Cases & Commentaries

Liposuction Gone Awry

Commentary By James A. Yates, MD

The Case

A 54-year-old man with HIV was referred to a
plastic surgeon for cosmetic surgery. In the plastic
surgeon’s office, he underwent neck and facial liposuction
with eyelid tightening under local anesthesia. There were no
complications at the time of the procedure and the patient was sent
home.

After arriving home, the patient noticed an
expanding neck mass near the incision site and progressive
shortness of breath. He contacted the plastic surgeon, who directed
him to the nearest emergency department. Upon arrival, the patient
was in severe respiratory distress and needed an emergent
tracheostomy, secondary to neck swelling and edema. He was taken to
the operating room, where he was found to have a laceration of the
external jugular vein. The vessel was repaired and the patient
required a prolonged stay in the intensive care unit. He eventually
was discharged to home.

The Commentary

Location, location, location—this is the
mantra of the real estate market. But is location a factor in the
occurrence of the complication reported in the aforementioned case?
Is patient safety better assured if surgery is performed in a
hospital outpatient facility versus an ambulatory or office
surgical facility setting? This question has generated considerable
controversy, with proponents on both sides of the argument. The
case presentation lacks many details and leaves several unanswered
questions. Although the temptation is to see only operator-related
complications, several additional causative factors may have been
at play in this case:

  1. Facility accreditation. Was the
    facility accredited by any of the three nationally known
    accrediting organizations: American Association for Accreditation
    of Ambulatory Surgical Facilities (AAAASF), Joint Commission on
    Accreditation of Healthcare Organizations (JCAHO), or Accreditation
    Association for Ambulatory Health Care (AAAHC)? Was there state
    licensure or Medicare certification? Such accreditation generally
    ensures that the facility has all the equipment, staff, and
    medications needed to manage on-site adverse events and
    emergencies.
  2. Patient status. What was the
    patient’s American Society of Anesthesiologists (ASA) status?
    In addition to his known HIV, could other comorbid conditions have
    made him a poor candidate for an office surgical procedure? A
    recent study (1)
    found that men have a two times greater risk of hematoma than women
    in cosmetic procedures, possibly due to higher rates of
    hypertension.
  3. Surgical site marking. Did the
    surgeon mark the skin externally to identify the location of the
    external jugular vein prior to injecting the site? Safe and sound
    practice requires such identification of all potential high-risk
    areas, such as blood vessels, nerves, or areas of unstable skin due
    to radiation or other prior trauma.
  4. Techniques used. What liposuction
    techniques were employed (dry, wet, superwet, tumescent,
    ultrasound)?(2)
    Currently, all of the “wet” methods appear to provide
    much easier “passes” of the cannulae for the operating
    surgeon; when lidocaine is used as part of the wetting solution, it
    also seems to reduce post-operative pain. Additionally, bleeding
    and post-operative bruising are far better controlled when
    epinephrine is part of the solution being instilled.
  5. Cannulae. What size cannulae were
    used? Were they sharp or blunt? The sharp and larger
    diameter–tipped cannulae have, for the most part, faded out
    of use primarily because of the risks of nerve, vessel, skin, and
    muscle damage.
  6. Post-operative wound management.
    Were pressure dressings or ice packs applied to the treated areas?
    Using these modalities as part of the post-operative wound
    management has been shown to be moderately effective in controlling
    swelling, edema, and, to some degree, hematomas.(3,4) These possible benefits and their minimal expense
    should prompt their general use.
  7. Post-operative observation. In
    this case, given the type of vessel lacerated and its size, it is
    surprising that marked swelling was not immediately observed prior
    to the patient’s discharge. Was there a planned and
    implemented period of post-operative observation for possible
    immediate complications? The period for evaluation prior to
    discharge on any patient should be based on a validated scoring
    system. The most widely used is the Aldrete method, which estimates
    the adequacy of recovery based on the patient’s level of
    consciousness, activity, respiration, circulation, and color
    (similar to an Apgar score).(5)
    Patients should only be considered for discharge when all the
    parameters in this 10-point scale have been achieved. The method is
    not entirely prescriptive, however, since it does not define the
    time frame to meet the discharge parameters, and so the recovery
    time could be very short (eg, 30 minutes) to as long as several
    hours. Much is also dependent on procedure performed, ASA levels,
    and age of patient.
  8. Post-operative instructions. Were
    written post-operative instructions given to alert the patient of
    any possible complications that could necessitate immediate
    attention?

One must be careful not to use any of the above
as an indictment of office surgery procedures, since similar cases
have occurred in other settings. For example, I know a case in
which a patient died after an uncomplicated facelift performed
under general anesthesia. The patient strangled from a hematoma
under her dressing. This case took place in a community
hospital’s outpatient department, not an ambulatory
office.

That said, office-based facilities have been the
site of many reports of serious complications and deaths. These
reports have received tremendous media attention, especially in
Florida. Between 2000 and 2002, Florida reported a ten-fold
increase in adverse events in procedures done in office-based
facilities versus freestanding ambulatory surgery
centers.(6)
However, when these cases were reevaluated with more rigorous
techniques, the concerns were unfounded, with fewer than 1 adverse
event in 10,000 cases.(6) In
January 2002, a multi-disciplinary meeting convened by the National
Institutes of Health also found a low degree of adverse events in
office-based surgical procedures. These results mirrored similar
studies (involving voluntary reporting) by the AAAASF (7),
which found that the safety in accredited office-based surgery
facilities was equivalent to that in hospital outpatient
facilities.

In 1999, the American Society of Plastic Surgeons
(ASPS) and the American Society of Aesthetic Plastic Surgery
(ASAPS) mandated that to maintain membership in either society one
must perform outpatient procedures only in an accredited facility
(by JCAHO, AAAHC, or AAAASF) or in a state-licensed unit.
Accreditation tells the potential patient that a certain standard
of patient safety has been achieved and evaluated and assures the
facility’s staff that they are working in a safe
environment.

Despite the above data, adverse events in
office-based facilities continue to be intensely reported by the
media. In view of this, the ASPS convened a task force on patient
safety in office-based facilities. One of its first advisories
concerned liposuction (8) and
incorporated many of the above concerns regarding cannula type,
safe amounts of wetting solutions, amounts of fat extracted, and
fluid replacement requirements.

This task force is developing additional
guidelines, partly trying to fill an information void, since there
are presently no reporting systems for office-based surgeries. One
recent study used an internet and peer review reporting system to
analyze 400,000 cases (since the report, the database has grown to
more than 800,000 cases) performed in roughly 1200 accredited
AAAASF facilities.(9) Of
the 2,597 reported unanticipated sequelae, hematoma was the most
common problem, reported in 0.18% of cases. Such hematomas
represented nearly one-third of reported sequelae. Other lesser
complications included infection, with an incidence of 0.09% of
performed procedures. Cardiac irregularities and sequelae accounted
for 0.007%. Less frequent complications were blood pressure
alterations, deep venous thrombosis, and pulmonary embolism (each
approximately 0.01%). A related study (10) of liposuction of the neck and jowls also found an
extremely low risk of voluntarily reported complications.

It is estimated that 10 million procedures were
performed in office-based facilities in the US in 2005 (11), a
remarkable volume. Patients appear to value the convenience,
privacy, staff consistency, and efficiency of such facilities.
Nevertheless, the fact that only 1200 of 40,000 office-based
facilities in the United States are currently accredited by the
AAAASF is a concern (12);
it should be noted that some other office-based practices are
accredited through JCAHO (13)
and AAAHC. All these organizations have fairly similar bases for
evaluation of the facilities (Table) (14),
scrutinizing all areas of the facilities carefully for possible
safety hazards.(15)

Overall, our organization believes that the
accreditation process is needed to ensure that office-based
practices are as safe as hospital-based practices. Present evidence
clearly demonstrates that the accredited office facility, staffed
by appropriately trained and credentialed providers, is as safe as
any other environment for care today.(16) To date, there have been no studies to the contrary.
Additionally, for surgeries in office-based facilities, the length
of the surgical procedures has no bearing on the frequency of safe
outcomes.

Take-Home Points

  • If performed in an accredited facility,
    office-based surgery is as safe as hospital-based surgery.
  • All office-based surgical facilities
    should be accredited by AAAASF, JCAHO, AAAHC, or the
    equivalent.
  • Evidence-based techniques should be
    employed in outpatient plastic surgery to reduce the risk of
    complications.
  • Validated scoring systems should be used
    to assess adequacy of recovery from surgery prior to discharge
    post-operatively in office-based procedures.

James A. Yates, MD
President, American Association for the Accreditation of Ambulatory
Surgical Facilities

References

1. Baker DC, Stefani WA, Chiu ES. Reducing the
incidence of hematoma requiring surgical evacuation following male
rhytidectomy: a 30-year review of 985 cases. Plast Reconstr Surg.
2005;116:1973-1985.
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2. Rohrich RJ, Beran SJ, Fodor PB. The role of
subcutaneous infiltration in suction-assisted lipoplasty: a review.
Plast Reconstr Surg. 1997;99:514-519.
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3. Peck GC. Complications and Problems in
Aesthetic Plastic Surgery. New York, NY: Gower Medical Publishing;
1992:sec. 3.8.

4. Wilkinson TS. Practical Procedures in
Aesthetic Plastic Surgery. New York, NY: Springer-Verlag;
1994:241.

5. Aldrete JA, Kroulik D. A postanesthetic
recovery score. Anesth Analg. 1970;49:924-934.
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6. Hancox JG, Venkat AP, Hill A, et al. Why are
there differences in the perceived safety of office-based surgery?
Dermatol Surg. 2004;30:1377-1379.
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7. Morello DC, Colon GA, Fredricks S, Iverson RE,
Singer R. Patient safety in accredited office surgical facilities.
Plast Reconstr Surg. 1997;99:1496-1500.
[
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8. Iverson R, Lynch D, and the American Society
of Plastic Surgeons Committee on Patient Safety. Practice advisory
on liposuction. Plast Reconstr Surg. 2004;113:1478-1490.
[
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9. Keyes GR, Singer R, Iverson RE, et al.
Analysis of outpatient surgery center safety using an
internet-based quality improvement and peer review program. Plast
Reconstr Surg. 2004;113:1760-1770.
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10. Yu TC, Perez MI. Dermatologic liposuction:
safety record and techniques. Cosmet Dermatol.
2004;17:209-212.

11. Office-Based Anesthesia and Surgery. American
Society of Anesthesiologists Web site. Available at:
http://www.asahq.org/patientEducation/officebased.htm.
Accessed February 21, 2006.

12. Schneider EM. Most office-based surgery
centers unregulated. Cosmetic Surgery Times. November-December
2005.

13. Office-Based Surgery Standards Sampler. Joint
Commission on the Accreditation of Healthcare Organizations Web
site.

14. Standards and Checklist. Gurnee, IL: American
Association for Accreditation of Ambulatory Surgery Facilities;
2002.

15. Manuel BM, Nora PF, eds. Surgical Patient
Safety: Essential Information for Surgeons in Today's Environment.
Chicago, IL: American College of Surgeons; 2005.

16. Gordon N, Koch M. Duration of anesthesia as
an indicator of morbidity and mortality in office-based facial
plastic surgery. Arch Facial Plast Surg. 2006;8:47-53.
[
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Table

Table. Bases for Evaluation of Surgical
Facilities*

General Environment

  • How does the facility look in terms of
    cleanliness, convenience, comfort?
  • Is the lighting sufficient?
  • Are there convenient restroom
    facilities?
  • Is there adequate space for
    administrative activities?
  • Is there adequate space for
    storage?

Operating Room Environment

  • Is the operating room distinct and
    separate?
  • Is it of sufficient size to accommodate
    all required equipment?
  • Does it have all the necessary
    lighting?
  • Does it have sources for emergency
    power?
  • Does it have resuscitative
    equipment?
  • Is proper aseptic technique
    followed?

Recovery Room Environment

  • Are the appropriate policies and
    procedures in place to score the patients prior to discharge?
  • Is there significant recovery monitoring
    equipment?
  • Is there a means for communicating with
    other office personnel?

General Safety

  • Are there fire exits, fire
    extinguishers?
  • Is exit lighting in place?

Blood and Medications

  • Are appropriate intravenous fluids
    available?
  • Are narcotics stored appropriately?
  • Are there any outdated drugs?

Medical Records

  • Are they secure?
  • Are they legible?
  • Is HIPAA being followed?
  • Is there proper documentation?
  • Are laboratory reports and operative
    reports present?

Quality Assessment and Quality
Improvement

  • Is there a type of peer review plan in
    effect to evaluate the performance of those individuals in this
    facility?

Personnel

  • Are they properly trained?
  • Are they certified for their various
    positions?
  • Do they have their appropriate
    inoculations?
  • Are they properly supervised?

Governance

  • Who is responsible for the rules and
    regulations of the facility?
  • Who is in charge of missions and
    goals?
  • Who establishes policies and
    procedures?

Anesthesia

  • Who is qualified to administer the
    anesthesia?
  • Is there proper anesthetic equipment and
    medications available?
  • Is the anesthesiologist available until
    full discharge of the patient from the facility?
  • Has the anesthesiologist evaluated the
    patient preoperatively?

* Although each accrediting organization
covers generally the same standards, the titles may vary
somewhat.