**6. Other contour deformities**

Seromas account for 2–5% of complications from liposuction [44]. Seromas are a result of excessive fat removal and destruction of fibrous bands using either larger cannulas or aggressive techniques. They occur when a potential space is created and fills with fluid. They usually occur within 2 weeks post-operatively. Proper garment fitting is essential in avoiding seromas. Scrotal and vulvar swelling is a frequent complication especially when the suprapubic is suctioned. This is primarily due to edema from fluid movement due to gravity and rarely a hematoma or seroma. Bodysuits are available that put pressure on the suprapubic, but care must be taken that the garment is not so tight that edema in the vulva or scrotum results in cyanosis or numbness. Needle aspiration is the primary treatment, followed by compression. The seroma may need to be drained several times until it stops forming. It is important to manage seromas so that a permanent cavity is not created.

Hematomas form via a similar mechanism when vascular damage is sufficient for blood to fill a potential space (**Figure 3**). Larger cannulas, muscle trauma and aggressive liposuction increase the risk of hematomas. After tumescence Klein recommends a period of detumescence to allow vasoconstriction and so that tissue is more easily pinched and manipulated. A good medical history should include the use of blood thinners, including over-the-counter non-steroidal anti-inflammatory drugs (NSAIDS) and herbal supplements such as garlic, ginseng, and *Gingko biloba*.

Prevention of hematomas, bleeding and ecchymosis may be achieved by adding tranexamic acid (TXA) to the tumescent fluid. Rodriguez-Garcia et al. report a decrease in blood loss as measured by hematocrit [45]. Adding TXA to lipoaspiration sites post-liposuction also has decreased bruising [46].

Drainage of hematomas followed by compression is essential and may require several treatments. Rapidly developing hematomas may indicate a significant vascular bleed and require direct compression. In severe cases, a drain may be required. A chronic hematoma can form a fibrotic mass, and some have demonstrated calcification. If left untreated, hematomas can take months to resolve. It has been postulated that laser-assisted liposuction may have a lower rate of bleeding and ecchymosis because of cauterization. The 1064/1319 nm devices may improve skin tightening slightly better than others. The risks of thermal injury and ulceration are increased using lasers. Radiofrequency assisted liposuction (RFAL) devices demonstrate a very safe profile. The rate of minor complications including hematomas

**Figure 3.** *Post-liposuction hematoma of the right lower abdomen at 1 week.*

is significantly reduced with second-generation RFAL devices as reviewed and discussed by Chia et al. [47].

Normally temporary hyperpigmentation is the only residual evidence of an access port after healing. Keloids and hypertrophic scars can occasionally occur at these sites. They can also occur where ulceration or necrosis occurred. A patient with a history of keloids should be warned about the increased risk. The risk of scarring is increased if an undersized port undergoes significant friction. The treatment of hypertrophic scars and keloids is generally the same. Intralesional triamcinolone 5–10 mg/cc injected once every 4–6 weeks is usually sufficient to flatten the scar. Silicone sheets, gels and gentle massage are very helpful but are much slower. Transcutaneous delivery of triamcinolone or 5-flourouracil has been reported as beneficial. Laser-assisted delivery of medications via fractional ablated channels may prove promising, but the FDA has warned against using products not designed to be used systemically or subcutaneously. Botulinum toxin may also act via myofibroblasts. Hypertrophic scars respond to fractionated ablative lasers via a remodeling mechanism and this may be appropriate as sole therapy.

Superficial skin irregularities are very common. Illouz reports 8.2% of patients experienced skin irregularity post-procedure [48]. Superficial aspiration can result in a bound down or peau d'orange appearance with dermal scarring and fibrosis. Avoid this by always keeping the cannula window faced downward away from the dermis. Illouz as well as Dixit and Wagh recommend leaving 5 mm of fat beneath the dermis and over the fascia to prevent scarring and waviness [16, 48]. Lax skin may tighten better by traumatizing the subdermis either mechanically or with heat. Devices using ultrasound, radiofrequency, lasers, and helium plasma are marketed for this purpose. Care must be taken not to damage the fragile superficial vascular plexus and lymphatics. Being too aggressive near the dermis can result in dimpling, ecchymosis, ulceration and permanent reticular erythema referred to as erythema ab lipoaspiration (**Figure 4**). Correcting peau d'orange skin and erythema ab lipoaspiration is incredibly difficult. Mesoglycan-based therapy orally at a dose of 50 mg twice daily worked in one case report of erythema ab igne, which is similar. Treatment lased 1 month at twice a day and 2 months at daily dosing [49]. Cho et al. report a case of a 23-year-old woman with erythema ab igne treated with a 1064 nm ND:YAG using low fluences (1.8–2.5 J/cm<sup>2</sup> , 2 passes). She was treated with three treatments separated by 2 weeks [50].

Post-inflammatory erythema and ecchymoses may be improved with intense pulsed light (IPL). In the authors' opinion, IPL is beneficial for post-liposuction erythema generally. Using a broadband light device, a 560 nm filter and a 4.5 cm spot size (12 J cm, 30 ms and 20° cooling; two passes) every 2 days resulted in improvement of ecchymoses and erythema after 2 weeks.

Permanent skin creases frequently occur after liposuction when redundant skin folds onto itself. Properly fitted garments that do not pinch or fold the skin are essential. The patient should be made aware that folds of the skin should be flattened when the garment is adorned. Even when a garment is in place, sitting in certain positions can fold the skin. Folded skin can make permanent creases with resulting shelves of redundant tissue that persist indefinitely (**Figure 5**). Treatment can be challenging and includes lymphatic massage to assist in scar release and fluid drainage from the area superior to the crease. Subcision using a forked cannula may be required. If this is performed the area can scar again, which may be alleviated with fat grafting below the site or collagenase as discussed elsewhere. Collagenase may also be considered, especially if followed with radiofrequency and targeted pressure energy. This has been demonstrated clinically with cellulite as a model [51].

*Complications and Solutions for Post-Operative Liposuction Deformities DOI: http://dx.doi.org/10.5772/intechopen.101284*

**Figure 4.** *Scar from dermal necrosis from laser-liposuction.*

*(a) Post-liposuction creases from the inappropriately worn garments. (b) The same patient after massage for a month.*

Liposhifting may also be beneficial [33]. Bound-down skin that moves with muscle contraction is attached to the fascia. This should be carefully subcised. An alternative is triamcinolone injection and/or 5-flourouracil injectable solution. (Illouz) Chacur et al. reported a case of liposuction fibrosis and dermal scarring treated with a combination of subcision, injected polymethyl methacrylate and fractionated CO2 (epidermal). A single session resulted in notable improvement

extending to 4 years [52]. It should be remembered that triamcinolone can also cause fat atrophy and in some cases fat atrophy may exacerbate the problem.
