**5.1 Combining suction lipectomy with other procedures**

Safety in liposuction combines proper education, patient selection, and proper application of science while achieving the goal of esthetics. Providing safe surgery in a hospital or accredited surgery center (or Ambulatory Surgery Center (ASC) has become increasingly a topic of discussion as the roles of fat grafting (breast surgery, Brazilian Butt Lift, facial surgery, etc.) have increased. Office based procedures can be done safely and should still follow proper guidelines. As noted above, the role of wetting solutions allowed safe and reproducible results over the past several decades.

There are various oversight organizations and governmental regulations that have been well established. These are designed to help ensure patient safety. As this is not a comprehensive review of each organization, some general parameters are presented below. For those that will be using freestanding ASCs through Medicare and or Medicaid, rules include An ASC must be certified and approved to enter into a written agreement with CMS, The regulatory definition of an ASC does not allow the ASC and another entity, such as an adjacent physician's office, to mix functions and operations in a common space during concurrent or overlapping hours of operations., and ASCs are not permitted to share space, even when temporally separated, with a hospital or Critical Access Hospital outpatient surgery department, or with a Medicare-participating Independent Diagnostic Testing Facility (IDTF), as noted on CMS.gov. (REF- CMS.gov). ASCs must comply with a multitude of state as well as federal regulations and statutes. This includes proper licensing, Health Insurance Portability and Accountability Act (HIPAA) and more (REF ASCassociation.org). Furthermore, the ASC is also responsible to ensure that the providers comply with all the standards that govern ensuring professional training, equipment, medications, physical layout of the facility and operational safety. Outpatient surgery is suited best for healthy people undergoing minor or intermediate procedures (plastic surgery, ob-gyn, limited urologic, ophthalmologic, or ear, nose and throat procedures and procedures involving the extremities). However, health care reform and the Affordable Care Act of 2010 have expanded the types and complexity of surgical procedures, with much of the growth driven by advancements in anesthesia and technology. (REF AAAASF.org).

#### **5.2 Wetting solutions and volume extractions**

Wetting solutions were covered earlier in this chapter. The surgeon should become familiar with the various solutions. Furthermore, the amount of blood loss with the different must be accounted for by the surgeon to maintain safety. (ADD TABLE FOR APPROXIMATE BLOOD LOSS?) That percentage of blood loss can range from 1% with solutions such as tumescent and superwet to nearly 40% in the infranatant with the dry technique. (REF?) Preoperatively the patient should be healthy and optimized and laboratory studies should be checked to help guide proper patient selection. These solutions can also vary in terms of lidocaine load to the patient. The surgeon should be familiar with the correct calculations to not over-deliver lidocaine to the patient as well as understanding that absorption can be variable between patients. As lidocaine absorption from the subcutaneous fat, the plasma lidocaine levels may not peak until 10–12 hours after delivery. Furthermore, chronic disease, stress, tobacco use, hormones, and more will influence the protein binding and when the peak will effect the patient. Care must be taken and individualized for each patient.

Volume extraction concerns have evolved to help protect patients, but discussions continue how to apply and ensure proper application. In general, the most commonly accepted guideline is based on "Large volume lipoplasty" as greater than 5000 cm3 of supranatant fat during a single surgery. Volumes greater than this can be done, and patient safety parameters should be utilized and regulations followed. These large volume liposuction procedures can be completed in a hospital setting or often mandate overnight monitoring. Patient age, general health and even the percentage of body surface are examples of considerations. While we have discussed lidocaine issues previously, general fluid shifts should be considered for patient safety as well. High quality teamwork and communication with all team members are critical. Volume overload, shock, pulmonary edema, hypovolemia, myocardial infarction are all risk factors, as is fat embolism. Proper teamwork, communication, monitoring, etc., are so important to add to proper patient selection.

Cannula selection is another component of patient safety, from tissue injury to contour irregularities. Proper cannula selection is a combination of education, experience, esthetic goals and more. While there is a role for some of the cannulae that can cut (release of fibrous bands) or "post-tunneling" (such as basket cannulae), the accepted safe cannula systems are generally blunt tipped. These most commonly range from 2 to 5 mm, but larger are available for harvesting and smaller are often used for fat grafting. Furthermore, the number of holes, location and patterns of the holes will all play a role in both efficiency of fat extraction and patient safety. While the cannulas play a role in patient safety, so do the aspiration devices and assistance devices (syringes, pumps, oscillating tips, energy based, etc.) must be considered for patient safety. Proper education on the devices, mechanisms of action, technique, etc. must be employed to avoid complications such as thermal injury, contour irregularities, incorrect cannula positioning and more.

Beyond the previously mentioned complications of liposuction, the surgeon must also be concerned about several other issues and these include Fat Embolism Syndrome, bleeding, and Deep Vein Thrombosis among others. Bleeding and clotting issue concerns should be addressed pre-, intra-, and postoperatively. A complete history should discuss any family history of blood clots, early myocardial infarction, multiple miscarriages, bleeding history, previous deep vein thrombosis, etc. Several measures can be done on the day of surgery such as proper patient and operating room temperature, placement and application of sequential compression devices before induction and not being removed until after the patient is fully awake (home compression therapies are also available), and even consideration for pre and post operative anti-thrombotic (chemoprophylaxis) medications. Early ambulation has been a largely accepted proper therapy to help minimize deep venous thrombosis and pulmonary embolism risk. Fat Embolism Syndrome (FES) is less understood, but classically demonstrates respiratory distress, petechial rash along with cerebral dysfunction. Other concerns include tachycardia, fever,

#### *History of Body Contouring DOI: http://dx.doi.org/10.5772/intechopen.99098*

hypocalcemia and even thrombocytopenia. FES is the syndrome that is a secondary consequence of Fat Embolism. Proper diagnosis is critical for the patient long term outcome and the surgeon should be familiar with the diagnosis and willing/able to work with other team members to get early and proper treatment for the patient.

Proper patient selection, maximizing pre-, intra- and post operative management is the responsibility of the surgeon. The surgeon should coordinate the team and maintain maximum communication so that all team members can maximize their experience and opportunities to protect the patient.

As suction lipectomy became universally accepted as a stand-alone procedure, it was quickly added to other body contouring procedures. Frequently, liposuction is performed along with reduction mammoplasty, abdominoplasty, high-definition liposuction, brachioplasty, thigh lifts, lower body lifts, gynecomastia, breast reconstruction, etc. Although liposuction can be safely added to other body contouring procedures, it has been shown to increase morbidity and mortality when combined with a full abdominoplasty especially worrisome in patients with a high BMI and/or a high Caprini score [34].
