**1. Introduction**

One of the most challenging aspects of liposuction is patient satisfaction. Patients undergoing liposuction, fat grafting or other forms of fat sculpting are present primarily for cosmetic reasons. Whether removing fat or adding it, contour correction is the goal. As such a very scientific and clinically complex procedure must have an esthetic outcome and the surgeon is truly acting as physician and artist.

G. Neuber is commonly called the father of fat grafting for his innovative 1893 transfer of fat from the arm to the orbital rim to correct an osteomyelitis deformity. Dr. Neuber is also the grandfather of the modern surgical suite and other than Ambroise Paré did more to revolutionize the aseptic technique than any predecessor [1].

Contour deformities have been the bane of our existence as practitioners since the dawn of the procedure. Khanna et. al. review a case by Dujarrier of a ballerina from whom fat was removed from the knee. Unfortunately, the femoral artery was damaged necessitating a below-the-knee amputation. Certainly, an unfortunate contour deformity [2].

The introduction of cannula in 1975 by the Fischer's, a father and son physician team, dramatically altered the landscape of liposuction. While still performed under general anesthesia, three small incisions were made allowing the introduction of blunt cannulas with suction. This allowed a more uniform, less invasive procedure [3]. The technique was further adapted until late 1987 when Klein reported the first use of the tumescent technique for performing liposuction under localized anesthesia. These solutions used very dilute lidocaine and epinephrine. This technique significantly improved outcomes via several mechanisms, as discussed below, and decreased the rate of serious complications. Before this liposuction was predominantly an inpatient procedure. The tumescent technique resulted in a shift of the procedure to outpatient clinics and day surgery centers. Klein continued to perfect the procedure and elucidate the metabolism of lidocaine and the maximum safe doses of lidocaine allowed [4, 5].

This chapter is dedicated to the discussion of post-procedure deformities resulting from liposuction, and an up-to-date review of their prevention and correction.

Of course, to the novice, the term deformity might only suggest areas of over or under treatment, but the term, in this case, is broad and must also include defects of the superficial layer (peau de orange, ulcerations, etc.), deformities of the intermediate and deep layers (over-correction, under-correction, hematomas, seromas) and those arising from damage to deeper structures (ablation of the gluteal sulcus, damage to the marginal mandibular nerve, etc.). More serious complications such as pulmonary embolism, the obese patient, volume overload and perforation of deeper structures are reviewed elsewhere [6].

### **2. Prevention**

Iatrogenic deformities should be avoided. Technique and surgical environment each play a significant role in reducing the chance of clinical error. The facility in which liposuction is performed historically played a greater role in avoiding complications than it does today. The safety of outpatient surgical procedures improved after the formation of the American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF) in 1980 [7]. The number of ambulatory care centers increased 20-fold from 275 in 1980 to 5500 in 2014. The first quality control measure implemented was a limitation on the total volume of fat aspiration. Centers using officebased anesthesia experienced a decrease in severe complications as safety protocols and standards were implemented. Most complications, however, were due to surgical technique rather than anesthesia or facility regulations.

The lowest fatality rates are reported with "true" tumescent liposuction in which general anesthesia is not used. Complication rates are decreasing as new technologies emerge, for example, laser liposuction [8]. Gupta et al. reviewed procedures across several accredited facilities and found evidence that in-office procedures are a very safe alternative when adequate patient selection is used. Overall complication rates for these procedures were estimated at 1.3%, lower than that for other larger facilities [9].

Fatality rates for liposuction appear to be very low overall, and exceedingly rare with pure tumescent anesthesia. Hanke et al. surveyed Fellows of the American Society of Dermatologic Surgery. 15,336 respondents reported complications. Of those, none reported a fatality. Skin irregularity (dimpling, retraction) occurred at a rate of 0.34% and was the third most frequently reported complication. Other reported contour deformities included hematomas/seromas (0.17%), patient dissatisfaction with appearance (0.08%) and ulceration (0.01%) [10]. These results are

comparable to a review of 9002 patients by Boeni and Waechter-Gniadek of which 0.1% had hematoma/seroma and 0.01% had skin necrosis [6].
