Position Statement and Guidelines
New York, NY (February 9, 2004) – The American Society for Aesthetic Plastic Surgery (ASAPS) presents the following guidelines developed to assist physicians in clinical decision-making. The guidelines were developed in conjunction with plastic surgery organizations participating in a Lipoplasty Task Force. This document is not intended to establish a standard of care, but to spell out recommendations that can help to ensure the highest level of patient satisfaction. As such, it is subject to periodic review, updating and revision.
Nearly two decades of clinical experience in the United States and Canada have demonstrated that lipoplasty (liposuction) is safe and produces effective therapeutic outcomes when performed by a trained surgeon in accordance with accepted standards of surgical practice. Lipoplasty is generally recommended for patients of normal weight who have localized fat deposits that are resistant to diet or exercise or have areas of fat deposits that are disproportionate. Lipoplasty to remove a greater volume of fat is sometimes performed on patients who exceed their ideal body weight but who otherwise are appropriate candidates for fat suctioning. Lipoplasty is not a surgical treatment for obesity.
Lipoplasty is the single most requested aesthetic (cosmetic) surgical procedure in the United States, with 372,831 procedures performed in 2002 (statistics from the American Society for Aesthetic Plastic Surgery). From its introduction in the U.S. in 1982 until the early 1990s, lipoplasty had among the lowest complication rates of all aesthetic surgical procedures. However, as new techniques were introduced, and physicians found they could remove larger amounts of fat, the incidence of major complications, including fatal outcomes, rose.
Data on Lipoplasty Safety
While data prior to 1994 showed a very low rate of lipoplasty complications, surveys examining procedures performed between mid-1994 and mid-1998 suggested mortality rates as high as 1 in 5,000. Educational efforts conducted to alert plastic surgeons to lipoplasty risk factors have produced a dramatic effect on the procedure’s safety record since 1998, according to results of a major survey published in Aesthetic Surgery Journal (ASJ) , ASAPS’ peer-reviewed journal. Survey respondents reported a total of 94,159 lipoplasty procedures performed from September 1998 through August 2000. Based on the results, the estimated risk of death from lipoplasty performed as an isolated procedure (not in combination with any other surgeries) was found to be 1 per 47,415 procedures. For more information on this research, see: Major Survey Reports Turnaround in Lipoplasty Safety (May, 2001).
The educational efforts that led to these significant improvements in lipoplasty safety focused on data from earlier studies showing that the following factors contribute to increased risk:
1) administration of excessive amounts of fluid and local anesthesia,
2) excessive fat removal,
3) performance of multiple unrelated procedures in the same surgical session and
4) poor patient selection/patient health.
All these factors can be avoided.
It is ASAPS’ position that since lipoplasty is a surgical procedure, physicians performing lipoplasty should be trained as surgeons. Such training is absolutely necessary to ensure the highest standard of care, to ensure patient safety, and to minimize potential complications. Physicians who perform liposuction without having had the customary surgical training, including fluid management, may not be prepared to prevent or handle unexpected complications. Yet no current state laws prohibit any physician, including those without appropriate specialty training, from performing lipoplasty and other cosmetic surgery. Physicians may use titles such as “plastic surgeon,” “cosmetic surgeon,” or similar names without actually being certified in the specialty of plastic surgery or even being formally trained in surgery.
Medical education is comprised of three components: undergraduate medical education (“medical school”), graduate medical education (“residency training”), which prepares a physician to practice a specialty, and continuing medical education (CME), which continues throughout a physician’s professional life. Following medical school, doctors performing lipoplasty should either have completed a general surgery residency program approved by the Accreditation Council on Graduate Medical Education (ACGME); a plastic surgery integrated residency program approved by the ACGME; or a surgical specialty residency program approved by the ACGME in a specialty recognized by the American Board of Medical Specialties (ABMS). The physician should also have specific training in lipoplasty. The American College of Surgeons has stated that qualification of a surgeon as a specialist implies that practice will be conducted within specialty limits.
The American Board of Plastic Surgery (ABPS) is recognized by the ABMS to certify doctors in the specialty of plastic surgery. Plastic surgeons certified by the ABPS have successfully completed a minimum of 5 years of surgical training including approved residency training specifically in plastic surgery . All ASAPS members are ABPS certified.
Hospital Privileges and Outpatient Surgical Facilities Credentials to perform specific surgical procedures within an acute care hospital setting are a form of physician accreditation. Hospital surgical privileges to perform specific procedures are granted only after a hospital review committee evaluates a surgeon’s training and competency. This involves peer review and monitoring of results and complications. Permission to perform new surgical techniques may be granted upon documentation of additional training.
ASAPS maintains that cosmetic surgical procedures and treatments may be safely performed in facilities outside of a hospital. Published data regarding complications associated with a variety of plastic surgery procedures performed in accredited office-based facilities showed a complication rate of less that ½ of 1 percent (0.47%) in over 400,000 operations. This number compares favorably with the rate of complications for similar procedures performed in hospitals.
It is recommended that out-of-hospital facilities, including office-based surgical facilities, meet strict quality standards, peer review, and external quality assurance assessment, such as accreditation by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) or equivalent agency. All facilities should be adequately staffed and equipped to monitor patients and deal with potential complications. All facilities should have appropriate resuscitation equipment, and be required to report morbidity and mortality data.
Beginning in July 2002, ASAPS required its membership of ABPS-certified plastic surgeons to perform operations requiring anesthesia (other than local anesthesia and/or minimal oral or intramuscular tranquilization) only in accredited surgical facilities.
It is ASAPS’ position that the performance of cosmetic surgical procedures and treatments in any venue requires ABMS board certification in a surgical specialty and hospital privileges, based on documented training and peer review. The hospital privileges should be for the aesthetic procedure to be performed whether the procedure is performed in the hospital or an approved outpatient setting. Issues of patient safety must be addressed when planning procedures, wherever they may be performed. The common denominator is prudent surgical judgment with respect to patient evaluation, risk disclosure, amount/length of surgery planned, and postoperative care.
Lipoplasty is well suited for women and men who are within 30 percent of their ideal body weight and have adequate skin elasticity to ensure good cosmetic results, but who have localized fat deposits that are resistant to diet or exercise. It is not an indicated treatment for obesity. Appropriate patient selection should include candid discussion of any pre-existing medical conditions, and any current medications, including dietary or herbal supplements. An appropriate physical examination, including laboratory work based on the patient’s general health and age, is necessary; the American Society of Anesthesiologists (ASA) has set general standards for preoperative testing. Special attention should be given to possible drug interactions.
Lipoplasty should be considered a major surgical (not a “lunch time”) procedure, with the need for accurate disclosure of risk and potential complications to patients electing to undergo this procedure using any of the currently performed techniques.
Preinjection of Fluids (Wetting Solutions)
Lipoplasty is based on the principle of the aspiration of subcutaneous fat through an inserted cannula that is attached to a vacuum pump or syringe. A “superwet” technique has become the one most surgeons choose, wherein a small volume dilute solution of local anesthetic and a vasoconstrictor is infiltrated into the surgical areas prior to beginning the procedure. Significant medical complications are rare, although the risk of significant complications and fatalities has been shown to increase with larger volume infusion and removal.
Preinjection of fluids containing local anesthetics and vasoconstrictors in a volume equal to the expected volume of fat to be removed has enabled lower morbidity and has decreased blood loss, swelling, bruising, and discomfort. Prior to the use of preinjection techniques, most fat removals of greater than 1500-2000 cc required blood transfusions to replace intraoperative blood loss.
It is recommended that patients undergoing moderate (greater than 2000 cc) and large volume lipoplasty (greater than 5000 cc) have extended postoperative monitoring of vital signs and urine output. Only experienced surgeons should consider volumes of aspirate above 5000 cc, and they should monitor all intake and output fluids. Patients undergoing removal of significant amounts of fat may require additional intravenous fluid replacement and monitoring by an overnight stay in a hospital or an accredited extended outpatient care facility.
Fluid management is a fundamental part of surgery. A physician possessing core knowledge in surgery is best equipped to manage fluid and electrolyte balance in patients undergoing lipoplasty. Physicians who perform lipoplasty without having received thorough surgical training may be unable to prevent, identify, or treat potential complications should they occur.
Some patients and their doctors prefer local anesthesia, or epidural anesthesia (with or without conscious sedation), while others prefer general anesthesia. A board-certified/board-eligible anesthesiologist or a certified registered nurse anesthetist should administer general anesthesia.
Over time, several techniques have evolved as modifications of standard lipoplasty (Suction-Assisted Lipoplasty [SAL]), including Power-Assisted Lipoplasty (PAL), and Ultrasound-Assisted Lipoplasty (UAL) and using terms such as superwet or tumescent to refer to the ratios of injected fluid to aspirate (including fat) removed during lipoplasty. It is ASAPS’ position that the technique used is subject to the determination of the operating surgeon and is of less consequence than the training of the surgeon and the accreditation of the facilities.
Lipoplasty is a serious surgical procedure that has been demonstrated to be safe and effective when safety guidelines are in place. Among the risks are those associated with all surgery, such as wound infection, scarring, bleeding, deep vein thrombosis (DVT), and pulmonary embolism.
General recommendations include:
- Physicians performing lipoplasty in any facility should be required to have surgical privileges/ accreditation to perform this procedure in an acute care hospital.
- Physicians should be qualified for examination or certified by an ABMS-recognized surgical board.
- Facilities outside of acute care hospitals should possess a peer-review system, should report morbidity and mortality data, and should be accredited by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), or an equivalent agency such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or the Accreditation Association for Ambulatory Health Care (AAAHC).
- Appropriate patient monitoring and resuscitation equipment and medication are essential, regardless of who is performing the procedure and how much fat is being removed.
- Precise records of fluid intake and output should be maintained during the perioperative period.
- Communications to patients seeking cosmetic surgery should properly represent the risks of these procedures, so that fully informed consent can be given.
- In addition to the standard discharge criteria, patients and their caregivers should be provided with written information on the symptoms of drug reactions and fluid overload and with instructions on how to respond if these symptoms occur.
- Duration of care should include close monitoring 2-4 hours post operative and physician follow-up in 24 to 48 hours, with outcome reviews scheduled at intervals from a week to a year.