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The Tumescent Technique By Jeffrey A. Klein MD



Chapter 8:
Miscellaneous Complications

Minor or miscellaneous complications are defined as those associated with minimal mortality risk. Most minor complications are the result of clinical inexperience, carelessness, dogmatic technique, or simple bad luck.

An abecedarian is someone who is just beginning to learn, a novice. Abecedarian liposuction complications are the result of mistakes typically associated with inexperience or inadequate training. Abecedarian-like complications can occur in the hands of an experienced liposuction surgeon who has failed to learn from previous mistakes. If a better technique will avoid a problem, the problem can no longer be considered an expected sequela, but rather below the current standard of care and therefore an unnecessary sequela.

Excessive Liposuction

Excessive liposuction probably accounts for the most complications associated with liposuction surgery. Too much fat may be removed from a single area, creating a cadaveric appearance. Irregular amounts removed from a single area may produce lipotrops and liponots.

Too much volume removed, too many areas treated during a single surgery, and too many hours of surgery can prove fatal and therefore are discussed in later chapters that focus on catastrophic complications.

Cadaveric Appearance

Excessive liposuction in a specific body area can produce a cadaveric or cachectic appearance in the affected area of subcutaneous fat. Removing too much fat does not yield a cosmetic result that appears natural and attractive. The goal of liposuction is not to remove the maximum amount of fat, but rather to produce an optimal cosmetic improvement and maximize patient satisfaction through careful conservative surgery, with minimal exposure to the risks of surgical complications.

In particular, the normal female body has subcutaneous fat. In general, complete lack of subcutaneous fat on a female body does not appear normal, cosmetically attractive, or sexually appealing. The lack of subcutaneous fat feels peculiar to the touch and does not produce a tactile sensation normally associated with femininity.

Attempting to remove the entire subcutaneous adipose deposit in any area of the female body is a mistake and a prime example of abecedarian surgical naivete. Pierre Fournier has said, “It is not the fat that is removed, but the fat that remains after liposuction that determines success.”

Excessive Superficial Liposuction

Excessive superficial liposuction is a special case of excessive liposuction that requires special attention. Superficial liposuction has become a common practice, without much attention to its associated complications. Several significant, well-defined cosmetic complications can result from too much superficial liposuction.

Before the advent of tumescent technique liposuction, surgeons only used large cannulas, which precluded the ability to perform liposuction in relatively superficial planes of subcutaneous fat. The intense tumescent vasoconstriction and its associated surgical hemostasis permitted the use of smaller cannulas (see Chapter 27). With smaller cannulas, liposuction can be performed more superficially with less risk of producing irregularities of the skin.1

Dermatologic liposuction surgeons have been doing superficial liposuction since the late 1980s,1 and in the 1990s other surgeons became aware of the advantages of the tumescent technique in this regard.2 Unfortunately, authors who have promoted superficial liposuction have not detailed the undesirable consequences of excessive superficial liposuction.

Dermatologists are well aware of the superficial vascular plexus that is intimately associated with the immediate undersurface of the dermis. Other specialties have not appreciated the clinical and histopathologic consequences of injury (immunologic, thermal, or mechanical) to this delicate network of blood vessels and lymphatics.

Direct and intentional physical injury to the undersurface of the dermis is done by some surgeons in the mistaken belief that such an injury will induce dermal contraction. No histologic evidence supports the theory that subsurface dermal trauma produces an increase in dermal collagen or dermal elastin. Any apparent liposuction-induced contraction of the skin is the direct consequence of unweighting the skin (removing the gravitational effect of subcutaneous fat) as well as a consequent fibrotic contraction of the collagenous subcutaneous fascia. Every liposuction surgeon knows that when re-treating an area by liposuction, there is ample clinical evidence of subcutaneous fascial fibrosis resulting from previous liposuction in the fatty tissue.

A deliberate iatrogenic injury to the dermis with a liposuction cannula is reminiscent of “blood letting” as treatment for inflammation; there is no scientific support that either is beneficial. Dermal injury is not necessary for skin contracting after liposuction. The dermis does possess innate elastic properties that allow it to contract uniformly after liposuction in a way similar to the contraction of abdominal skin after pregnancy or breast skin after lactation.

Excessive superficial liposuction can produce a wide range of adverse clinical and aesthetic problems that range from annoyance to catastrophe, including erythema ab liporaspiration, lipotrops, liponots, postoperative seromas, and full-thickness dermal necrosis. Most of these iatrogenic problems have not been well described in the medical literature.3,4 Surgeons who advocate superficial liposuction must be careful to understand the full range of these consequences. Some surgeons “do superficial liposuction” but are not aware of the distinction between sufficient and excessive superficial liposuction (Figure 8-1).

Erythema Ab Liporaspiration. Erythema ab liporaspiration is a common result of excessive superficial liposuction. Its clinical appearance is similar to erythema ab igne, which is a distinct reticulate erythema resulting from prolonged chronic exposure to radiant heat, for example, from chronic application of an electric heating pad (Figure 8-2). Erythema ab liporaspiration is a persistent, iatrogenic reticulated erythema resulting from trauma to the superficial subdermal vascular plexus by aggressive rasping of the dermal undersurface with a liposuction cannula. One surgeon openly advocates aggressive superficial liposuction and deliberately applies the apertures of liposuction cannulas directly against the undersurface of the dermis.5

Unfortunately, no treatment exists for this chronic reticulated erythema, and it does not seem to improve with time (Figure 8-3).

Postoperative Seromas. Postoperative seromas as a result of tumescent liposuction with microcannulas are rare. Causes of seromas include (1) liposuction done too superficially, with damage to subdermal lymphatic plexus, and (2) prolonged excessive liposuction in a local area with complete transection of all fibrous subcutaneous strands and sheets, creating a subcutaneous cavity. When liposuction ceases to yield additional fat, continued aspiration may merely damage the connective tissue, causing an exudative process and diminishing the septa’s absorptive surfaces.

Using microcannulas in a crisscross pattern that radiates from several incisions and initiating liposuction as deeply as possible may minimize the risks of seromas. Factors that predispose to seromas include the use of large cannulas, excessive liposuction in a focal area, insufficient hemostasis as a result of insufficient tumescence, use of ultrasonic liposuction, and recent ingestion of drugs such as aspirin or ibuprofen, which predispose to hematoma and seroma (Figure 8-4).

Full-Thickness Dermal Necrosis. Full-thickness dermal necrosis can result from excessive superficial liposuction that directly injures the vascular supply of the overlying skin. Other causes of full-thickness dermal necrosis after liposuction include flap necrosis, infection, thrombosis, and vasculitis. Placing ice packs on a patient with cryoglobulinemia can precipitate cryoglobulins and produce dermal thrombosis with intense vascular insufficiency, leading to dermal necrosis. When excessive superficial liposuction precipitates patchy partial-thickness dermal necrosis, a secondary infection may precipitate a full-thickness necrosis.

At best, deliberate trauma to the undersurface of the skin will injure the dermal vascular supply and cause induration and delayed healing. At worst, it will result in full-thickness dermal necrosis and its sequelae (Figure 8-5).

Surgical Site Complications

Allergic Contact Dermatitis

Reston foam, when applied to the skin after liposuction, can produce an allergic contact dermatitis. Although some surgeons use Reston foam to reduce postoperative ecchymosis, this adhesive-backed, centimeter-thick foam does not reduce swelling, local tenderness, or soreness. Use of the foam prevents postoperative showering or bathing. The allergic response to the adhesive is aggravated by the effect of prolonged occlusion, which delays the diagnosis, produces bullae, and results in a prolonged postinflammatory hyperpigmentation. Friction and shearing forces exerted on the skin by the edges of the foam sheets can also produce bullae and prolonged postinflammatory hyperpigmentation. The denuded skin resulting from open bullae predisposes to infection.

The brief cosmetic benefits of reduced ecchymosis do not justify the risks of prolonged postinflammatory hyperpigmentation, the inconvenience of not being able to shower daily, and the risk of infection. Postoperative management with open drainage and bimodal compression not only provides an equivalent reduction in ecchymosis, but also avoids the risks and inconvenience of Reston foam.

Polymyxin B, neomycin, and bacitracin topical antibiotic ointments (e.g., Neosporin) applied to liposuction incision sites have been associated with allergic contact dermatitis. These preparations are not necessary and can be eliminated from routine postliposuction care. In a small clinical study of wound care after liposuction, we asked 10 consecutive patients to apply bacitracin to the incision sites on one side of their body and to apply nothing to the incisions on the opposite side. Asked to judge which side healed the best, three patients found no difference, and seven stated bacitracin delayed healing and was associated with incisional erythema.

Retracted and Indented Scars

Retracted scars at the sites of liposuction cannula access incisions are rarely encountered. The best treatment or repair is uncertain, although tincture of time would be a primary consideration. If the scars have persisted for more than a year, however, they probably will not resolve in the near future. Injections of triamcinolone (Kenalog) are unlikely to improve a retracted scar and would risk the additional disfigurement of subcutaneous fat atrophy. The potential benefits of an excision of such a scar would have to be balanced against the risk of an even more unsightly scar.

The most important consideration is how to avoid such scars. Preventive strategies include the following:

  1. Make the incision sites large enough to obviate any puckering as the cannula moves in and out of the incision.
  2. Use the smallest effective cannulas.
  3. Do not bruise or injure the incision site by allowing the cannula hub to pound, rub, or abrade the incision site. Protecting the incision site by placing tip of the index finger over the cannula hub is helpful.
  4. Use multiple incision sites so that the friction and trauma from the cannula are not concentrated on only a few sites.
  5. Do not close incisions with sutures.

Hyperpigmentation and Hypopigmentation

Postinflammatory discoloration of incisions used for microcannula access can be avoided, except in darkly pigmented individuals. Preventing pigmentation requires careful surgical technique that minimizes epidermal trauma and friction caused by a liposuction cannula as it is advanced and retracted through a skin incision. In the vast majority of patients, postinflammatory dyschromia is not a problem.

Darkly pigmented patients are especially susceptible to prolonged postoperative hyperpigmentation of incision sites. Such patients must be informed about the risk of pigment changes. The liposuction surgeon can minimize hyperpigmentation and hypopigmentation of incision sites by (1) minimizing the number of incisions, especially in darkly pigmented patients; (2) avoiding incisions that are too small and that can result in excessive friction as the cannula passes through an incision; and (3) directing the cannula so that it enters the incision without rubbing and abrading the skin.

Trauma to the dermal-epidermal junction and the dermis will lead to postinflammatory dyschromia and scarring. The interface between the epidermis and the dermis is where melanocytes are found. Injury and inflammation in this area cause rupture of melanocytes, releasing melanosomes into the interstitium of the papillary dermis. An ensuing phagocytosis of free melanosomes by local macrophage cells produces long-term hyperpigmentation of the involved dermis.

Postinflammatory hyperpigmentation also involves capillary vascular proliferation and ectasia. With eventual resolution of the inflammatory response, local capillaries return to normal, and the vascular component of the hyperpigmentation resolves (Figure 8-6).

In most patients with light pigmentation the microincision sites on the skin become invisible within a few months. Occasionally, hyperpigmentation of incisions can persist for more than a year. The degree of postoperative or postinflammatory hyperpigmentation depends on the patient’s skin type and the degree of trauma to the incision site. Incisions on the lateral aspect of the torso, the outer thighs, the inner thighs, and the arms are less prone to hyperpigmentation. Hyperpigmentation of incisions on the back and abdomen resolves much more slowly. Avoiding trauma to an incision site requires an incision large enough to accommodate the cannula without undue friction. The surgeon should avoid injuring the epidermis by rubbing the cannula over the skin adjacent to the incision. Small 1.5-mm and 2-mm punch excisions can be used for cannula insertion sites and will also minimize microcannula trauma.

Most liposuction patients do not experience bothersome hyperpigmentation. Any person is susceptible to postinflammatory hyperpigmentation. As a general rule, the darker a person’s natural pigmentation, the darker and the more persistent will be any postinflammatory hyperpigmentation. Allergic contact dermatitis, such as from adhesive tape or Reston foam, can precipitate hyperpigmentation that can last for months to years. Similarly, a minor abrasion or friction burn that affects the epidermis can produce persistent hyperpigmentation.

Trauma and friction caused by the cannula rubbing the skin can cause injury. As a cannula is advanced into an incision, the skin adjacent to the incision is susceptible to a traumatic abrasion or friction burn whenever the cannula rubs the skin too vigorously. Clumsy or aggressive actions that allow the hub of the liposuction cannula to pound the epidermis repeatedly are guaranteed to produce epidermal injury and postinflammatory hyperpigmentation. If an incision is too small, the in-and-out cannula friction will injure both the dermis and the epidermis with each cannula stroke, producing a hypertrophic and hyperpigmented scar. An often unrecognized source of epidermal trauma is an incessant tangential cannula stroking that rubs across the epidermis at the skin surrounding an incision. The surgeon can avoid this frictional epidermal trauma by gripping and subtly elevating the skin surrounding an incision; this permits the cannula to enter an incision at a slight angle, thereby avoiding repeated rubbing on the skin.

Incisional hyperpigmentation occurs most often on the upper abdomen and the back and least often on the skin of the thighs, arms, and submental chin, cheeks, and jowls.

When no excessive incision site trauma has occurred, the vast majority of hyperpigmented incision sites return to “normal,” eventually becoming invisible to the casual observer. In some patients with darkly pigmented skin, initial hyperpigmentation may eventually become mild hypopigmentation.

The risk of hyperpigmentation can be minimized with a gentle liposuction technique and judicious choice of incisions. In some patients the postinflammatory appearance at an incision site is caused by vascular prominence and capillary neogenesis, in addition to pigment deposition in macrophages after inflammation. On resolution of the hyperpigmentation and the capillary prominence, residual focal hypopigmentation is possible. Both hyperpigmentation and hypopigmentation usually improve with time (Figure 8-7).

Treatment. Incisional postinflammatory hyperpigmentation can be treated using topical agents, such as a hydroxyquinone or a kojic acid cream, that suppress pigment formation. This is a prudent approach, with minimal risks of exacerbating the clinical situation. Although significant postinflammatory hyperpigmentation is uncommon, all patients should be warned before their surgery about the potential for this type of dyschromia.

There have been anecdotal reports of using lasers to treat incision site hyperpigmentation. The effectiveness of lasers in the reduction of postinflammatory hyperpigmentation is somewhat debatable. Theoretically, a tunable pulsed-dye laser having a 585-angstrom wavelength might accelerate the disappearance of the capillary vascular component of postinflammatory hyperpigmentation. The Q-switched ruby laser has been mentioned as an effective treatment for certain pigmented lesions. Any laser, however, has the potential to exacerbate hyperpigmentation or precipitate hypopigmentation.

Vasovagal Syncope

Vasovagal presyncope and syncope (also known as neurocardiogenic, neurogenic, reflexogenic, vasodepressor, and neurally mediated syncope) are characterized by transient failure of physiologic mechanisms responsible for maintaining both blood pressure and cerebral blood flow. Vasovagal syncope is one of the most frequent causes of recurrent syncope in patients with a structurally normal heart. Two circulatory phenomena, systemic arterial vasodilation and bradycardia, are typically present. Cerebrovascular constriction may also contribute to the fainting.6 Neurocardiogenic syncope has been suggested as a cause of sudden infant death syndrome (SIDS).7

Vasovagal syncope is a sudden transient loss of consciousness that resolves spontaneously. It is caused by a reduction of blood flow to the brain. Abnormal autonomic nervous system control of cardiovascular homeostasis can impair blood supply to the brain and produce syncope in two different disorders: autonomic failure and vasovagal syncope. In autonomic failure, sympathetic regulation of vasoconstriction is chronically impaired, causing chronic orthostatic hypotension and syncope or presyncope. The head-up tilt table is a recent technique for evaluating autonomically mediated syncope.8,9 In vasovagal syncope, some episodic triggering event precipitates a failure of sympathetically mediated vasoconstriction, producing hypotension and syncope. Between syncopal episodes, patients with vasovagal syncope have normal blood pressure and orthostatic tolerance.10

Head or neck trauma resulting from a fall is the greatest risk associated with syncope. Fainting or syncope can occur before, during, or after surgical procedures done under local anesthesia, including liposuction. From 1990 through 1995, the Vaccine Adverse Event Reporting System in the United States documented 697 cases of syncope (57.5% female) within 12 hours after vaccination. Tonic or clonic movements, which have been associated with the anoxia of vasovagal syncope, were reported in 30.4% of syncopal episodes occurring 15 minutes or less and in 12.8% of those occurring 15 minutes or longer after vaccination (P<.001). The hospitalization rate was 9.6%. Six patients suffered skull fracture, cerebral bleeding, or cerebral contusion after falls; three of these patients required neurosurgery.11

Any surgical procedure in an awake patient can trigger vasovagal syncope. Vasovagal reactions occur in a small but significant number of blood donors.12 Among shoulder surgery patients in the sitting position under interscalene block anesthesia, at least 13% experience a vasovagal episode characterized by a sudden decrease in heart rate and blood pressure.13 Vasovagal reactions are a common complication during diagnostic hysteroscopy with endometrial biopsy in postmenopausal women.14

Liposuction Syncope

Because tumescent liposuction patients have mild fluid overload and slight hemodilution, it is unlikely that intravascular fluid deficiency is the cause of syncope associated with tumescent liposuction. Twenty-four hours after tumescent liposuction, patients are generally in a state of mild fluid overload with 5% to 10% hemodilution.

In the operating room (OR), near-syncope with lightheadedness and vomiting or nausea typically occurs in predisposed individuals with a history of fainting or dizziness at the sight of a medical procedure. A vasovagal loss of consciousness is unusual when lying supine.

Postliposuction lightheadedness or syncope most often occurs the morning after liposuction. It can be caused by at least three different stimuli: (1) the sight of blood-tinged anesthetic drainage on absorptive pads, (2) orthostatic decompression of the lower extremities on removal of postoperative compression garments, and (3) micturition syncope.15

Liposuction surgery is not necessarily the cause of syncope. For example, a patient who had not been given preoperative medication fainted from a standing position while the surgeon was taking preoperative photographs. She sustained a laceration on her occipital scalp; fortunately, neurologic examination and skull radiographs were normal. A husband fainted while helping his wife remove her blood-soaked absorptive pads; immediately afterward the wife also fainted.

Operating Room Near-Syncope

In the OR setting during tumescent liposuction totally by local anesthesia, true syncope is unusual. The syndrome of vasovagal near-syncope may occur, however, and represents the premonitory phase of neurocardiogenic syncope, which stops just before complete loss of consciousness.

Vasovagal near-syncope in a supine OR patient is distinctly different from a vasovagal event in a sitting or standing patient. Because the patient is already supine, loss of consciousness rarely occurs, and therefore the experience is more prolonged and causes more patient anxiety. With the onset of symptoms, the patient becomes intensely aware that something is wrong during a surgical procedure. It is a frightening experience. The situation must be managed quickly and efficiently, or the patient will lose confidence in the surgeon.

The first hint of the syndrome is often a vague sensation of malaise and lightheadedness. Then the patient’s skin appears ashen or pale and is damp, moist, and clammy; beaded perspiration and dilation of pupils may be seen. Within moments the patient experiences abdominal or epigastric distress, tachypnea, weakness, and confusion. The cardiac monitor reveals a relative bradycardia and confirms the diagnosis. Clinical examination reveals hypotension.

The OR staff should always be ready to treat an episode of vasovagal near-syncope. All the necessary items should be gathered together and easily accessible near the OR, such as an emesis basin and a prefilled syringe of atropine. Treatment of vasovagal syncope or near-syncope is 0.5 mg of IV atropine.

The primary concern is that patients may sustain injuries resulting from syncope before, during, or after surgery. The surgical team must take precautions to prevent such injuries. Preoperative photographs should be taken with a nurse standing next to the patient, ready to provide assistance if the patient becomes lightheaded.

Prevention. The question, “Do you ever become light-headed or feel faint when blood is taken for a laboratory test?” is a sensitive predictor of vasovagal near-syncope in the OR. If the patient has a positive history of fainting or lightheadedness that occurs with phlebotomy, a preemptive or prophylactic dose of IV atropine (0.3 to 0.4 mg) is given before surgery, as soon as IV access is established. An effective protocol consists of preparing a syringe by adding 1 mg of atropine (1 mg/ml) to 9 ml of bacteriostatic saline, which yields atropine at 1 mg/10 ml = 0.1 mg/ml.

Also, when inserting the IV catheter through the skin, the surgeon should inject a tiny bleb of plain lidocaine with bicarbonate into the dermis using a 30-gauge needle. Anesthetizing the skin before placing the IV catheter decreases the incidence of pain and anxiety and thus near-syncope.

Syncope at Home

Female patients in particular may experience lightheadedness, dizziness, near-syncope, or syncope at home after liposuction. This typically occurs in the bathroom on the morning after surgery, when the patient first removes her elastic compression garments. She may experience decompression orthostatic hypotension. The sight of the blood-tinged drainage on the absorptive pads may also contribute to the emotional stimuli that can precipitate vasovagal syncope. Urination followed by suddenly standing up may also contribute to the incidence of this “morning-after-liposuction syncope.” Postliposuction syncope causing a fall with head and neck trauma in a postliposuction patient has resulted in the subluxation of the second cervical vertebra and complete quadriplegia.

This morning-after-liposuction syncope is somewhat analogous to the common postpartum orthostatic postmicturition lightheadedness or dizziness that women experience the first two or three times they stand up to walk to the toilet after giving birth. It is said that 90% of women in the immediate postpartum period experience some degree of this orthostatic micturition near-syncope. Maternity ward nurses often have a vial of ammonia (smelling salts) taped to their name tag and ready for immediate use should a new mother faint.

Prevention. Liposuction surgeons should be aware that patients may faint after being discharged home. Postoperative instructions for the first 24 hours after liposuction should include suggestions for preventing syncope and the trauma resulting from a fall (Box 8-1).

Common Unwanted Consequences

Common unwanted consequences of liposuction are relatively minor problems that can usually be repaired. With skill, care, and experience the incidence of undesirable results can be minimized, but such problems can confront any surgeon. Even the most experienced surgeons must be alert and constantly vigilant to avoid the many potential pitfalls in liposuction technique.

Minor Superficial Irregularities

Lipotrop. Lipotrop is the excessive and uneven removal of fat that results in depressions, dimples, and grooves in the skin. The lipotrop is the most common undesirable effect of liposuction. Surgeons with an overaggressive surgical approach have attitudes that predispose to this abecedarian complication. It is usually the result of (1) excessively superficial and uneven liposuction using oversized cannulas, (2) overaggressive or clumsy technique, (3) inappropriate intraoperative patient positioning, (4) poor cannula selection, and (5) carelessness, inexperience, or haste.

Some patients might be predisposed to lipotrops in the sense that their fat is aspirated so effortlessly that more fat is removed than anticipated. Certain cannulas remove fat so quickly that an inattentive surgeon can easily remove an excessive volume. Lipotrops are usually apparent to both the surgeon and the patient within weeks.

Liponot. Liponot is a focal area of insufficient liposuction. Liponots that become apparent within weeks or months after surgery are typically the result of a grossly uneven liposuction technique.

Some subtle liponots may only appear years later after the patient has gained weight. There is a particular risk of creating liponots when too much fat has been removed from a wide area, for example, when a surgeon attempts to remove all the fat in an area, leaving skin and muscle fascia in direct contact. In attempting to achieve this goal, the surgeon will invariably leave small areas of thin fat deposits, which become apparent only after the patient has gained weight. Areas with no residual fat remain devoid of new fat after a weight gain, whereas adjacent areas with thin residual fat deposits increase in thickness as the patient gains weight and deposits fat in existing fat cells.

Irregularities, dents, waviness, and furrows are types of liponots and lipotrops.

Temporary Lumpiness

Transient nodular lumpiness is a common sequela of liposuction, typically first noticed by the patient 1 to 2 weeks after surgery. The condition becomes most pronounced between 2 and 4 weeks after surgery. This lumpiness may be the result of impaired lymphatic drainage and may be part of the normal healing process after liposuction.

The intensity of this tender condition can be minimized using open drainage and bimodal compression, which also decreases the duration of this phase in the postliposuction healing process.

Postliposuction Panniculitis

Postliposuction panniculitis is a peculiar variety of postoperative inflammation that results from microseroma formation due to incomplete drainage of blood-tinged tumescent anesthetic solution. Microseromas have become rare with the use of open drainage and bimodal compression.

Microseromas occur more frequently when drainage is inadequate. They are usually solitary, but occasionally several areas may be involved. The typical lesion appears as a discrete, pink, warm, tender, flat area of subcutaneous inflammation. These lesions are sterile, but an infection must be considered in the differential diagnosis.

Typically the patient complains of localized warmth, swelling, and tenderness, with visible erythema. The onset occurs after the drainage has ceased. Postliposuction panniculitis is more common when incisions are closed with sutures, thus entrapping the inflammatory blood-tinged anesthetic solution. It is less likely to occur when drainage is facilitated by open drainage and bimodal compression (Figure 8-8).

Bacterial culture and sensitivity testing are usually negative after incision and drainage of these localized subcutaneous lesions. If the surgeon cannot aspirate fluid for Gram stain or bacterial culture and the patient feels well, without other signs or symptoms of an infection, treatment of the inflammation can begin. First the patient is given oral antibiotics for a possible low-grade infection. Several days later, if there is no clinical change or evidence of an infection (fever, elevated polymorphonuclear leukocyte count, significant malaise), 10 mg of prednisone daily decreases inflammation in 2 days. Postliposuction panniculitis responds quickly to treatment with antibiotics and prednisone. Nonsteroidal antiinflammatory drugs (NSAIDs) are less effective.

When in a clinical situation that suggests postliposuction panniculitis, the surgeon must rule out the possibility of a localized infection before treatment with corticosteroids. Most patients show definite clinical improvement within 48 hours of treatment with prednisone. In addition, once an infection has been ruled out, the patient can receive NSAIDs (e.g., ibuprofen). NSAIDs can impair leukocyte function and are therefore relatively contraindicated in the clinical setting of a possible postoperative infection.

Facial Flushing

A transient, often subtle, and totally benign flushing of the face, neck, and chest can occur after tumescent liposuction, usually within 18 to 36 hours. Typically persisting for 12 to 48 hours, besides a redness of the affected skin, the flushing is asymptomatic and often unnoticed. Occasionally the flushing is obvious and often prompts a telephone call to the surgeon’s office. No treatment is required.

The process is probably mediated by prostaglandins generated by the inflammatory response to the tissue trauma. Surgical trauma and inflammation can generate prostaglandins, which are known to cause flushing (Figure 8-9).

Temperature Elevation

A minimal temperature elevation, less than 1° C, may occur in the first 24 hours after surgery. The pathogenesis of this mild febrile reaction is probably related to the systemic effects of prostaglandins generated by surgical trauma and inflammation. Prescribing acetaminophen (1 g) by mouth every 6 hours for at least the first 2 days after surgery seems to attenuate this febrile response.

Infections are extremely rare with tumescent liposuction. Nevertheless, the surgeon cannot ignore a possible infection when a patient reports a slight fever. Careful questioning over the telephone is usually sufficient to rule out infection. With no localized pain and tenderness, focal erythema, or malaise, infection is unlikely. If the surgeon cannot rule out an infection, the patient must have an immediate examination and clinical evaluation.

A significant elevation of body temperature after liposuction may be the result of an influenza-type viral syndrome. Typically the patient mentions a history of flulike symptoms among family or friends.

Edema and Ecchymosis

Legs and Ankles. Edema of the legs and ankles can occur after liposuction on any part of the lower extremity; this pitting edema is usually mild to moderate in degree. The risk of this distal edema increases with circumferential liposuction of either the leg or the thigh. Placing sutures in liposuction incision sites promotes and prolongs this edema. Pitting edema results from a combination of cannula-induced injury to subcutaneous lymphatics and postoperative edema, causing compression and occlusion of these lymphatic vessels.

The incidence of distal edema is greatly reduced by using open drainage and bimodal compression and avoiding circumferential liposuction of the thigh or leg.

Genitals. Swelling and bruising of the genitalia after abdominal liposuction result from blood-tinged fluid tracking distally under the effect of gravity and being funneled toward the genitalia by Scarpa’s fascia. Immediately after passing over the inguinal ligament, Scarpa’s fascia blends into the deep muscle fascia of the thigh. Scarpa’s fascia extends over the lower abdomen into the pubic area, where it is continuous with the fascia that envelops the female vulva and the male penis and scrotum (Figure 8-10).

This dependent postoperative edema of the genitals can be minimized with 2-mm adits and adequate compression. Before surgery, patients should be told that this edema is a common sequela of abdominal liposuction and resolves in 2 to 3 days.

Postoperative Soreness. Postoperative swelling, soreness, and ecchymosis can be dramatically reduced using open drainage and bimodal compression for postoperative care. Using sutures to close the incisions for cannula access increases postoperative edema and bruising. Prolonged high-compression dressings impair lymphatic drainage and thus prolong postliposuction edema (see Chapter 11).

With the tumescent technique, postoperative hematomas are rare and usually associated with inadequate compression during the first 12 postoperative hours (Figure 8-11; see also Chapter 30).

Typical postoperative bruising in any given patient is usually symmetric, with minimal variation between sides in terms of intensity and extent of ecchymosis. Symmetric bruising indicates that the bruising is not the result of a random injury to blood vessels.

On the other hand, the degree of bruising in individual patients varies greatly despite identical intraoperative and postoperative care. The variability among patients may be caused by endogenous or exogenous factors. Possible endogenous factors include genetic biochemical differences in the coagulation system. Exogenous sources include substances that affect platelet function, such as red wine, large quantities of garlic, or vitamin E supplementation.

Postoperative care that includes open drainage and bimodal compression minimizes bruising, swelling, discomfort, and tenderness (Figure 8-12).

Perioperative Tachycardia

Perioperative tachycardia can result from anxiety, epinephrine in the local anesthetic solution, and oral medications (e.g., ephedrine-like nasal decongestants). Patients with no significant history of cardiac dysrhythmias may have a genetic or congenital predisposition to tachydysrhythmias. An uncomfortably full bladder can also cause tachycardia and hypertension. Patients should be advised to avoid ephedrine-like drugs preoperatively.

Minimizing the exposure to epinephrine by limiting the dose contained in the tumescent local anesthetic solution is helpful. On most areas of the body an epinephrine concentration of 0.65 mg/L provides sufficient hemostasis and delayed absorption of lidocaine. On other areas, such as the medial abdomen, scapular back in women, breasts, and chin/neck areas, an epinephrine concentration of at least 1.0 mg/L is recommended. The preoperative history should specifically focus on any possibility of mitral valve prolapse, palpitations, or tachycardia. Clonidine, 0.1 mg by mouth immediately preoperatively, attenuates the tendency for tachycardias and provides sedation without the risk of respiratory depression seen with benzodiazepine sedatives.

Vascular Lacerations

Vascular injury by the liposuction cannula is rare when microcannulas are used. Good postoperative compression for the first 24 hours postoperatively should preclude any significant bleeding from veins. Significant arterial or venous bleeding is rare with liposuction. Exceptions may be the result of impaired platelet function, such as from aspirin, vitamin E, red wines, and high-dose garlic supplementation. Diabetic patients have an increased incidence of small vessel insufficiency, which might predispose to local tissue or skin necrosis after an otherwise insignificant injury to a blood vessel (Figure 8-13).

Fascia. Cannula-induced laceration of muscle fascia has been reported but likely is rare. Microcannulas reduce the risk of significant fascial damage. Patients are more likely to notify the surgeon of a fascial injury if awake and alert versus anesthetized by general anesthesia or heavy IV sedation.

Menstrual Irregularity

An occasional patient experiences transient menstrual irregularity. Typically the onset of menstruation is 1 or 2 weeks earlier than expected. No treatment is necessary, and the menstrual cycle returns to its predictable course within 1 or 2 months. The phenomenon is probably the result of posttraumatic perioperative prostaglandins. The use of corticosteroids in the early postoperative period also increases the incidence of breakthrough bleeding.

Skin Excisions

Modern liposuction techniques have made an anachronism of large, disfiguring skin excisions as an adjunct to body contouring (Figures 8-14 and 8-15). Excisions of skin after liposuction often produce scars and disappointing results. Skin excision is a last resort in cosmetic surgical body contouring. Liposuction should be done first and then an excision considered only if the results of liposuction are unsatisfactory. Liposuction can usually achieve superior cosmetic results. Disappointment in the appearance of the scars often outweighs any cosmetic improvement.

Most abdominal liposuction patients are satisfied with the results of simple liposuction. When liposuction is insufficient, abdominoplasty can be done as a secondary procedure. If skin excision and rectus muscle plication are found to be necessary despite previous liposuction, an abdominoplasty, done as a secondary, separate procedure, will minimize postoperative discomfort and the risk of complications.


Pseudocomplications are problems unrelated to liposuction that the patient or surgeon might perceive as complications of liposuction. They occur independent of liposuction, however, or the anesthesia used for liposuction.

Dimples and Muscles

Dimples of the thigh are easily visible and are not always a function of voluntary control. Dimples in this area are uncommon but not rare. The surgeon should mention a preexisting dimple to the patient before liposuction is attempted. A patient who only becomes aware of a dimple after liposuction may suspect the dimple is the result of inept surgery (Figure 8-16).

Voluntary dermal dystrophy is seen in patients who can voluntarily cause extensive dimpling of the skin. When a patient flexes the muscles, subcutaneous attachments between skin and muscle fascia cause dimpling and deformity that mimic the appearance of excessive or incompetent liposuction. It is important to identify and document this deformity preoperatively. Liposuction in an area affected by voluntary dermal dystrophy might exacerbate the situation (Figure 8-17).

Idiopathic Lipoatrophy

Idiopathic localized lipoatrophy is characterized by loss of adipose tissue without antecedent clinical inflammation. The terms fat atrophy, lipoatrophy, and lipodystrophy are often used as synonyms in the dermatology literature. Lipoatrophies, either generalized or localized, are uncommon conditions affecting the subcutaneous fat.

Localized involutional lipoatrophy is a common pattern of fat tissue response characterized by diminutive fat lobules resembling embryonic adipose tissue and macrophage infiltration. It is often associated with IM or intraarticular corticosteroid injections and antibiotic injections into the affected subcutaneous fat. The buttock and proximal extremities are most frequently involved.16

Generalized lipoatrophy is usually associated with some type of systemic disease, such as autoimmunity, inflammatory diseases, idiopathic conditions, and renal disease.17 Insulin lipoatrophy is a direct consequence of local insulin injections; this condition can improve with time if the patient can avoid repeated injection in the affected area. Other types of localized fat atrophy include connective tissue panniculitis, granulomatous lipoatrophy, α1-antitrypsin deficiency, scleroderma, lupus erythematosus, juvenile rheumatoid arthritis, lichen sclerosus, and dermatomyositis.18

Several well-recognized forms of lipoatrophy are not localized. Total lipoatrophy (Lawrence-Seip syndrome) is a rare acquired, congenital, or familial condition with total atrophy of visceral and subcutaneous fat. Familial cases appear to be autosomal recessive, with homozygous patients affected by the full syndrome. Associated conditions include hepatomegaly, increased bone growth, hyperlipidemia, and progression to diabetes mellitus. Partial lipoatrophy (Barraquer-Simons syndrome) characteristically is associated with cadaveric facies and often with glomerulonephritis and C3 hypocomplementemia.19 Lipoatrophic diabetes mellitus (Dunnigan syndrome) is a rare condition characterized by insulin-resistant diabetes and generalized lipoatrophy.20,21

Although idiopathic localized lipoatrophies are uncommon, liposuction surgeons should be aware of the various types of idopathic conditions that have been identified. When an idiopathic fat atrophy occurs at a site that is distant from any previous liposuction surgery, liposuction patients still might incorrectly conclude that the disfiguring localized loss of fat loss was caused by the liposuction procedure. To avoid such an accusation, the surgeon should document the areas treated by liposuction, using photographs of the preoperative topographic markings (Figure 8-18).

Semicircular Lipoatrophy. Semicircular lipoatrophy, or lipoatrophia semicircularis, is an unusual but well-described form of idiopathic localized lipoatrophy. The peculiar appearance, symmetric distribution, and unique and identical location of this localized fat atrophy are remarkable. It affects only the anterolateral thighs and is characterized by a bandlike semicircular depression 2 to 4 cm in width.22-24 I have seen two patients with this problem (Figure 8-19).

If semicircular lipoatrophy occurred in a patient after liposuction, most surgeons who are unaware of this clinical entity might conclude that the disfiguring localized fat atrophy was caused by liposuction.

Distal Lipoatrophy. Two unrelated patients with idiopathic distal lipoatrophy had complete absence of subcutaneous fat in the forearms and distal arms as well as in the legs and distal thighs (Figure 8-20). The condition had been present for years in both patients. The face was not affected, there was no family history of similar involvement, and neither patient was aware that the condition was unusual. Both patients were rather thin and had a truncal accumulation of subcutaneous fat. The distal fat atrophy of all four extremities produced the appearance of diproportionate central deposition of fat on the trunk.

Both patients were otherwise healthy, and no specific medical workup was indicated. Both requested liposuction of the abdomen. Because I did not understand the long-term prognosis for this condition, however, they were both advised that liposuction might not be in their best interest.

Several patients with adult-onset insulin-dependent diabetes mellitus had lipoatrophy that affected only the buttock and lower extremities.

Posttraumatic Lipoatrophy. Posttraumatic localized lipoatrophy is probably caused by localized inflammation of subcutaneous fat, which results in the replacement of fat lobules by fibrosis. This atrophy may be associated with liposuction, blunt trauma, or injections. When localized blunt trauma induces localized fat atrophy, the onset is usually delayed.

Posttraumatic localized lipoatrophy is rarely seen in association with liposuction. In my experience, only one patient might have had this localized lipoatrophy as the result of liposuction.

Patient Misperceptions of Drainage

Patients are told that open drainage and bimodal compression are specifically designed to encourage copious postoperative drainage. Despite these careful explanations, some patients become concerned that the drainage of blood-tinged anesthetic solution is whole blood. The resulting telephone call from a concerned patient or spouse requires serious consideration. Careful questioning, evaluation, and reassurance usually are sufficient to resolve the problem, but some patients still require examination by either the surgeon or an experienced staff nurse.

With the opposite type of “anxiety,” the patient is concerned that insufficient drainage of blood-tinged anesthetic solution will result in excessive swelling or delayed healing. This concern is usually unfounded. In any case, no serious long-term consequences occur from less-than-maximal drainage. Simple reassurance should allay the patient’s concern.


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  2. Gasparotti M: Technique. In Gasparotti M, Lewis CM, Toledo LS: Superficial liposuction, New York, 1993, Springer-Verlag.
  3. Pitman GH: Liposuction & aesthetic surgery, St Louis, 1993, Quality Medical Publishing.
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  5. Goodstein WA: Superficial liposculpture of the face and neck, Plast Reconstr Surg 98:988, 1996.
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  9. Barbey JT: Vasopressor syncope: diagnosis and management, Cardiol Clin 15:251-256, 1997.
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  11. Braun MM, Patriarca PA, Ellenberg SS: Syncope after immunization, Arch Pediatr Adolesc Med 151:255-259, 1997.
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  17. Peters MS, Winkelman RK: The histopathology of localized lipoatrophy, Br J Dermatol 114:27-36, 1986.
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Figure 8-1 Trauma-induced vesicles and ecchymosis on inner thigh and knee from excessive superficial liposuction. Such vesiculation is often an early clinical sign of inchoate, full-thickness dermal necrosis.

Figure 8-2 Erythema ab igne. This reticulated, hyperpigmented erythema results from excessive chronic thermal trauma to subdermal vascular plexus. This patient’s source of chronic heat exposure was an area (space) heater under his desk.

Figure 8-3 Erythema ab liporaspiration. This reticulated, blanching erythema is typically seen after superficial liposuction trauma to subdermal vascular plexus. As with erythema ab igne, the erythema of these three patients will not improve with time.

Figure 8-4 Seroma on right lower abdomen of this male patient first became apparent after vigorous physical activity 5 days after liposuction.

Figure 8-5 Full-thickness dermal necrosis after excessive superficial liposuction. Four different patients, all treated by same surgeon, developed full-thickness necrosis. Surgeon might have believed that dermal trauma would produce dermal contraction. A, Left medial thigh. B, Right medial thigh. C, Left back and flank area. D, Necrosis resulted in necrotizing fasciitis requiring extensive surgical debridement, with consequent disfiguring scars (see Figure 12-3).

Figure 8-6 Hyperpigmentation at microincision sites on flank and hip. Making too many incisions, as in this patient, should be avoided. Using microcannulas 15 and 22.5 cm (6 and 9 inches) long can help reduce number of incisions. Gentle technique minimizes cannula-induced trauma to epidermaldermal junction. These hyperpigmented areas were virtually invisible within 6 months.

Figure 8-7 Hypopigmentation of incision sites on abdomen. These scars were originally hyperpigmented because of trauma to incision site during vigorous liposuction of excessively fibrous subcutaneous fat in patient with previous abdominal liposuction. Hypopigmented scarring may eventually develop after initial postinflammatory hyperpigmentation.

Figure 8-8 Microseroma (postliposuction panniculitis) on lateral hip several days after surgery and cessation of drainage.

Figure 8-9 Flushing reaction on face, neck, and upper chest after liposuction. This reaction is transient, usually less than 24 hours, and completely benign.

Figure 8-10 Edema of genitals is common sequela of liposuction of lower abdomen and suprapubic area after tumescent liposuction. A, Lower abdomen shows area of liposuction. B, Penile and scrotal edema typically resolves in 3 to 4 days. In females, labial edema can occur after lower abdominal liposuction.

Figure 8-11 Hematoma and bruising of male breast resulting from inadequate postliposuction compression. Patient returned because of asymmetric bruising and bleeding approximately 6 hours after liposuction. Treatment included brief aspiration by liposuction, which removed approximately 60 ml of bloody fluid. Absorption pads held in place with two 6-inch torso binders provided high compression. Patient had no further bleeding, and problem resolved without further treatment.

Figure 8-12 Different degrees of bruising 5 days after tumescent liposuction in two patients. A, Greater degree of bruising without open drainage and bimodal compression. B, Minimal bruising with open drainage.

Figure 8-13 Full-thickness skin necrosis resulting from hematoma in patient with adult-onset diabetes. A, Eschar on left lower abdomen 4 weeks after surgery. B, Wound after debridement and wound contracture. During preoperative examination and immediately before surgery, patient repeatedly denied taking aspirin. After excessive intraoperative bleeding forced termination of liposuction surgery, patient admitted, “I never take aspirin. I only take baby aspirin.” Hematoma may have decreased cutaneous perfusion in this patient with impaired microvascular circulation.

Figure 8-14 Cosmetically displeasing scars on three patients who had skin excision for surgical body sculpturing. Such excisions usually are unnecessary and are not always a cosmetic improvement. A and B, Scars on abdomen and back after abdominoplasty and removal of “excessive” skin on waist. C, Scar after posterolateral thigh lift. D, Scars on proximal thigh after medial thigh lift.

Figure 8-15 Dermal necrosis after abdominoplasty resulting from liposuction and skin excision that compromised cutaneous vascular supply.

Figure 8-16 Bilaterally symmetric dimples of lateral thigh are unusual. Patient may not notice a preexisting unilateral dimple until after liposuction.

Figure 8-17 A and B, Voluntary dermal deformity of buttocks, before and after tightening buttock muscles. C and D, Voluntary dermal deformity of lateral thigh and buttock area. E and F, Another voluntary dermal deformity of buttocks.

Figure 8-18 Forms of idiopathic fat atrophy are pseudocomplications that may first become apparent months or years after liposuction. Because idiopathic fat atrophy may easily be confused with true lipotrop, patient might wrongly attribute defect to excessive liposuction. A, Idiopathic focal fat atrophy on right thigh. B, Morphea, or localized scleroderma, on buttock of patient who never had liposuction. Focal hypopigmentation overlying this peculiar form of lipoatrophy histologically shows marked degree of fibrosis within superficial subcutaneous fat.

Figure 8-19 Idiopathic semicircular lipoatrophy is characterized by bandlike semicircular depression 2 to 4 cm in width affecting anterolateral thighs.

Figure 8-20 Idiopathic distal fat atrophy of all four extremities, with compensatory relative degree of truncal obesity. A, Complete loss of subcutaneous fat overlying lateral thigh and trochanteric tubercles. B,

Upper extremity fat atrophy contrasts with relatively fat abdomen and torso. C, Posterior view demonstrates contrast between extremities with fat atrophy and unaffected torso.

BOX 8-1 Preventive Measures for Syncope
1.   Remove postoperative compression garments slowly and if possible with someone’s assistance. Take garments off one at a time, waiting a minute or two before removing successive garments.
2.   Stand up slowly after urinating.
3.   Have someone in the bathroom for assistance when showering for the first time.
4.   If feeling dizzy or lightheaded, immediately sit or lie down in the shower or on the floor until free of symptoms.
5.   Do not be alarmed by a large amount of blood-tinged drainage on the absorptive pads; the more drainage, the less bruising and swelling.
6.   Do not remove the garments with a completely empty stomach. To avoid hypoglycemia, which may increase the risk of postoperative syncope, eat before removing garments to take a shower and change the dressings.
7.   Do not lock the bathroom door when showering or urinating.
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