Excessive Superficial Liposuction

Excessive Superficial Liposuction



Excessive superficial liposuction can produce significant cosmetic complications. The use of the tumescent technique and microcannulas allows the surgeon to do liposuction more superficially and to produce smoother results than could be done with old-fashioned techniques that used larger cannulas. Some surgeons mistakenly believe that scraping the undersurface of the skin with the liposuction cannula will cause the skin to contract. There is no scientific evidence to support the theory that intentional injury to the skin by doing excessive superficial liposuction produces improved cosmetic results. Excessive superficial liposuction can injure the superficial blood and lymphatic vessels located on the immediate undersurface of the skin resulting in significant complications including scars, lumpiness, permanent irregular coloration, and full thickness necrosis (death) of the overlying skin. Skin naturally contracts after liposuction because 1) skin naturally contains elastic fibers, 2) skin is relieved of the gravitational effect of subcutaneous fat, and 3) liposuction naturally results in contraction of the collagen in subcutaneous fat. Surgeons who advocate superficial liposuction must be careful to avoid excessively superficial liposuction.
 
Focal Excessive Liposuction
 
Focal Excessive Liposuction is the removal of an excessive amount of fat from localized area of the body. Removing too much fat yields an unnatural and unattractive appearance. If uneven or irregular excessive liposuction of a single area occurs, it produces depressions (lipotrops) or lumps and bumps (liponots). If smooth or uniform, focal excessive liposuction can appear abnormal and disproportionate. The goal of liposuction is not to remove the maximum amount of fat, but rather to produce an optimal cosmetic improvement and maximize patient happiness. The normal female body has subcutaneous fat. Thus, the complete lack of subcutaneous fat on part of the female body appears abnormal, and feels peculiar to the touch. Patients should not ask for or expect "maximum fat removal". Dr. Pierre Fournier has said, "It is not the fat that is removed, but the fat that remains after liposuction that determines success."

Focal excessive liposuction can cause unsightly depressions and irregularities of the skin. The use of large liposuction cannulas contributed to a permanent depression in this woman's outer thigh.

Erythema Ab Liporaspiration
 
Erythema Ab Liporaspiration is a permanent blotchy (net-like pattern) pink-brown discoloration of the skin resulting from rasping the undersurface of the skin during superficial liposuction. Inadvertent or intentional rasping of the undersurface of the skin will injure the superficial vascular network. Unfortunately, there is no treatment for this chronic discoloration. It does not seem to improve with time.

Erythema Ab Liporaspiration seen on this patient's thighs is a permanent blotchy pink-brown discoloration of the overlying skin as a result of excessively superficial liposuction that injured the small blood vessels on the undersurface of the skin.

Hematomas and Seromas
 
Whole blood consists of red blood cells plus serum (clear yellow fluid). A hematoma is a lake-like collection of whole blood that has leaked out of injured blood vessels and become trapped inside the body. The vasoconstriction produced by the tumescent technique for liposuction has virtually eliminated the occurrence of hematomas. A seroma is a volume of serum that has leaked out of blood vessels and collected as a "lake" of fluid within some part of the body.

Seroma under the skin on the inner knee is a collection of serum (clear yellow fluid) that accumulated after liposuction when the tiny incision sites were closed with stitches. Allowing the incisions to remain open after liposuction and thus encouraging drainage of tumescent fluid and serum can prevent such seromas. HK Pads are placed over the open incisions to absorb the otherwise messy drainage.

Minor Complications



A surgical complication is defined as any undesirable result of surgery. Minor complication has little risk that the patient will die. The causes for minor complications include unpredictable factors such as a patient's wound healing ability, misjudgment by the surgeon, patients' failure to follow instructions, or just bad luck such as an unexpected allergic reaction to a drug. Ultimately any result that produces an unhappy patient, is a complication.



Unrealistic Expectations


Unrealistic Expectations are the most frequent source of disappointing liposuction results.



If a patient has unrealistic expectations before surgery, then it is almost impossible for the surgeon to achieve results that will make the patient happy. To avoid unrealistic expectations surgeons must ask what the patient expects to achieve with liposuction. Surgeons must clearly state how much improvement is likely to be achieved. Patients must honestly state their hopes and expectations with the surgeon. Patients must not expect perfection. It is realistic to expect a significant improvement, but it is unrealistic to expect perfect results. This entire web site is dedicated to providing patients with information so that they can make a well-informed decision about having liposuction.






Skin Irregularities and Depressions


Significant irregularities and depressions of the skin are frequently the result of the surgeon's inattention to detail. For example, if a liposuction surgeon attempts to do too much on a single day, and becomes fatigued, then the result may be inattention to detail, and undesirable cosmetic results. A liposuction cannula is stainless steel tube inserted through an incision in the skin that is employed to suction the fat. The size of the liposuction cannula can influences the smoothness of the skin after liposuction. The use of large cannulas tends to create irregularities more commonly than microcannulas (outside diameter less than 3 millimeters). Surgeons who do total-body liposuctions tend to use larger cannulas.

Too much fat removed from a localized area of the lateral buttock has resulted in a permanent irregularity of the skin.

Full Thickness Skin Necrosis



Full Thickness Skin Necrosis (death of the affected skin) can result from excessive superficial liposuction that injures the vascular supply of the overlying skin. Deliberate trauma to the undersurface of the skin can injure the vascular supply to the skin and cause partial or full thickness necrosis of the skin. A partial thickness dermal necrosis may become a full thickness necrosis if it is complicated by an infection. Other causes of full thickness dermal necrosis following liposuction include infection (necrotizing fasciitis) , blood vessel thrombosis (clotting inside a blood vessel), injury to blood vessels, and vasculitis (blood vessel inflammation). For example, in patients who have a disease known as cryoglobulinemia (cold-induced blood clots), the application of ice-packs to the skin after liposuction can produce clotting in blood vessels of the skin and full thickness skin necrosis.
 
Blisters from Reston Foam



Reston foam is an adhesive-backed 3/8 inch thick foam that some surgeons apply to patients' skin to reduce bruising after liposuction. The manufacturer of Reston foam, 3M Corp., has warned against the use of Reston foam for liposuction. Reston foam is not intended to be applied to patients' skin. An allergic reaction to the adhesive on the foam (similar to an allergic reaction to poison oak or poison ivy) can cause blisters and an increased the risk of necrotizing fasciitis, a potentially lethal infection. An allergic reaction of this type can also cause a prolonged discoloration of the affected skin.






Hyperpigmentation of Incision Sites


Any inflammatory injury of the skin can cause rupture of skin cells containing pigment with release of melanin pigment granules into the surrounding skin. Escaped pigment is regarded as a foreign substance by the body. Scavenger (macrophage) cells ingest this pigment where it can persist a long time causing prolonged hyperpigmentation. In most individuals who have little natural pigmentation in their skin, post-inflammatory hyperpigmentation resolves in less than a 4 to 6 months. In people who naturally have darkly pigmented skin, the hyperpigmentation can last for a number of years. Trauma from the friction of a liposuction cannula moving in and out of a skin incision can cause inflammation and hyperpigmentation. Prospective liposuction patients who naturally have darkly pigmented skin must be informed of their increased risk of such pigmentation. In darkly pigmented patients, the surgeon must take extra care to minimizing the number of incisions, and to choose incision sites that are easily covered by clothing or bathing suits.






Fainting (Vasovagal Syncope)


Fainting or vasovagal syncope is a reflex reaction involving the brain and the heart that produces a sudden brief reduction of blood flow to the brain and loss of consciousness that resolves spontaneously. When a person faints it is usually when they are sitting or standing upright. Events that can trigger a fainting episode include anxiety, pain, or even the sight of blood. Fainting can occur before, or after any surgical procedure, and even during surgery if the surgery is done under local anesthesia. For example one patient fainted prior to liposuction while the surgeon was taking preoperative photographs. Another example involved the husband of a liposuction patient. While helping his wife change her dressing the morning after liposuction, the husband fainted at the mere sight of the blood-tinged absorptive pads, and immediately afterwards, the wife also fainted at the sight of her fainted husband. Head or neck trauma resulting from a fall is the greatest risk associated with fainting.






Vasovagal Symptoms


Vasovagal Symptoms in the O.R. Fainting (loss of consciousness) is unusual in the operating room (O.R.) when the patient lying flat. Instead, an awake patients who starts to faint will linger on the verge of fainting with vasovagal symptoms that include lightheadedness, cold sweats, and nausea or vomiting. Vasovagal symptoms typically occur in predisposed individuals who have a history of fainting or becoming dizzy or lightheaded at the sight of blood or at the thought of a medical procedure.
 
Vasovagal Near-Syncope Syndrome



In the operating room setting during tumescent liposuction totally by local anesthesia, true syncope is unusual. However, the syndrome of vasovagal near-syncope (light-headedness, cold-sweats with nausea or vomiting) is not uncommon and represents the early phase of fainting that simply stops short of the complete loss of consciousness. The first hint of the syndrome is typically a vague sensation of feeling queasy and lightheaded. Shortly thereafter, the patient's skin will appear ashen or pale, with damp, moist, clammy skin, perhaps with visible beaded perspiration, and dilation of pupils. Within a few brief moments, the patient experiences a slow heart rate and low blood pressure. Although vasovagal near-syncope is not dangerous, it is unpleasant. Treatment consists of a small intravenous dose of atropine (0.5 mg) after which the patient soon feels dramatically better.






Preventing Vasovagal Syndrome in the Operating Room


If a patient has previously experienced sudden lightheadedness or fainting for any reason, for example when having blood taken for a laboratory test, then he or she has a predisposition for the vasovagal syndrome. The vasovagal syndrome in the operating room can be prevented by giving 0.3 mg of atropine intravenously immediately prior to surgery. Every patient who is scheduled to have liposuction totally by local anesthesia should be asked the question, "Have you ever fainted or suddenly become light-headed for any reason?"






Post-Liposuction Syncope at Home


Post-liposuction lightheadedness and fainting most commonly occurs after urinating the morning after liposuction. Fainting after urination is called post-micturition syncope that occurs commonly in postpartum women the morning after childbirth upon standing up immediately after urination. Other stimuli that can trigger a fainting episode after liposuction include: 1) the sight of the blood-tinged anesthetic drainage on the absorptive pads, and 2) decompression of the lower extremities upon removal of postoperative compression garments. For at least 24 hours after tumescent liposuction, patients are generally in a state of mild fluid overload due to all the tumescent fluid remaining in the patient's system. Except in cases of excessive liposuction, it is unlikely that post-liposuction syncope is caused by a deficiency of intra-vascular fluids.






Preventing Post-Liposuction Syncope


Liposuction patients should be aware that fainting can occur at home after liposuction. A few suggestions may help patients prevent injury:






Remove postoperative compression garments slowly, if possible, with someone's assistance. If wearing more than one garment or elastic binder, take garments off one at a time, waiting a minute or two between removing successive garments.


Stand up slowly after urinating.


It is reasonable to have someone in the bathroom for assistance when showering for the first time after liposuction.


If feeling dizzy or lightheaded, immediately sit down or lie down in the shower or on the floor until feeling better.


Do not be alarmed by a large amount of blood-tinged drainage on the absorptive pads; the more drainage, the less bruising and swelling there will be.


Do not remove the garments with a completely empty stomach. To avoid hypoglycemia, which may increase the risk of this post-liposuction fainting, a patient should eat something before removing the garments to take a shower and change the dressings.


Do not lock the bathroom door when showering or urinating.
 
Wrong Areas Treated



Miscommunication between patient and surgeon may lead to confusion about which areas are to be treated. It is important that the patient and surgeon agree on which areas are to be treated by liposuction, and that this agreement be put in writing so that there is no confusion. This is especially important if the surgeon who does the consultation is not the same surgeon who does the liposuction. It is also important if liposuction is done under general anesthesia, because the patient will not be able to alert the surgeon who is about to treat the wrong area. Patients must insist that the areas to be treated are listed in writing.



Insufficient Volume of Fat Removed can be a complaint after liposuction. Among the reasons for insufficient removal of fat by liposuction are:





Patient had unrealistic expectations. It is unrealistic for a patient to expect perfection. On the other hand, it is reasonable to expect a significant improvement.


Surgeon wanted to avoid doing too much liposuction. If too much fat has been removed, it is very difficult to repair the situation. Other the other hand, if the initial liposuction was insufficient, it is relatively easy to return to have a little more liposuction.


Surgeon is in a hurry, and does not spend enough time to carefully complete each area. This unacceptable situation might be avoided by not attempting to do an excessive amount of liposuction on a single day, and by not doing other unrelated surgical procedures on the same day as liposuction.


Surgeon did not use microcannulas and is fearful of causing irregularities. It is more difficult to get smooth results when large cannulas are used. Using microcannulas (less than 3 mm in outside diameter) for liposuction can require a little more time than using larger cannulas, but microcannulas permit both the removal of more fat and smoother results.


Minor Superficial Irregularities


Dents, waviness, lumpiness and furrows can occur after any liposuction. These can usually be repaired with a minor "touch-up" liposuction procedure. Although perfectly smooth results can be achieved in some patients, it is not realist for every patient to expect absolute smoothness. It is reasonable for every patient to expect that liposuction will provide both a significant cosmetic improvement, and that eventually there will be almost no visible scars or irregularities that provide evidence that the patient has had liposuction. A 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. A liponot is a focal area of insufficient or uneven liposuction (note to web master: hyperlink to Glossary of Terms).






Temporary Lumpiness


Temporary lumpiness and bumpiness is common after liposuction. This condition becomes noticeable within one to two weeks after surgery and becomes most pronounced between two to four weeks after surgery. This temporary lumpiness is the result of the normal healing process after liposuction. The intensity and duration of this condition can be minimized using open-drainage and bimodal-compression.

Post-Liposuction Panniculitis



Post-Liposuction Panniculitis is a manifestation of postoperative inflammation due to incomplete drainage of blood-tinged tumescent anesthetic solution and the formation of small seromas. Seromas have become rare with the use of open-drainage and bimodal-compression. Patients typically complain of localized warmth, swelling and tenderness. There is often visible redness overlying the affected area. The onset occurs after the drainage of blood-tinged anesthetic solution has ceased. It is important that the surgeon distinguish between Post-liposuction panniculitis and an infection. Post-liposuction panniculitis is often preventable by using adits, open-drainage and bimodal-compression. Post-liposuction panniculitis is more common when incisions are closed with sutures thus preventing complete drainage and entrapping the inflammatory blood-tinged anesthetic solution beneath the skin.






Swelling


Swelling of the Legs and Ankles can occur following liposuction on any part of the lower extremity. This swelling is usually mild to moderate in degree. There is an increased risk of prolonged swelling when liposuction of the entire circumference of either the leg or the thigh is attempted on a single day. Placing sutures in liposuction incision sites promotes and prolongs this swelling. The incidence of distal edema is greatly reduced by using open-drainage and bimodal-compression, and avoiding circumferential liposuction of the thigh or leg.



Bruising


Bruising and Swelling of the Genitals in both males and females can occur following liposuction of the abdomen and is the result of blood-tinged fluid percolating downward under the effect of gravity. This bruising and swelling of the genitals is common after abdominal liposuction, and it usually resolves within two to three days. The use of 2 mm adits placed along the inferior border of the abdomen and the use of a good elastic compression garment can reduce the risk of this condition.






Postoperative Bruising


Postoperative bruising is a common result of liposuction. The use of the tumescent technique for liposuction has dramatically reduced the amount of bruising and the duration of bruising. The degree of bruising can vary between patients due to a number of factors including genetic differences in the coagulation system and exposure to substances that affect platelet function such as aspirin, ibuprofen, Nuprin, red wine, large quantities of garlic, or vitamin E taken with 7 to 10 days before surgery. Bruising, swelling, discomfort, and tenderness after liposuction can be minimized by using postoperative care techniques that include open-drainage and bimodal-compression.

Rapid Heart Rate



Rapid heart rate can occur during or after liposuction as a result of the epinephrine (adrenalin) that is an essential ingredient of the tumescent local anesthetic solution. Rapid heart rate can also be caused by medications containing ephedrine-like drugs often found in nasal decongestants such as Sudafed or pseudoephedrine. Patients should avoid ephedrine-like drugs before tumescent liposuction. The anti-hypertension medication clonidine, 0.1 mg by mouth, given immediately preoperatively, reduces the risk of rapid heart rate and also provides a degree of sedation without the risk of respiratory depression.


Vascular Injury and Excessive Bleeding


Vascular injury and excessive bleeding are rarely caused by liposuction with the use of microcannulas. Good postoperative compression for the first 24 hours postoperatively should preclude any significant bleeding from veins. Exceptions may be the result of drugs that impair blood clotting mechanisms by interfering with platelet function. Drugs that increase bleeding include aspirin, ibuprofen, other NSAIDS, vitamin E, red wines, large doses of garlic supplements. Diabetic patients are known to have an increased incidence of small vessel insufficiency that might predispose them to local tissue or skin necrosis following an otherwise insignificant injury to a blood vessel. Ultrasonic liposuction has been known to cause dangerous injury to major arteries. See Risks of Ultrasonic Liposuction.




Worry About Blood-Tinged Drainage


Patients are told that open-drainage and bimodal-compression are specifically designed to encourage copious postoperative drainage. The larger the volume of postoperative drainage, the shorter will be the duration of postoperative healing and soreness. Despite these careful explanations, some patients will inevitably become overly concerned that the drainage of very dilute blood-tinged anesthetic solution is actually a hemorrhage of whole blood. The resulting telephone call from a concerned patient or spouse requires careful evaluation and consideration. Usually careful questioning, evaluation and reassurance will be sufficient. Nevertheless, some patients will require an examination by either the surgeon or an experienced staff nurse. Another source of worry for liposuction patients is the concern that there is not enough drainage. In this case, the patient is worried that insufficient drainage of blood-tinged anesthetic solution will result in excessive swelling or delayed healing. This concern is usually unfounded. In any case, there is no serious long-term consequence of less-than-maximal drainage. Simple reassurance should calm the patient's concerns.