I love liposuction. I have done it for over 20 years, written a chapter in a book about it, have done more surgeries using liposuction than I can count. Liposuction can repattern your fat deposits and help sculpt and shape you in a way that sometimes diet and exercise cannot. It is an essential tool for me in so many of my surgeries- I use it to sculpt in breast reductions at the bra strap and inframammary fold, in my tummy tucks in the pubis, flanks, and inner thigh. I remove fat to use it for all of my fat transfer to the face or breast patients. And of course I do liposuction for the sake of liposuction.
But what amount is safe to remove?
Back when I was a baby surgeon, there were surgeons at my center who would take out 7 liters, 10 liters, even more. When I started that was not unusual for certain patients (higher BMI patients in general), and they did well. But my center is well run, and our anestheiologists were the ones who lectured at our national meetings about the hemodynamics of liposuction. In other areas of the country, liposuction of those volumes were not being done safely. So caps were encouraged at 5 liters.
These authors want to revisit the cap on the amount of fat removal due to advancements in surgical care, technique, and equipment. They argue it can be done safely. This was in November 2023, Aesthetic Surgery Journal, “Outpatient Based High Volume Liposuction: A Retrospective Review of 310 Consecutive Patients.”
Study:
- Single surgeon
- retrospective study from 2019-2021
- 586 cases performed. 310 were more than 5 liters of total aspirate
- All patients had liposuction under general anesthesia.
- They had 360degree liposuction which includes the 8 areas: abdomen, pubis, bra line, upper back, middle back, waist/flank, presacral triangle, and hip roll.
- Additional procedures were done in some (fat transfer to buttock, breast surgery, or tummy tuck)
- All patients had a catheter , blood pressure monitor, and vital signs monitoring.
- Urine output was 0.5cc/kg/hour was maintained by IV fluids
- Superwet technique was done.
- All patients had at least 5 liters of total aspirate
- AAAASF facility was used.
Findings?
- Mean age 38 (range 20-66)
- Females 98%
- All patients were anesthesia class I or II (except for 4 Class III patients)
- Mean BMI 29
- OR time was 202 minutes
- Average amount removed was 7.5 liters
- Urine output was carefully watched
- No major complications
In their discussion they talked about why limits were placed on liposuction. This was due to highly publicized deaths in a office based operating room, with bleeding and prolonged operative times. States then instituted rules, which vary by state. The guidelines were made by an “arbitrary decision that was based on the best available knowledge at the time.” The authors were frustrated by the perception that those who do large volume are “unsafe.” They cite multiple studies which showed the safety of high volume liposuction. The risks: blood loss, hypothermia, fluid overload, DVTs, and prolonged time can all be managed by advances in technique, care, and equipment.
My thoughts?
I am a believer in large volume liposuction being safe. The original study on this with over 600 patients was published in 2001 by one of my colleagues at my center and our anesthesiologist, Drs Commons and Halperin. Read the Study. All of our patients are done under general anesthesia, with a board certified anesthesia MD very familiar with fluids for liposuction, with temperature probes, SCDs, warmers, foley catheters, tumnescent mix, and more. Now with being more proactive- heating patients preoperatively, using TXA, and other techniques- it is even better. We have always watched the fluid status of our patients carefully.
This is one where I agree with the authors- high volume liposuction can be safely performed when best practices are followed, and that best practices should be the standard, not necessarily a concrete number.