**8. Risks and complications**

Liposuction risks and complications are undervalued and underreported. When analyzing the medical literature related to the subject, it is always necessary to take into consideration the context from which the experiences are taken, since it is very different to perform liposuction of low volumes than liposuction of high volumes. In this way, there are interesting publications [23] but refer to cosmetic surgery performed in the office, for which the following possible contraindications are mentioned:

• Liposuction >5 liters

**Propofol Methylprednisolone Amiodarone** Flunitrazepam Dexamethasone Verapamil Diazepam Itraconozole Atenolol Triazolam Ketoconazole Labetalol Paroxetine Miconazole Pindolol Carbamazepine Fluconazole Propranolol Fluoxetine Isoniazid Metoprolol Sertraline Clarithromycin Diltiazem Nefazodone Chloramphenicol Nicardipine Terfenadine Erythromycin Timolol Methadone Tetracycline Nadolol Danazol Cimetidine Nifedipine Thyroxine Quinidine Pentoxifylline

compliance, compared with the reference white loop before infiltration.

80 Anesthesia Topics for Plastic and Reconstructive Surgery

**Figure 7.** Increase of blood pressure during the infiltration of the solution for tumescence in a hypertensive patient. In the upper part of the figure in yellow, we can see the current loop of spirometry, produced by the decrease in thoracic

**Table 2.** Drugs that inhibit the 3A4 subfamily of cytochrome P450.


Risks associated with tumescent infiltration and liposuction include DVT/PE, fatty embolism, anemia, perforation of the abdominal wall, pleural perforation, infection, fluid overload, pulmonary edema, hypothermia, and toxicity by local anesthetics and epinephrine. It is quite important to consider the necessary care during changes in position (ventral decubitus to prone decubitus) to minimize hemodynamic changes when patients are turned around and protect certain areas to avoid pressure injuries, corneal injuries, neural damage, and even blindness after anesthesia surgery. A recent report [24] mentioned the five more frequent serious complications of liposuction: thromboembolic disease, fat embolism, pulmonary edema, lidocaine intoxication, and intraabdominal visceral lesion. These events are easily preventable by simple measurements and safety protocols. The literature is full of reports of complicated patients during or after liposuction, and it is enough to mention some of these complications to encourage specialized care and stay within the recommended guidelines.

#### **8.1. Deep vein thrombosis and embolism**

Abdominoplasty is the plastic surgery procedure with the highest incidence of death secondary to PE. In addition, it must be considered that if the abdominoplasty is associated with liposuction of large volumes, the risk of PE increases. It is estimated that the rate of thromboembolism if these procedures are combined increases 6.6 times. The rate of nonlethal PE was 8.8% in patients who had an abdominoplasty with wide resection, combined with liposuction with surgical times of more than 140 minutes [25]. The causes that increase the risk of PE are the mechanical factors that favor blood stagnation in the lower extremities, such as the surgical position, abdominal compression, and the use of bandages and garments in the postoperative period [26]. In a survey conducted by the American Society of Plastic and Esthetic Surgery, a mortality of 1 for 47,415 liposuctions was reported, 1 for 7314 if liposuction was combined with other procedures, and 1 for 3281 when liposuction had been combined with abdominoplasty; this is 14 times greater than with liposuction alone [27]. Ibarra et al. [20] contributed to the elaboration of the Consensus of the Colombian Society of Anesthesiology and Resuscitation (SCARE) and of the Colombian Society of Plastic Surgery on the recommendations for the management of low-risk elective patients. Within this consensus, the following measures are mentioned: prevention of DVT, comfortable position (legs in partial flexion of knees and extremities), intermittent pneumatic compression during surgery and until discharge. Elastic compression stockings from the preoperative period until ambulation are mandatory (**Figure 8**).

Consider the use of low-molecular-weight heparin every 12 h until ambulation is normal. The following should be considered for patients with increased risk of DVT: patients with a history of previous episode of DVT, patients undergoing procedures lasting more than 5 h, patients with liposuction of large volumes (>5 liters), patients who undergo combined procedures that include abdominoplasty, patients who arrive in cities of high altitude (>2000 m asl) 2 or less days before surgery, patients traveling in the immediate preoperative or aspire to travel with a duration of 4 h or more within the first week of the postoperative period, and the patients who undergo gluteal lipoinjections.

that their thromboprophylactic effects and side effects are similar to each other and to low-

**Figure 8.** Comparison of spirometry loops, the basal with a peak pressure of the airway of 15 cm of water, and the second

Anesthesia Management for Large-Volume Liposuction http://dx.doi.org/10.5772/intechopen.83630 83

Anemia is a frequent postoperative complication in patients undergoing liposuction, especially in liposuction of large volumes. The use of vasopressors in the tumescent solutions that are injected into the fatty tissue at the beginning of this procedure decreases bleeding due

molecular-weight heparin [28].

obtained once the patient's back has been infiltrated, rising to 22 cm of water.

**8.2. Anemia**

Morales and his group studied the prophylactic effect of rivaroxaban and apixaban in patients undergoing liposuction of large volumes and other body contouring procedures, finding

**Figure 8.** Comparison of spirometry loops, the basal with a peak pressure of the airway of 15 cm of water, and the second obtained once the patient's back has been infiltrated, rising to 22 cm of water.

that their thromboprophylactic effects and side effects are similar to each other and to lowmolecular-weight heparin [28].

#### **8.2. Anemia**

Risks associated with tumescent infiltration and liposuction include DVT/PE, fatty embolism, anemia, perforation of the abdominal wall, pleural perforation, infection, fluid overload, pulmonary edema, hypothermia, and toxicity by local anesthetics and epinephrine. It is quite important to consider the necessary care during changes in position (ventral decubitus to prone decubitus) to minimize hemodynamic changes when patients are turned around and protect certain areas to avoid pressure injuries, corneal injuries, neural damage, and even blindness after anesthesia surgery. A recent report [24] mentioned the five more frequent serious complications of liposuction: thromboembolic disease, fat embolism, pulmonary edema, lidocaine intoxication, and intraabdominal visceral lesion. These events are easily preventable by simple measurements and safety protocols. The literature is full of reports of complicated patients during or after liposuction, and it is enough to mention some of these complications

Abdominoplasty is the plastic surgery procedure with the highest incidence of death secondary to PE. In addition, it must be considered that if the abdominoplasty is associated with liposuction of large volumes, the risk of PE increases. It is estimated that the rate of thromboembolism if these procedures are combined increases 6.6 times. The rate of nonlethal PE was 8.8% in patients who had an abdominoplasty with wide resection, combined with liposuction with surgical times of more than 140 minutes [25]. The causes that increase the risk of PE are the mechanical factors that favor blood stagnation in the lower extremities, such as the surgical position, abdominal compression, and the use of bandages and garments in the postoperative period [26]. In a survey conducted by the American Society of Plastic and Esthetic Surgery, a mortality of 1 for 47,415 liposuctions was reported, 1 for 7314 if liposuction was combined with other procedures, and 1 for 3281 when liposuction had been combined with abdominoplasty; this is 14 times greater than with liposuction alone [27]. Ibarra et al. [20] contributed to the elaboration of the Consensus of the Colombian Society of Anesthesiology and Resuscitation (SCARE) and of the Colombian Society of Plastic Surgery on the recommendations for the management of low-risk elective patients. Within this consensus, the following measures are mentioned: prevention of DVT, comfortable position (legs in partial flexion of knees and extremities), intermittent pneumatic compression during surgery and until discharge. Elastic compression stockings

Consider the use of low-molecular-weight heparin every 12 h until ambulation is normal. The following should be considered for patients with increased risk of DVT: patients with a history of previous episode of DVT, patients undergoing procedures lasting more than 5 h, patients with liposuction of large volumes (>5 liters), patients who undergo combined procedures that include abdominoplasty, patients who arrive in cities of high altitude (>2000 m asl) 2 or less days before surgery, patients traveling in the immediate preoperative or aspire to travel with a duration of 4 h or more within the first week of the postoperative period, and

Morales and his group studied the prophylactic effect of rivaroxaban and apixaban in patients undergoing liposuction of large volumes and other body contouring procedures, finding

to encourage specialized care and stay within the recommended guidelines.

from the preoperative period until ambulation are mandatory (**Figure 8**).

the patients who undergo gluteal lipoinjections.

**8.1. Deep vein thrombosis and embolism**

82 Anesthesia Topics for Plastic and Reconstructive Surgery

Anemia is a frequent postoperative complication in patients undergoing liposuction, especially in liposuction of large volumes. The use of vasopressors in the tumescent solutions that are injected into the fatty tissue at the beginning of this procedure decreases bleeding due to vasoconstriction, although there are some areas such as the torso and neck where bleeding is usually more abundant. Cansancao et al. [29] administered 10 mg/kg of intravenous tranexamic acid preoperative and postoperative vs. placebo in patients undergoing liposuction. The volume of blood loss for every liter of lipoaspirate was 56.2% less in the tranexamic group compared with the control group (p < 0.001). Hematocrit levels at day 7 postoperatively were 48% less in group 1 compared with group 2 (p = 0.001). Furthermore, a 1% drop in the hematocrit level was found after liposuction of 812 ± 432 ml in group 1 and 379 ± 204 ml in group 2. The authors concluded that tranexamic acid could allow for aspiration of 114% more fat, with comparable variation in hematocrit levels. Although erythropoietin has been used to improve anemia after liposuction and decrease the frequency of hemotransfusions, its usefulness has not been demonstrated [30]. It is advisable to check the hematocrit value before discharging the patient; in our patients, the hemoglobin values obtained by co-oximetry have a good correlation with the values obtained by the laboratory.

**8.5. Fat embolism**

**8.6. Miscellaneous complications**

oping complications [40].

Fat embolism and fat embolism syndrome are another serious complication whose incidence is not known, but apparently has increased [32]. Fat embolisms are fat drops that enter the circulatory system, typically after trauma, that may or may not lead to the development of fat embolism syndrome, a rare and ill-defined diagnosis that can cause multiorgan failure and death. Fat embolism syndrome is defined as the entry of fat into the blood circulation with a clinical pattern characterized by hypoxemia, respiratory failure, neurological deterioration, and petechiae that occur in the appropriate clinical context; it is a continuum of fat embolism [33–35]. A study in 30 Wistar rats showed that there was an increased risk of systemic fat embolism in the animals that underwent liposuction-lipoinjection compared to those who only underwent liposuction (3/10 vs. 6/10, respectively). Fat embolism was not detected in rats that were only anesthetized [36]. There is no specific treatment for fat embolism syndrome, therefore prevention is so important as well as prompt detection, and supportive therapy are critical. Most patients with fat embolism or fat embolism syndrome are undiagnosed or misdiagnosed, so their mortality is very high. Most of these cases are diagnosed at autopsy [34].

Anesthesia Management for Large-Volume Liposuction http://dx.doi.org/10.5772/intechopen.83630 85

The literature is full of varied reports of complicated patients during or after liposuction, and it is enough to mention some of these complications to encourage specialized care and stay within the recommended guidelines. There is a wide spectrum on liposuction complications: pleural and lung injury, bilothorax, bowel herniation, hematoma, seroma, lymphedema, and abdominal wall injury with damage to intra-abdominal viscera such as the liver, biliary tract, intestinal, or bladder perforation necrotizing fasciitis, blindness, and coronary fat embolism [37–39].

The main risk factors for the development of complications are deficient standards of hygiene, infiltration of multiple liters of wetting solution, prompt postoperative discharge, and selection of unfit patients, lack of surgical anesthesia experience, and early identification of devel-

Postoperative analgesics are extraordinarily mandatory in the professional management and prevention of acute and chronic pain after liposuction. It is usually started from the beginning of the surgery with an infusion with 300 mg of ketorolac, 300 mg of tramadol in 100 mL/2 mL/h, considered as basal analgesic scheme. It is also valid to resort if necessary to some rescue strategies, in which the analgesic and anti-inflammatory effect of hyperbaric oxygenation therapy can be considered. This therapy is routinely provided to all of our patients

The use of hyperbaric oxygenation therapy (**Figure 9**) has also reduced the need for pharmacological thromboprophylaxis, since it has been shown that hyperbaric oxygen by the action of nitric oxide decreases the expression of intracellular adhesion molecules (ICAM-1),

**9. Postoperative analgesia and hyperbaric oxygen therapy**

in the next 4 to 5 days after their procedure [41, 42].

#### **8.3. Drug interactions**

Take care of possible drug interactions including natural products and anabolic steroids. Clarify in informed consent the high risk of interaction of substances such as cocaine, amphetamines, ecstasy, and other recreational drugs, with anesthetic and vasoactive medications. In suspected cases, antidoping and toxicology tests can be done [20].

Liposuction of large volumes is associated with important hemodynamic alterations: an increase in the cardiac index, heart rate, mean arterial pressure of the pulmonary, ejection volume index, and right ventricular work index are observed as well as a decrease in mean arterial pressure. Epinephrine, which is usually used at considerable doses during liposuction, may be responsible for tachycardia and increased cardiac index. The decrease in mean arterial pressure and systemic vascular resistance is probably due to the effects of general anesthesia and opioids in the transoperative period, but also the reduction of peripheral vascular resistance may be due to the dominant action of the epinephrine on the beta2 receptors of skeletal muscle vessels, where an increase in blood flow is observed.

#### **8.4. Hypothermia**

There is an increased risk of hypothermia in patients of large volume liposuction since there are large areas of body surface exposed to temperature loss. If the anesthesiologist does not insist, the nursing staff tends not to adequately heat the dermoclysis solutions, or if the surgeon has no experience or does not care about hypothermia, he/she can make the procedure excessively long, without considering that regardless of the type of anesthesia, this will always help to facilitate hypothermia. It is necessary to maintain the temperature of the operating room, even in hot climates in no less than 25°C or 77°F, even if it goes against the surgeon's comfort and other operating room staff. We must bear in mind the complications that hypothermia can cause, such as cardiac dysrhythmias, coagulopathies, oliguria, and electrolyte imbalance and an important increase in the consumption of oxygen during the chill phase. Both the hemodynamic changes and the tendency to hypothermia persist at least in the first 24 h of the postoperative [31].

#### **8.5. Fat embolism**

to vasoconstriction, although there are some areas such as the torso and neck where bleeding is usually more abundant. Cansancao et al. [29] administered 10 mg/kg of intravenous tranexamic acid preoperative and postoperative vs. placebo in patients undergoing liposuction. The volume of blood loss for every liter of lipoaspirate was 56.2% less in the tranexamic group compared with the control group (p < 0.001). Hematocrit levels at day 7 postoperatively were 48% less in group 1 compared with group 2 (p = 0.001). Furthermore, a 1% drop in the hematocrit level was found after liposuction of 812 ± 432 ml in group 1 and 379 ± 204 ml in group 2. The authors concluded that tranexamic acid could allow for aspiration of 114% more fat, with comparable variation in hematocrit levels. Although erythropoietin has been used to improve anemia after liposuction and decrease the frequency of hemotransfusions, its usefulness has not been demonstrated [30]. It is advisable to check the hematocrit value before discharging the patient; in our patients, the hemoglobin values obtained by co-oximetry have

Take care of possible drug interactions including natural products and anabolic steroids. Clarify in informed consent the high risk of interaction of substances such as cocaine, amphetamines, ecstasy, and other recreational drugs, with anesthetic and vasoactive medications. In

Liposuction of large volumes is associated with important hemodynamic alterations: an increase in the cardiac index, heart rate, mean arterial pressure of the pulmonary, ejection volume index, and right ventricular work index are observed as well as a decrease in mean arterial pressure. Epinephrine, which is usually used at considerable doses during liposuction, may be responsible for tachycardia and increased cardiac index. The decrease in mean arterial pressure and systemic vascular resistance is probably due to the effects of general anesthesia and opioids in the transoperative period, but also the reduction of peripheral vascular resistance may be due to the dominant action of the epinephrine on the beta2 receptors of skeletal muscle vessels,

There is an increased risk of hypothermia in patients of large volume liposuction since there are large areas of body surface exposed to temperature loss. If the anesthesiologist does not insist, the nursing staff tends not to adequately heat the dermoclysis solutions, or if the surgeon has no experience or does not care about hypothermia, he/she can make the procedure excessively long, without considering that regardless of the type of anesthesia, this will always help to facilitate hypothermia. It is necessary to maintain the temperature of the operating room, even in hot climates in no less than 25°C or 77°F, even if it goes against the surgeon's comfort and other operating room staff. We must bear in mind the complications that hypothermia can cause, such as cardiac dysrhythmias, coagulopathies, oliguria, and electrolyte imbalance and an important increase in the consumption of oxygen during the chill phase. Both the hemodynamic changes and the tendency to hypothermia persist at least in the

a good correlation with the values obtained by the laboratory.

suspected cases, antidoping and toxicology tests can be done [20].

where an increase in blood flow is observed.

first 24 h of the postoperative [31].

**8.3. Drug interactions**

84 Anesthesia Topics for Plastic and Reconstructive Surgery

**8.4. Hypothermia**

Fat embolism and fat embolism syndrome are another serious complication whose incidence is not known, but apparently has increased [32]. Fat embolisms are fat drops that enter the circulatory system, typically after trauma, that may or may not lead to the development of fat embolism syndrome, a rare and ill-defined diagnosis that can cause multiorgan failure and death. Fat embolism syndrome is defined as the entry of fat into the blood circulation with a clinical pattern characterized by hypoxemia, respiratory failure, neurological deterioration, and petechiae that occur in the appropriate clinical context; it is a continuum of fat embolism [33–35]. A study in 30 Wistar rats showed that there was an increased risk of systemic fat embolism in the animals that underwent liposuction-lipoinjection compared to those who only underwent liposuction (3/10 vs. 6/10, respectively). Fat embolism was not detected in rats that were only anesthetized [36]. There is no specific treatment for fat embolism syndrome, therefore prevention is so important as well as prompt detection, and supportive therapy are critical. Most patients with fat embolism or fat embolism syndrome are undiagnosed or misdiagnosed, so their mortality is very high. Most of these cases are diagnosed at autopsy [34].

#### **8.6. Miscellaneous complications**

The literature is full of varied reports of complicated patients during or after liposuction, and it is enough to mention some of these complications to encourage specialized care and stay within the recommended guidelines. There is a wide spectrum on liposuction complications: pleural and lung injury, bilothorax, bowel herniation, hematoma, seroma, lymphedema, and abdominal wall injury with damage to intra-abdominal viscera such as the liver, biliary tract, intestinal, or bladder perforation necrotizing fasciitis, blindness, and coronary fat embolism [37–39].

The main risk factors for the development of complications are deficient standards of hygiene, infiltration of multiple liters of wetting solution, prompt postoperative discharge, and selection of unfit patients, lack of surgical anesthesia experience, and early identification of developing complications [40].
