Liposuction Principles and Practice - part 8 pot

398 59 Medical Legal Problems in Liposuction posuction. Two hours postoperatively there was a significant drop in blood pressure to 80/47. He was given increased intravenous fluids. For the next 3.5 h, the blood pressure varied from a high of 105/68 to a low of 66/40. This was followed for the next 1 h and 10 min by systolic blood pressures in the 70s. The patient was then transferred to the intensive care unit. HCT ordered at 1945 hours was reported at 2100 hours as 30.9. Repeat HCT at 2245 hours was 20.8. Packed cells were ordered at 0005 hours on July 3, 1998, and trans - fusions were begun at 0015 hours. The patient had cardiac arrest at 0030 hours and was pronounced dead at 0135 hours. Autopsy showed the cause of death to be from exsanguination with 1,600 ml of blood in the liposuction area of the abdominal wall, 400 ml in the scrotal sac, and extensive hemorrhage in the subcutaneous tissues extending to the back. There was a settlement for an undisclosed amount. Comment: Hypotension following a major surgical procedure is primarily caused by blood loss. HCT should have been ordered 2 h postoperatively when the first hypotensive episode occurred. The low blood pressure did not respond adequately to crystalloids. When the HCT was 30.9 at 2100 hours, blood should have been given. Packed cells are not indicated for hypotension following blood loss unless albumin or Hespan is used at the same time. Whole blood is the better means of expanding the vascular volume. By the time the patient had had severe hypotension for over 1 h, there was little likelihood of survival because of irreversible shock from extensive tissue damage. A timely diagnosis and treatment of blood loss would have saved this patient’s life. 59.16 Estate of Marinelli vs Geffner, New Jersey Superior Court (1999). In Medical Malpractice Verdicts, Settlements & Experts 1999;15(8):37 The 23-year-old female plaintiff’s decedent had liposuction by the defendant dermatologist in May 1994. One day following the surgery the patient died from a pulmonary embolus. The plaintiff claimed that the defendant was negligent in failing to tell the decedent not to take birth control pills and also applied the bandages in a manner which cut off the circulation and caused blood clots to form. There was also a ques- tion raised about the use of liposuction in a woman weighing only 115 lb. There was a $558,000 verdict. Comment: It is essential that patients discontinue birth control pills prior to cosmetic surgery over 1 h. Cutting off the circulation with bandages would result in edema of the extremity but not deep vein thrombo- sis. Liposuction can be performed in a patient of any weight and is dependent upon the abnormal location of the fat deposits rather than the patient’s weight. 59.17 Donnell-Behringer vs McCann, Los Angeles County (CA) Superior Court, Case No. VC26507. In Medical Malpractice Verdicts, Settlements & Experts 2000;16(8):50 The 45-year-old plaintiff had surgery on her shoulder and liposuction in the defendant’s outpatient surgery clinic. She had follow-up visits with the defendant on the first and second postoperative days. On the third postoperative day, the plaintiff was admitted to the hospital by another doctor for infection of the liposuction site that required surgery. The plaintiff alleged that the defendant negligently performed liposuction, failed to utilize proper surgical techniques, and was negligent in postoperative care. The defendant claimed that he was not negligent, that the standard of care had been met, and that infection was a risk of the procedure. There was a $902,000 verdict that was reduced through MICRA to $660,000. Comment: Infection is a known risk of any surgical procedure. The fact that infection occurred and was not timely recognized by the surgeon despite regu- lar office visits was enough to convince the jury of a breach in the standard of care. Since the patient had to be admitted to the hospital and operated upon by another doctor, there is evidence that the infection was diagnosable by another physician within 1 day of having been seen by the defendant 59.18 Trebold vs Fowler, Dallas County (TX) District Court, Case No. 00-6073-D. In Medical Malpractice Verdicts, Settlements & Experts 2002;18(8):55 The 44-year-old plaintiff had liposuction of the abdomen and thighs. Postoperatively discoloration and necrosis of the skin of the abdomen and thighs developed that required debridement and packing. The result was disfiguring scars of the abdomen and thighs. The plaintiff alleged breach in the standard of care. The defendant claimed that the plaintiff failed to follow postoperative instructions. There was a $291,000 verdict with the plaintiff 20% negligent. Comment: Infection, necrosis, and scarring are known complications of liposuction. Despite a lack in the breach of the standard of care, the jury found for the plaintiff possibly because of the severity of the necrosis and scarring and prolonged recovery. 399 59.19 Medical Board of Texas vs Ramirez, 1987 In 1987, a young 5’ 1’’, 117-lb female patient had liposuction of the abdomen. No preoperative or postoperative antibiotics were administered. Two days postoperatively the patient developed an overwhelming infection and sepsis. She was admitted to the hospital and treated with intravenous antibiotics, but she died. Comment: Sterility is a sine qua non of any surgical procedure. Instruments and wounds should be handled with strict sterile precautions. The cavalier attitude of some surgeons not to use masks, gowns, sterile drapes, and a sterile surgical suite to perform liposuction risks patient lives. Liposuction causes extensive internal tissue damage and the standard of care requires perioperative antibiotics. 59.20 Informed Consent 59.20.1 Definition The patient has the absolute right to receive enough information about his/her diagnosis, proposed treatment, prognosis, and possible risks of proposed therapy and alternatives to enable the patient to make a knowledgeable decision. The patient is the one who makes all the decisions in opposition to the old pater- nalistic theory that gave the physician complete control over all decisions. A physician would now have to prove that the decision he/she made was because of the patient’s inability to make the decision or because there was an extreme emergency. Other requirements of the “informed consent” doctrine in law require that a complication which was not explained to the patient did in fact occur and that the patient would not have agreed to have the surgery if informed of that particular risk or complication. 59.20.2 Legal Definition In terms of surgical procedures, the patient must have explained to him/her the nature and purpose of any proposed operation or treatment, any viable alternatives, and the material risks and benefits of both. All questions must be answered. In order for the plaintiff to succeed in a complaint for lack of informed consent, he/she must show both of the following: 1. That the risk or complication, which was not ex - plained to him, indeed did occur 2. That if he had been informed of that particular risk, he would not have consented to the surgical procedure There are different means of proof at trial depending upon the jurisdiction (state). The expert opinion as to what risks are “material” to the patient in order to make his/her decision, under the same or similar circumstances, can be that of: 1. A reasonably prudent physician. This allows a phy - sician to testify as to what is material. 2. A reasonably prudent patient. This allows the jury to decide what a reasonably prudent patient would consider material risks. 3. The plaintiff patient. This places the onus on the plaintiff to decide what would be material risks for him/her. The Illinois Appeals Court, in Zalazar vs Vercimak (1994) [21], decided that the subjective (patient) standard is less of an “insurmountable” barrier than the objective standard (reasonably prudent physician or reasonably prudent patient) would be. The court be- lieved that the decision whether to elect cosmetic surgery is personal and third-party testimony as to the decision a reasonably prudent person would make under similar circumstances would be of limited value. In Parikh vs Cunningham (1986) [22] the plaintiff had signed a release prior to surgery, which authorized the treatment, recited the procedures to be performed, and recited that the risks and consequences had been explained and that no guarantees or assurances had been made as to the results. The court reversed a jury verdict for the defendant physician where the jury in- struction stated that a written consent, executed by a person mentally and physically competent to give consent, gave rise to a conclusive presumption of informed consent. The court held that there must be more than just a writing introduced as evidence and that the ele- ments of informed consent must be established. In Largey vs Rothman (1988) [23], the New Jersey Supreme Court adopted the “prudent patient” standard for informed consent. The court held that the disclosure of “material risks” is determined by what a reasonable patient, in what the physician knows or should know to be in the patient’s position, would be likely to attach significance to the risk or cluster of risks in deciding whether to forego the proposed therapy or to submit to it. 59.20.3 Suggestions For Office Methods for preventing litigation concerning informed consent are misunderstood by most physi- 59.20 Informed Consent 400 59 Medical Legal Problems in Liposuction cians who are convinced that a patient’s signature or initials on a list of risks and complications will forego the problem. You can be assured that every time there is litigation, the patient will testify to the “fact” that the defendant physician did not explain the risks to him/her and that he/she did not read the consent form with all the risks listed despite his/her signature. The following recommendations are made: 1. The physician should explain all material risks and viable alternatives and their risks and complications and answer all the patients’ questions. In the alter- native, if the surgical procedure, alternatives, and risks and complications are explained by audiovi- sual methods or by other health care personnel, the physician has the responsibility to meet with the patient to answer all questions and verify the patient’s understanding of the surgery and risks. 2. The medical record should contain the following: “The surgical procedure was explained to the patient and risks and complications were discussed as well as viable alternatives and their risks and complications. All questions were answered.” 3. Any witness to the patient’s signature or initials concerning information for informed consent should have the following statement above the witness signature: “I requested that the patient read the complete form. I personally observed the patient read the form. The patient stated to me that all the material was read and, after all questions were answered, understood the complete form before signing.” 4. Except under special circumstances, the physician should meet with the patient prior to the day of surgery to establish some personal rapport. Some- times it is not possible to consult with the patient directly before the day of surgery if the patient is from out of town and arrives shortly before the day of surgery. It is usually possible to meet with this type of patient the evening before surgery if the physician is insistent. Remember that it is the physician’s ultimate responsibility to establish the relationship and make sure the information necessary for the patient to make a knowledgeable decision has been received and understood. The day of surgery is a relatively poor time to try to explain all that is necessary when the patient is nervous, fear- ful, and is finding it hard to concentrate on what the physician is trying to explain. 59.20.4 Medications The patient has the right to know what medications are being given, the purpose of the medication, and the possible risks and complications of the medication. This can usually be done by means of a written explanation describing all the information about the drug or by discussion with the patient by the physician or by other adequately trained health care personnel. The following recommendations are made: 1. The medical record should contain the fact that a discussion about the medication was held or that the patient received written information. 2. Check allergies to drugs. 3. Evaluate need for laboratory studies as per the Phy- sician’s Desk Reference (PDR). 4. Prescribe for the purposes as set forth in the PDR. If off-label use is decided upon, all the reasons should be set down in the medical record. 5. Prescribe or dispense only in small quantities for the period of time needed. 6. Refills should be recorded in the chart and should be cautiously given especially if it is a controlled substance. Remember that the physician has the fi- nal determination as to how much and how often a medication should be taken. Do not let the patient control the medication prescription. If overuse is detected, then refuse all further refills and record this in the chart or refer to another physician for evaluation specifically for the drug use. 59.21 Discussion Analysis of the cases of liposuction disasters reviewed by the author, a few of which are included in this chap- ter, shows that most of the problems occur from lack of knowledge of or errors by the physician. Basically, many of the events, although not always preventable, are foreseeable and should have been planned for. Every office should be prepared for an acute aller- gic reaction or cardiopulmonary arrest. The proper equipment and medications must be available and the office staff trained for any type of emergency. At least one person in the office must have advanced cardiac life support (ACLS) certification as long as any postoperative patient is in the office. The physician and staff must know and understand all possible postoperative complications. Any inflammation, excessive swelling and pain in the wound area, or fever has to be timely investigated for possible infection. High fever treated with antibiotics and followed by hypotension should be considered possible toxic shock syndrome (Table 59.1). When a patient complains about bleeding from the wound, this must be taken seriously rather than 401 passed off as the usual wound drainage of tumescent solution. If a patient has persistent dizziness when standing up or even sitting up, blood loss with ortho- static hypotension should be the first consideration. Chest pain following surgery should be considered a possible life-threatening situation and a workup should be performed to rule out pulmonary embolus, pneumonitis, myocardial ischemia, and myocardial infarction. Rao et al. [25] reported four deaths related to tumescent liposuction. The authors concluded that two of the deaths were related to lidocaine toxicity or lidocaine-related drug interactions although this is not confirmed in the article. Both patients had hypotension, bradycardia, and then cardiac arrest. Another patient had severe postoperative anemia and received blood transfusions, morphine and intravenous fluids. She was discharged after 2 days but developed wors - ening dyspnea and an episode of syncope. Ventricular fibrillation ensued and the patient was resuscitated. Pulmonary edema was diagnosed and apparently treated but she remained in anoxic coma. Death ensued 3 days later. The last patient died from a saddle pulmonary embolus 25 h after surgery. Lidocaine lev - els were 5.2and 2 mg/l in the first two patients and 2.9 mg/l in the last patient. Plasma concentration of lidocaine is related to toxicity symptoms [26] (Table 59.2). The rapider the injection, the lower the plasma concentration necessary for toxicity. Respiratory acidosis, and to a lesser degree metabolic acidosis, with increased PaCO 2 and decreased arterial pH decreases the convulsant threshold of local anesthetics. Cardiovascular collapse has been described at concentrations of 10 mg/l [27]. In postmortem studies, concentrations of 4–6 mg/l have been reported in deaths attributed to lidocaine [28, 29]. Anesthetists and anesthesiologists should be warned to limit intravenous fluids when more than 3,000 ml tumescent fluid is infiltrated into the sub - cutaneous space. If there is a preoperative blood pressure problem, no anesthesia, even local, should be administered until the pressure has been controlled and the cause identified. Certainly, surgery should not be continued until the cause of hypotension is determined and treated. Megaliposuction (over 10,000 ml total aspirate) should be done only with proper monitoring and in a hospital setting. The morbidly obese (more than 100 lb overweight) patient will usually have medical problems which increase the risk of anesthesia. Pos- sible fluid balance problems and blood loss requires ready access to laboratory studies. Patient safety is more important than simply achieving a successful megaliposuction in the office. 59.22 Conclusions Liposuction disasters are usually preventable or treatable with adequate preparation by the surgeon, including information to the patient, being cognizant of the causes of complications and avoiding them, timely diagnosis of complications, and understanding the various treatments available for each possible complication. References 1. Dillerud, E.: Suction lipoplasty: A report on complications, desired results, and patient satisfaction based on 3511 procedures. Plast Reconstr Surg 1991; 88(2):239–246 Table 59.1. Centers for disease control: criteria for diagnosis of toxic shock syndrome (Adapted from Ref. [24]) 1. Fever (>102°F) 2. Rash (diffuse, macular erythroderma) 3. Desquamation (1–2 weeks after onset, especially of palms and soles) 4. Hypotension 5. Involvement of three or more organ systems: – Gastrointestinal (vomiting, diarrhea at onset) – Muscular (myalgia, elevated CPK) – Mucous membrane (conjunctiva, oropharynx) – Renal (BUN or creatinine > 2 times normal) – Hepatic (bilirubin, SGOT, SGPT > 2 times normal) – Hematologic (platelets < 100,000) – CNS (disorientation) 6. Negative results on the following studies (if obtained): – Blood, throat, or CSF cultures – Serologic tests for Rocky Mountain spotted fever, leptospirosis, measles Table 59.2. Plasma concentration of lidocaine and toxicity symptoms Plasma level (µg/ml) Symptoms 3–4 Circumoral and tongue numbness 4–4.5 Lightheadedness, tinnitus 6–6.5 Visual disturbances 7.2–8.2 Muscular twitching 10–10.5 Convulsions 11.5–12 Unconsciousness 15–16 Coma 19–20 Respiratory arrest 23–25 Cardiovascular depression References 402 59 Medical Legal Problems in Liposuction 2. Hanke, C.W., Bernstein, G., Bullock, S.: Safety of tumes - cent liposuction in 15, 336 patients: National survey results. Dermatol Surg 1995; 21:459–462 3. Illouz, Y.G.: Body contouring by lipolysis: A 5-year experience with over 3000 cases. Plast Reconstr Surg 1983; 72(5):591–597 4. Pitman, G.H., Teimourian, B.: Suction lipectomy: Com- plications and results by survey. Plast Reconstr Surg 1985; 76(1):65–72 5. Fournier, P.F., Eed, M., Fikioris, A., Ioannidis, G.: La liposculpture dans l’obesite. Rev Chirurg Esthet Langue Fran- caise 1992; 17(69):43–52 6. Klein, J.A.: The tumescent technique for liposuction surgery. Presented at the Second World Congress of Liposuc- tion Surgery of the American Academy of Cosmetic Sur- gery, Philadelphia, June 1986 7. Klein, J.A: The tumescent technique for lipo-suction surgery. Am J Cosm Surg 1987; 4(4):263–267 8. Klein, JA: Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Der- matol Surg Onc 1990;16:248–263 9. Klein, JA: Tumescent technique chronicles: Local anesthesia, liposuction and beyond. Dermatol Surg 1995;21: 449–457 10. Lillis, P.J.: Liposuction surgery under local anesthesia: Limited blood loss and minimal lidocaine absorption. J Dermatol Surg Oncol 1988;14:1145–1148 11. Burk, R.W., Guzman-Stein, G., Vasconez, L.O.: Lidocaine and epinephrine levels in tumescent technique liposuction. Plast Reconstr Surg 1996;97(7):1378–1384 12. Coleman, W.P. III: Controversies in liposuction. Cosmet Dermatol 1995;8:40–41 13. Lillis, P.J.: The tumescent technique for liposuction surgery. Dermatol Clin 1990;8(3):439–450 14. Ostad, A., Kayeyama, N., Moy, R.L.: Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol Surg 1996;22:921–927 15. Samdal, F., Amland, P.F., Bugge, J.F.: Plasma lidocaine levels during suction-assisted lipectomy using large doses of dilute lidocaine with epinephrine. Plast Reconstr Surg 1994;93:1217–1223 16. Klein, JA, Kassardjian, N.: Lidocaine toxicity with tumescent liposuction: A case report of probable drug interactions. Dermatol Surg 1997;23:1168–1174 17. Illouz, Y-G: Refinements in lipoplasty technique. Clin Plast Surg 1989;16(2):217–233 18. American Academy of Cosmetic Surgery: 1997 Guidelines for liposuction surgery. Amer J Cosm Surg 1997:14(4): 389–392 19. Chrisman, B.B., Coleman, W.P.: Determining safe limits for untransfused outpatient liposuction: Personal experience and review of the literature. Dermatol Surg Oncol 1988;14(10):1095–1102 20. Shiffman, M.A.: Anesthesia risks in patients who have had antiobesity medication. Am J Cosm Surg 1998;15(1):3–5 21. Zalazar v. Vercimak, 261 Ill.App.3d 250, 199 Ill.Dec. 232, 633 N.E.2d 1223 (Ill.App. 3 Dist. 1993) 22. Parikh v. Cunningham, 493 So. 2d 999 (Fla. 1986) 23. Largey v. Rothman, 540 A. 2d 504 (N.J. 1988) 24. Morbidity Mortality Weekly Rev 1980;29:441–445 25. Rao, R.B., Ely, S.F., Hoffman, R.S.: Deaths related to liposuction. New Engl J Med 1999;340(19): 26. Strichartz, B.: Local anesthetics. In Anesthesia, Miller, R.D. (ed), New York, Churchill Livingstone, 1994 27. Goldfrank, L.R., Flomenbaum, N.E., Lewin, N.A., Weis- man, R.S., Howland, M.A., Hoffman, R.S. (eds), Gold- frank’s Toxilogic Emergencies, 5th edition, Norwalk, Connecticut, Appleton & Lange 1994:717–719 28. Christie, J.L.: Fatal consequences of local anesthesia: report of five cases and a review of the literature. J Forensic Sci 1976;21:671–679 29. Peat, M.A., Deyman, M.E., Crouch, D.J., Margot, P., Finkle, B.S.: Concentrations of lidocaine and monoethylglyclxyli- dide (MEGX) in lidocaine associated deaths. J Forensic Sci 1985;30:1048–1057 Part XII Commentary Part XII Editor’s Commentary Melvin A. Shiffman C  60 60.1 Introduction I have taken the liberty to try to place into perspective some of the material in this book and some material that is not in the book. This allows a general overview of liposuction from a personal point of view. 60.2 Terminology There is some confusion at times with the term “cellulitis,” meaning excess fat as may be used outside the USA. Cellulitis in the dictionary is described as sup- purative inflammation of the subcutaneous tissues [1]. The term “cellulite” (not found in the medical dictionary) is ordinarily used to mean indentations caused by excess fat (cheesy appearance). Outside the USA the term may be used to mean excess accumulation of fat, similar to the term lipodystrophy. “Li- podystrophy” is used by most cosmetic surgeons, at least in the USA, to mean an abnormal increase in fat accumulation especially in localized areas. In the dictionary, lipodystrophy is a term used to describe any disturbance of fat metabolism or defective fat metabolism with loss of subcutaneous fat [2]. Lipodysmor- phic refers to fat that is “dysmorphic” or malformed, disrupted, or deformed [3]. “Lipohypertrophy” may be a more appropriate term to use since it means hy- pertrophy of subcutaneous fat [4]. There has not been consensus as to the meaning of the terms “large-volume liposuction” and “megaliposuction.” Not only the total amounts taken out are at controversy but also the content, fat (supranatant) versus fat plus fluid (supranatant and infranatant). Some of this problem stems from the attempts to limit liposuction to 5,000 ml by government agencies where it is important to the cosmetic surgeon that the limitation concerns only the amount of fat removed. If fat (supranatant) alone is considered, then the total amount removed can be 20–40% more. The easiest method to define the terms is with total (fluid and fat) aspirant, 5,000–10,000 ml being large-volume li - posuction and over 10,000 ml being megaliposuction. In this way fat is not the only determining factor. 60.3 Obesity There is no doubt that liposuction is indicated for and can be used in the obese and morbidly obese (over 100 lb from the ideal weight) patient. There can be improvement in the cardiovascular status of the morbidly obese patient as well as a reduction in the need for cardiac or diabetic medication. Although the contours may be improved somewhat in the obese or morbidly obese patient, good cosmetic results should not be anticipated. Further procedures may be necessary to improve the appearance, i.e., abdominoplasty (usually less extensive after liposuction than a full abdominoplasty), repeat liposuction, brachioplasty, and other surgical contouring procedures. Liposuction may induce the obese patient to start losing weight. A weight-loss program may be started but most of these patients will not maintain a strict diet. 60.4 Power-Assisted Liposuction The use of powered equipment makes removal of fat easier in liposuction; however, the vibration is possibly a problem for the surgeon. Surgeons have a potential to develop arthritis, ulnar palsy, carpal tunnel syndrome, elbow problems, as well as a hand, arm, and shoulder syndrome. 60.5 New Technologies There are on the market many types of medications that can be injected into the tissues to cause loss of fat that is termed mesotherapy. Mesotherapy may contain aminophylline, plant extracts, phosphatidyl choline, vitamins, and other medications that sup- 406 60 Editor’s Commentary posedly cause a general dissolution of fat over parts of the body [5]. This is a common method of treatment outside the USA. Mesotherapy shows a reduction of fat in an area when phosphatidyl choline is injected into the mid dermis. There have not been substan- tial studies to show what percentage and amount of phosphatidyl choline should be used when injected, the amount of spread of the medication, and what the limitations are. I cannot comment on the procedure since I have not had experience with this method. Endermologie has been found to reduce fat, essen- tially by “crushing” the cells with the machine, and may be useful for some improvement in body contour [6]. Similar to the reciprocating cannula, the rotating cannula for liposuction can reduce fat in certain lipo- dystrophies that are not easy to treat, i.e., epigastrium, knees, and upper back [7]. The vibrations, as with any of the powered cannulas, have the potential of causing problems for the surgeon in the form of shoulder, arm, and hand syndromes. Injection of carbon dioxide has been utilized to treat localized adiposities [8]. This was found useful in accumulations located in the knees, thighs, and abdomen. This is not a permanent solution for the ac- cumulated fat. There is a report of a new device consisting of an external extension of the cannula with a guard wheel resulting in less uneven appearance, asymmetry, and inadequate removal of fat [9]. The device is very similar to Fischer’s “swan-neck” cannula that helps the surgeon to maintain an even cannula depth [10]. Laser-assisted liposuction (Neira, Chap. 47) is a new technology with the potential of reducing the work required to remove the fat. The most interesting aspect of this work is that laser does not destroy the fat cell but actually causes loss of the fat from the cell through micropores. A less expensive and equally effective method is with percussion massage-assisted liposuction (Shiffman and Mirrafati, Chap. 46). Lipostabil (phosphatidyl choline, Aventis, Stras- bourg, France) given intravenously is an alleged burner of fat and, theoretically, can break down fat [5]. The clinical studies show hypolipidemic effects of lipostabil but not actual fat cell breakdown [11–13]. 60.6 Anesthesia The use of articaine (Fatemi, Chap. 13) instead of lidocaine is an interesting idea with some merit since the toxicity of articaine is less than that of lidocaine. Local tumescent anesthesia is fine for those surgeons who do limited volumes of liposuction and are not concerned with a prolonged surgical procedure. Large-volume liposuction under local tumescent anesthesia would be limited because a ratio of tumescent fluid to total aspirate of 2:1 or 3:1 limits the amount used for tumescence to avoid lidocaine toxicity. There are many patients who do not wish to be awake during the procedure and hear what is going on around them. Others prefer one procedure to multiple procedures to remove the same amount of fat. The cost to the patient having local tumescent anesthesia is con- comitantly increased because of the prolonged time to perform the surgery and the surgeon has to limit the number of procedures that can be performed in one day. Local tumescent anesthesia assisted with intravenous sedation is a safe method to perform liposuction. General anesthesia is safe if given and monitored properly (Shiffman, Chap. 54). Marcaine should be contraindicated in liposuction tumescent fluid since it is totally unnecessary and highly dangerous since it can bind with the myocar- dium if excess is administered or if it is administered too rapidly. If cardiac arrest occurs, there is almost no chance to resuscitate the patient [14]. 60.7 Reduced Negative Pressure Elam (Chap. 44) has resolved one of the major causes of bleeding and bruising following liposuction with the reduction of the vacuum pressure (from 760 mmHg or 1 atm vacuum to 250–300 mmHg vacuum) when using the liposuction machine. This simple maneuver has not as yet been taken into account by most liposuction surgeons. The vacuum can also be reduced in syringe liposuction by venting the syringe with air or saline prior to use (place 2 ml of saline or air in a 20- ml syringe prior to use). 60.8 Ultrasound-Assisted Liposuction Surgeons still use ultrasonics, externally and internal- ly, to emulsify the fat prior to suctioning. The cost of the machines is excessive and perhaps unwarranted. The use of the external percussion massage machine (Shiffman and Mirrafati, Chap. 46) usually at a cost of less than US $100 results in the same emulsifica- tion and ease of removal. There may be indications for the use of ultrasound-assisted liposuction in the face but the amounts removed are so small that the cost of the machine would override the benefits to the surgeon. External ultrasound is more useful postoperatively, after 3 weeks ( bleeding may occur in the tissues if used sooner), to reduce the fibrosis. 407 60.9 Combination Liposuction and Abdominoplasty Despite Matarasso’s [15, 16] caution about doing liposuction on certain areas of the abdomen at the same time as doing full abdominoplasty, there is still some lack of understanding of the dangers by some phy- sicians. Combining extensive abdominal liposuction and full abdominoplasty at the same time increases the danger of fat embolism and thromboembolic complications as well as necrosis. When extensive liposuction is performed prior to and at a separate time from abdominoplasty it is important not to perform a full abdominoplasty because of the increased risk of flap necrosis. It may be more prudent to perform full abdominoplasty first and, after complete healing, liposuction can be performed without restriction to the extent and area of liposuction. 60.10 Aesthetic Medicine Gasparotti (Chap. 29) describes the reduction of fat, reduced circumference of the extremity, and improvement in cellulite with the use of Cellasene (a herbal medication) and compares this with data for liposuction patients. The author has no experience with this medication. References 1. Dorland’s Illustrated Medical Dictionary, 28 th Edition. Philadelphia, W.B. Saunders Company 1994:295 2. Dorland’s Illustrated Medical Dictionary, 28 th Edition. Philadelphia, W.B. Saunders Company 1994:948 3. Dorland’s Illustrated Medical Dictionary, 28 th Edition. Philadelphia, W.B. Saunders Company 1994:949 4. Dorland’s Illustrated Medical Dictionary, 28 th Edition. Philadelphia, W.B. Saunders Company 1994:516 5. Palkhivala, A.: Noninvasive fat melting: the facts and the fantasy. Cosm Surg Times 2004;7(1):1,48 6. Burkhardt, B.R.: Endermologie. Plast Reconstr Surg 1999;104(5):1584 Correspondence 7. Mole, B.: Suction with rotating cannula. Am J Cosm Surg 1996;13(3):219–225 8. Brandi, C., D’Aniello, C., Grimaldi, L., Bosi, B., Dei, I., Lattarulo, P., Alessandrini, C.: Carbon dioxide therapy in the treatment of localized adiposities: clinical study and histopathological correlations. Aesthet Plast Surg 2001;25:170–174 9. Lee, H.: A new device to avoid unfavorable results in suction lipectomy. Plast Reconstr Surg 1987;79(5):814–822 10. Fischer, G.: History of my procedure, the harpstring technique and the sterile fat safety box. In Fournier, P. (ed), Liposculpture: The Syringe Technique, Paris, Arnette- Blackwell 1991:9–17 11. Mel’chinskaia, E.N., Gromnatskii, N.I., Kirichenko, L.L.: Hypolipidemic effects of alisat and lipostabil in patients with diabetes mellitus. Ter Arkh 2000;72(8):57–58 12. Pogosheva, A.V., Bobkova, S.N., Samsonov, M.A., Vasil’ev, A.V.: Comparative evaluation of hypolipidemic effects of omega-3-polyunsaturated acids and lipostabil. Vopr Pitan 1996;4:31–33 13. Bobkova, V.I., Lokshina, L.I., Korsunskii, V.N., Tanano- va, G.V.: Metabolic effect of lipostabil-forte. Kardiologiia 1989;29(10):57–60 14. Ersek, R.: The risk associated with using Marcaine is too great. Aesthet Surg J 1997;17(4):268,270 15. Matarasso, A., Matarasso, S.L.: When does your Lipo- plasty patient require an abdominoplasty? Dermatol Surg 1997;23(12):1151–1160 16. Wallach, S.G., Matarasso, A.: Abdominolipoplasty: Clas- sification and patient selection. In Aesthetic Surgery of the Abdominal Wall, Shiffman, M.A., Mirrafati, S. (eds), Berlin, Springer-Verlag 2005:70–86 References Non-Cosmetic Applications of Liposuction Melvin A. Shiffman C  61 61.1 Introduction During the years that liposuction has been used for cosmetic purposes, there have been reports of noncosmetic uses of the procedure. Liposuction has been quite successful in treatment of these disorders with minimal incisions and rapid recovery time. The author utilized liposuction in a very difficult case involving chronic infection from Vicryl sutures that were contaminated at the manufacturer’s facility and despite multiple resections of tissue, the chronic recurring cellulitis continued. 61.2 Case Report A 32-year-old patient had breast reduction surgery in November 1996. One month later she developed bilateral cellulitis of the breasts that required hospitalization and intravenous antibiotics. Twice more, 2 months apart, she needed hospitalization for intra - venous antibiotics. In May 1997, she had excision of a left breast mass that was an abscess that grew out Staphylococcus. In February 1998, a mass was excised from the left breast that showed foreign body giant cell reaction and 1 month later had drainage of an ab - scess in the left breast. She continued to get cellulitis every 1.5–4 months that required intravenous anti - biotics intermittently for the next few years and she had surgical resection ten times to remove extensive amounts of subcutaneous tissues and skin where contaminated Vicryl sutures had been used for suturing. In April 2002, because there was very little subcutaneous tissue remaining in the inferior aspects of the breasts, liposuction, using the tumescent technique, was performed in the inferior aspects of both breasts where the cellulitis was present. Pathology of the various surgical specimens, including the liposuction specimen, showed remnants of Vicryl suture and suture granulomas. The liposuction procedure resulted in relief of the symptoms of cellulitis for a longer period of time (5 months) than the prior surgical proce - dures. A second liposuction procedure was necessary and following this procedure there was no further evidence of inflammation or infection (follow-up for 12 months). A prior lawsuit against Ethicon had been filed alleging contamination of the sutures by defective sterilizing apparatus at the Irving, Texas, facility. The company failed to recall all the sutures and only warned some of the hospitals of the contamination. The lawsuit was dismissed because of failure to obtain an expert to prove that the contamination caused the infection. After the statute of limitations had run, the attorney for this case was sued for failure to obtain adequate expert opinions and for allowing the statute of limitations to expire. There was a confidential settlement. The most recent lawsuit [1] against Ethicon alleged that the sutures were not only contaminated but that there was lack of adequate research as to the length of time for Vicryl suture to be absorbed, that defective manufacture resulted in the suture not absorbing over 6 years, and that the continued infections were made worse by the partial suture absorption causing break- ing up of the suture into multitudinous fragments making complete removal virtually impossible. There was an arbitration judgment for the defendant. 61.3 Non-Cosmetic Disorders Treated By Liposuction There are some non-cosmetic disorders that have been treated with liposuction that some may consider cosmetic. These include: 61.3.1 Breast Reduction The problems of macromastia and gigantomastia actually have significant medical symptoms (neck and upper back pain, grooving of the shoulders from the bra straps, inframammary fold irritation and derma- titis) that are treatable with breast reduction [2–11]. The utilization of liposuction to reduce breast volume [...]... Clin 1990 ;8: 381 – 384 6 Fields, L.: The dermatologists and liposuction- A history J Dermatol Surg Oncol 1 987 ;13:1040–1041 7 Newman, J.: Liposuction surgery: Past, present, future Am J Cosm Surg 1 984 ;1:1–2 8 Fournier, P.: Body Sculpturing Through Syringe Liposuction and Autologouos Fat Re-Injection United States, Rolf International 1 987 9 Asken, S.: Development, structure and metabolism of fat In Liposuction. .. cannulas [ 38] Handling of the tissues is gentle at all times during the procedure Both hands are used for the procedure, the working hand and the brain hand While the working hand performs the liposuction, the brain hand feels the tip of the cannula and molds the tissues for the proper functioning of the working hand When the working hand is tired, the brain hand becomes the working hand and vice versa... Acta Med Scand Suppl 1 988 ;723:91–94 16 Bjönstorp, P.: The associations between obesity, adipose tissue distribution and disease Acta Med Scand Suppl 1 988 ;723:121–134 17 Lapidus, L., Bengtsson, C.: Regional obesity as a health hazard in women Prospective studies Acta Med Scand Suppl 1 988 ;723:53–59 18 Larsson, B.: Regional obesity as a health hazard in men Prospective studies Acta Med Scand 1 988 ;723:45–51... insulin-induced lipohypertrophy by liposuction Dtsch Med Wochenschr 1994;119(12):414–417 87 Barak, A., Har-Shai, Y., Ullmann, Y., Hirshowitz, B.: Insulin-induced lipohypertrophy treated by liposuction Ann Plast Surg 1996;37(4):415–417 88 Ponce-de-Leon, S., Iglesias, M., Cellabos, J., OstroskyZeichner, L.: Liposuction for protease-inhibitor-associated lipodystrophy Lancet 1999;353(9160):1244 89 Hockel, M., Konerding,... lipo-suction surgery Am J Cosm Surg 1 986 ;3(3):27–34 Hallock, G.G.: Suction extraction of lipomas Ann Plast Surg 1 987 ; 18( 6):517–519 Carlin, M.C., Ratz, J.L.: Multiple symmetric lipomatosis: Treatment with liposuction J Am Acad Dermatol 1 988 ; 18: 359–362 Coleman, W.P.: Noncosmetic applications of liposuction J Dermatol Surg Oncol 1 988 ;1 085 –1090 Field, L.M.: Liposuction surgery (suction-assisted lipectomy) for symmetrical... tissue and risk of cardiovascular disease and death: 12 year follow-up of participants in the population study of women in Gothenburg, Sweden Br Med J 1 984 ; 289 (6454):1257–1261 20 Larsson, B., Svardsudd, K., Welin, L.: Abdominal adipose tissue distribution, obesity and risk of cardiovascular disease and death: 13 year follow-up of participants in the study of men born in 1913 Br Med J 1 984 ; 288 :1401–1404... with liposuction surgery J Am Acad Dermatol 1 988 ;19(3):570 84 Narins, R.S.: Liposuction for a buffalo hump caused by Cushing‘s disease J Am Acad Dermatol 1 989 ;52(2):307 85 Hardy, K.J., Gill, G.V., Bryson, J.R.: Severe insulin-induced lipohypertrophy successfully treated by liposuction Diabetes Care 1993;16(6):929–930 86 Hauner, H., Olbrisch, R.R.: The treatment of type-1 diabetics with insulin-induced... breast In Lipoplasty: The Theory and Practice, Hetter, G.P (ed), Boston; Little, Brown and Co 1 984 :227–231 3 Illouz, Y-G: New applications of liposuction In Liposuction: The Franco-American Experience Illouz, Y-G (ed), California, Medical Aesthetics, Inc 1 985 :365–414 4 Courtiss, E.H.: Reduction mammaplasty by liposuction alone Plast Reconstr Surg 1993;92(7):1276–1 284 5 Brauman, D.: Reduction mammaplasty... Med 2001;143(4) :8 Illouz, Y-G: Principles of liposuction In Liposuction: The Franco-American Experience, Illouz, Y-G (ed), Beverly Hills, Medical Aesthetics, Inc 1 985 :21–31 Rubenstein, R., Roenigk, H., Garden, J.M., Goldberg, N.S., Pinski, J.B.: Liposuction for lipomas J Dermatol Surg Oncol 1 985 ;11(11):1070–1074 Dolsky, R.L., Asken, S., Ngyen, A.: Surgical removal of lipoma by lipo-suction surgery... patients with steroidinduced lipodystrophy [82 88 ] can be achieved with liposuction of the excessive areas of fat The underlying endocrine problem also needs to be addressed at the same time 61.3.10 Liposuction- Assisted Nerve-Sparing Hysterectomy Nerve-sparing hysterectomy [89 , 90] can be performed more easily with the use of liposuction to remove excess fat and better exposure of the surrounding structures . No. 0 0-6 073-D. In Medical Malpractice Verdicts, Settlements & Experts 2002; 18( 8):55 The 44-year-old plaintiff had liposuction of the abdomen and thighs. Postoperatively discoloration and. lipomatosis: Treatment with liposuction. J Am Acad Dermatol 1 988 ; 18: 359–362 25. Coleman, W.P.: Noncosmetic applications of liposuction. J Dermatol Surg Oncol 1 988 ;1 085 –1090 26. Field, L.M.: Liposuction. 1996;37(4):415–417 88 . Ponce-de-Leon, S., Iglesias, M., Cellabos, J., Ostrosky- Zeichner, L.: Liposuction for protease-inhibitor-associated lipodystrophy. Lancet 1999;353(9160):1244 89 . Hockel, M.,