction. The sales pitch is that these additional modalities make lipolysis easier and more reproducible and, therefore, would enlarge the sphere of competence to individuals less trained or less skilled in cosmetic surgery.

Indeed, the introduction of these physical adjuvants to liposuction created a marketing phenomenon in which the public became more accepting and more desirous of liposuction procedures. As a result of greater patient acceptance, more physicians entered the field of liposuction surgery, albeit with less formal training in cosmetic surgery.

The pitfalls of liposuction, therefore, lie in two realms: morbidity due to the tumescent liposuction procedure itself and morbidity due to the introduction of machine-induced energy. I will discuss each separately, although one will quickly note morbid overlap between the two sources of injury.

Because the tumescent technique incorporates the administration of large quantities of lidocaine (a local anesthetic) into the fat compartment, much has been written about lidocaine toxicity and death due to cardiac toxicity. In fact, this has been extremely rare, and articles describing such events are fraught with inaccuracies and false assumptions. On the other hand, there have been a few deaths attributed to the use of marcaine in the tumescent solution, where physicians have deviated from recommended and time-tested techniques. In addition, some deaths have been due to too much fluid administration and inadvisable bed rest, which have produced DVT, pulmonary embolus, pulmonary edema, and congestive heart failure. These cases also are rare.

Most commonly, procedure morbidity centers around excessive fat extraction, improper contouring techniques, inappropriate scar formation, and skin sloughs. Less commonly, morbid events concern seromas, hematomas, infection, and nerve damage. Least common and most feared are necrotizing fasciitis and perforation. Not surprising, the cases which have been brought to my attention include the rare event of necrotizing fasciitis (in one case due to improper sterilization of surgical instruments for a procedure performed in a non-accredited medical office), several cases of perforation due to unrecognized penetration through the intestines with a liposuction cannula , resultant abscess formation, and acute abdominal events. Florida case reports indicate that neither the site of surgery (accredited vs. non-accredited facility) nor specialty certification correlates with the incidence of untoward events. Somewhat paradoxically, the vast majority of such events were at the hands of board- certified plastic surgeons although that might be a reflection of the percent of cases performed by plastic surgeons. My own experience anecdotally relates to a preponderance of cases of morbidity at the hands of non-surgically board-certified physicians. Additionally, while the Florida data does not support my experience, non-certified surgical facilities would seem to place patients at greater risk for unsafe surgical practices.

The second major cause of morbidity in liposuction surgery is the introduction of energy-producing equipment. Mechanical-assisted liposuction refers to the use of a vibrating cannula to ease the physical energy expended by the physician during the procedure. Initially touted as helping to prevent tendonitis and to make the procedure safer by requiring less force needed to move a cannula, it was likewise promoted as making the procedure easier to perform by female physicians. Its effect on the procedure appears to be minimal except for a preference by some doctors and conversely, it may reduce a physician's appreciation of the location of the tip of the cannula. Similarly benign is the introduction of cold lasers before or after a procedure in an attempt to promote easier surgery, reduced bruising or bleeding, faster healing, and a host of other unsubstantiated claims. Since the temperature of the tissue is not elevated, it appears to be an innocuous addition to the procedure.

More problematic is the introduction of ultrasound-assisted liposuction and laser lipolysis. Both techiniques introduce heat injury to the tissue, and therein lie their promoted benefits and obvious morbid potential. Uncontrolled heat presents a significant risk to the patient, and in a classic case, a patient suffered significant burns, evisceration, and bowel necrosis at the hands of a board-certified plastic surgeon who did not recognize the dangers in her technique of ultrasonic-assisted liposuction. While laser lipolysis also introduces heat to the procedure, industry has recently promoted temperature-monitoring devices to regulate heat transfer. The problem is that the standards of heat transfer have never been established, and a new laser liposuction device is being marketed as capable of achieving temperature elevations as high as 80⁰ centigrade when the industry standard is 42⁰  centigrade. A recent California case involves a professional bodybuilder who underwent abdominal laser lipolysis with resultant burns, scarring, and disfigurement of the abdominal wall. Furthermore, as the effects of energy introduction are not observed for periods as long as several months, inadvisable administration can result in subsequent over-resection of fat and evolving disfigurement.

In conclusion, while tumescent liposuction is a relatively safe and reproducible procedure for achieving improved body contour, poor performance due to facility inadequacy, errors in technique, and the introduction of energy transfer to surgically-altered tissue may result in unacceptable morbidity and subsequent lawsuits for redress of grievances.

This article discusses issues of general interest and does not give any specific legal or business advice pertaining to any specific circumstances.  Before acting upon any of its information, you should obtain appropriate advice from a lawyer or other qualified professional.