Tumescent liposuction is now the most commonly performed cosmetic surgery in the United States. The technique involves the subcutaneous infusion of saline, lidocaine and epinephrine, followed by aspiration of fat through microcannulas. The amount of fat removed varies but may be greater than 1,500 mL. Such large-volume liposuction may require infusion of several liters of the infusate. Lidocaine dosages may be as high as 55 mg per kg, but few complications have been reported. Rao and colleagues examined the causes of death in five patients who underwent tumescent liposuction.
The authors reviewed all autopsy reports from 1993 through 1996 and death-notification records from 1993 to March 1998, at the New York City medical examiner's office. They also questioned the city medical examiners about any deaths possibly related to liposuction that were under investigation. The medical record of a patient whose death was related to the procedure was reviewed for information about the liposuction procedure itself, the amount of lidocaine administered during the procedure, premorbid conditions and medication use.
Five of the 1,001 deaths certified by the medical examiner's office as resulting from therapeutic complications were related to liposuction. In four cases, the procedure was performed by a plastic surgeon and in one case, by a general surgeon. In all cases, an anesthesiologist was in attendance. Family members of four of the patients consented to a published description of the cases.
A complete autopsy, including examination of the heart and toxicologic studies of blood, urine and other available fluids and tissues, was performed in each patient. In all cases, the heart was normal and there were no illicit substances identified by toxicology testing.
Deaths occurred in a 33-year-old man and in three women who were 33, 40 and 54 years of age. In two cases, hypotension and bradycardia were followed by asystole during the procedure. A third patient had been discharged from the hospital for two hours when she had a syncopal episode and was found to be in ventricular fibrillation. This patient was resuscitated but remained unresponsive and in an anoxic coma. She was pronounced dead three days later. The fourth patient became “lightheaded” 18 hours postoperatively and then became unresponsive. Autopsy findings in this patient included a deep venous thrombosis of the calf with saddle and distal pulmonary emboli. In all cases, resuscitation was attempted.
The doses of lidocaine in the patients (including the fifth patient whose family did not permit disclosure of the details) ranged from 10 to 40 mg per kg. The duration of the procedure in the four cases that could be described was 2.5, 2.3, 4.5 and 7.0 hours.
The authors point out that lidocaine is known to cause bradycardia, vasodilatation and hypotension, and to suppress myocardial automaticity. The maximal dose of lidocaine recommended for subcutaneous infiltration is 4.5 mg per kg. The doses used in tumescent liposuction are reported to range from 10 to 88 mg per kg. In addition, the authors suggest that metabolism of lidocaine may be inhibited by other agents administered during an operation, such as medications for pain or nausea. Midazolam, in particular, may compete with lidocaine for enzymatic metabolism. The authors believe lidocaine toxicity or lidocaine-related drug interaction is a possible explanation for two deaths in the patients who developed hypotension and bradycardia.
The authors believe fluid overload may be another factor in liposuction-related deaths. Excessive fluid may cause hemodilution and pulmonary edema, features that were present at autopsy in the patient who developed complications after hospital discharge.
Another factor may be venous stasis and thrombogenesis following extensive tumescent liposuction of the lower abdomen and extremities, and immobilization. This procedure can cause impedance of venous flow and the release of tissue factors.
The authors state that data from the American Society of Plastic and Reconstructive Surgeons indicate that the number of liposuction procedures performed by plastic surgeons increased 200 percent from 1992 to 1997. Data from the American Academy of Cosmetic Surgery, which represents several surgical disciplines, show a 300 percent increase from 1990 to 1996. The authors believe this elective surgical procedure should be reevaluated. Because mandatory reporting of liposuction-related complications or deaths does not exist, the actual incidence of these events is unknown. The authors encourage a reassessment of drug absorption and interactions, fluid management, prothrombogenic factors and liposuction volume. They assert that “deaths due to cosmetic surgery should be a matter for serious public concern.”