Doctor Karol Gutowski was recently interviewed for an article in MedAesthetics Magazine. Read the full article below!
There are several factors to consider when assessing the right patient, anesthesia type and facility for your liposuction procedures.
Liposuction remains one of the most sought-after cosmetic procedures in the U.S. While the rate of adverse events is low, serious complications can occur. “Once you start doing large volume liposuction, you end up with a lot of fluid shifts, and you can stress the cardiovascular system and cause a lot of problems,” says Miami-based plastic surgeon Roger Khouri, MD.
Reducing the risks of liposuction requires surgeons to consider several factors, including the health of the patient, the facility in which the procedure will be performed and the volume of fluid to be both infiltrated and removed.
In September, researchers from Northwestern University’s Feinberg School of Medicine published the results of a retrospective study (Plastic and Reconstructive Surgery) conducted in an effort to determine safe lipoaspirate volume for liposuction procedures. They reviewed 4,534 lipectomy cases through the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database. “We wanted to see if there were any top threshold values at which the risk of complications increases,” says Karol Gutowski, MD, a plastic surgeon in Chicago and one of co-authors of the study. “We weren’t able to find a certain point at which the complications become prohibitive. We did find that it depends on a person’s body mass. A person with a higher BMI can tolerate more removal than someone who is lighter and that kind of makes sense.”
An upper limit guideline that was recommended by the study is 100cc per body mass index (BMI). “You could certainly go above that, but you need to have a discussion with the patient and let them know that the risk of seromas may increase,” says Dr. Gutowski, who notes that the data compiled from the TOPS database is based only on procedures performed by board certified plastic surgeons.
Since each individual patient presents with unique aesthetic and health concerns, the fi st step in reducing the risk of adverse events is careful patient selection. Liposuction is ideally suited to treat lipodystrophy—abnormal or unsightly, localized collections of fat. “This is not a treatment for obesity,” says Dr. Khouri. “If somebody has huge saddlebags that is a great case for liposuction. If someone has very wide flanks or huge love handles, those are very good cases. If the person is overweight and has a lot of skin, you are not going to help them with liposuction. Typically people who have gotten really heavy have stretched their skin beyond elastic recoil, so it’s going to be flaccid.”
Patients with disorders of the liver or kidney also pose concerns. “Because lidocaine is metabolized through the liver, you need to alter what you do,” says Dr. Gutowski. “You may need to do the procedure under general anesthesia so you don’t need to use lidocaine. If someone has a kidney problem and can’t process fluids very well, then maybe you should do only small volume liposuction, rather than large volume.”
Patients with significant heart problems are poor candidates for large volume liposuction, but you may be able to do multiple small volume procedures under local anesthesia. “Small area liposuction is possible in people who may not be the healthiest,” says Dr. Gutowski. “If someone wants liposuction on their abdomen, flanks and thighs, you don’t have to do it all at once. You can do their abdomen under local anesthetic and then have them come back later for another area.”
Dr. Khouri advises all patients to stop the use of daily aspirin, if their health permits, and all oral supplements at least two weeks prior to the procedure to avoid bleeding problems. “There are a lot of over-the-counter supplements that people take that are anticoagulant and antiplatelet, particularly the ones that start with G: ginkgo biloba, ginseng, garlic, even green tea,” he says. “These can prolong bleeding and cause more bruising following the procedure.”
If the patient is on anticoagulants for a cardiac problem, the surgeon should confer with the patient’s doctor to determine if the medication can be stopped safely prior to liposuction.
When considering patients with pre-existing health problems, Dr. Gutowski notes, “If someone just wants their neck done, it would be hard to find a health problem that would disqualify them short of a bleeding problem, such as a coagulopathy.”
While small volume liposuction performed under local anesthetic is quite safe, physicians who offer in-office procedures must make sure they can create a sterile environment for the procedure and that they are prepared for unexpected complications. “Whoever’s doing the procedure should have all the basic safety equipment in case there’s an allergic reaction, a breathing problem or other complication,” says Dr. Gutowski. “Also you should have privileges at a hospital so the patient can be transferred if there are complications.”
OFFERING GENERAL ANESTHESIA
Patients who are undergoing liposuction in multiple areas and/or having large volumes of fat removed will require general anesthesia. “Once you start doing more and more areas, it’s hard to make the patient comfortable because there is an upper limit to how much local anesthetic you can use,” says Dr. Gutowski. “If I’m doing three areas or more, I consider offering an anesthesiologist.”
In these cases, the patient must be treated in an operating room. Whether the OR is within a private practice, ambulatory surgical center or a hospital depends on the health of the patient, state regulations and requirements of the licensed anesthesiologist. “If you’re going to take more than a few hundred ccs, you can’t do it under local,” says Dr. Khouri. “And once you move beyond local, it’s good to have a certified anesthesiologist in the room so the surgeon can concentrate on his craft—making sure he does good work, concentrating on the contour, etc.—while there’s another physician in the room to focus on making sure the patient is comfortable and safe, is breathing and through the whole operation is fi ne from a systemic viewpoint. You as a surgeon cannot be giving anesthesia, taking care of the patient and, at the same time, sculpting their body to get a good result.”
Some states, such as Florida, have a limit on how much volume can be removed in an ambulatory surgical center. For states without regulations, Dr. Gutowski feels that an accredited ambulatory surgical center or office OR is fi ne for a healthy patient, provided the facility and anesthesiologist are comfortable with the procedure. “If you’ve got someone with significant health problems and you’re using general anesthesia, then a hospital may be better because the patient can be monitored,” he says. “But this is elective surgery, so instead of doing something risky, why not just lower the risk by breaking it down into smaller procedures that the person’s body can tolerate?”