The advent of newer surgical techniques and greater social acceptance has led to
a progressive increase in the demand for plastic surgery. Liposuction, a
surgical procedure in use for more than 30 years was devised by Fournier, Illouz
and others1. It is the second most
performed procedure in Brazil, with up to 209,165 procedures performed in 2016;
during the same period , 257,334 procedures were documented in the United States
Initially, the goal was to treat specific regions, but advances in understanding
the physiological effects of liposuction improved equipment and techniques,
increased safety in the surgical environment, and experience, over the years.
This led surgeons to routinely remove large amounts of adipose tissue. As
liposuction became commonplace, hematological alterations became evident, and
some adaptations were necessary.
However, patient safety remains the prime concern. Most research and publications
focus on the techniques and complications of liposuction, rather than on care
for safety, which involves attention to blood and metabolic changes, and their
Pre-operative evaluation is the key to performing a safe surgical procedure, and
this includes everything from detailed anatomical and physiological knowledge,
to decision-making regarding the most appropriate technique for individual
patients3. Patients undergoing
liposuction require similar evaluation to other surgical patients.
Observational studies indicate that findings of relevant pre-operative laboratory
tests (e.g., hemoglobin, hematocrit, clotting tests), may be predictive of
perioperative blood loss, transfusion risk, or other transfusion-related adverse
events4. Consequently, a thorough
pre-operative assessment is necessary, particularly to identify factors that may
predispose to complications.
Another important safety parameter to mention in relation to blood loss during
liposuction is the volume of the aspirate. The resolution of the Federal Medical
Council of Brazil determined that the volumes aspirated should not exceed 7% of
the body weight, when using the infiltrative technique, or 5% when using the
non-infiltrative technique. The same resolution also states that the total
liposuction area should not exceed 40% of the body area, regardless of the
In 2009, the safety committee of the American Society of Plastic
Surgery (ASPS)6 published an
article on safety recommendations, developed as a complete review of the
scientific evidence from the literature on liposuction. In addition to other
aspects of liposuction, recommendations on technique, cannulas, infiltrative
solutions, type of anesthesia, patient selection, aspirate volume, and fluid
replacement have been defined. However, most of the existing literature on
safety has little or no systematic evidence.
Thromboembolic phenomena, the surgery association, infections (necrotizing
fasciitis, perforations, toxic shock syndrome), and the surgical location, are
proven risk factors in mortality after liposuction; these complications are well
documented in literature.
The present study focused on the observation and reporting of our experience
related to post-operative hematological changes including fall in hemoglobin
levels, in patients undergoing liposuction alone, or in conjunction with
abdominoplasty. This is a particularly relevant aspect in regard to patient
safety, as it causes definitive delays in the patient’s recovery, requires
emergency admission, diagnostic failures, and exhaustion and misunderstanding in
the surgeon and patients alike.
This study intended to compare and evaluate levels of hemoglobin, serum iron, and
total protein in the peri-operative period (between 7 and 10 days). In addition,
the study also intended to assess the impact of these differences on patients
undergoing liposuction as an isolated procedure, or combined with
We conducted a prospective study including patients either undergoing liposuction
alone, or in conjunction with abdominal dermolipectomy, for esthetic
indications. A total of 30 patients aged between 23 and 59 years were studied
between 2017 and 2018; among these individuals, 27 were females and 3 were
males. All procedures were performed at the Plastic Surgery Clinic, in Belo
Horizonte-MG, by the same surgical and anesthetic team.
The peri -operative care was uniform in all cases, all evaluation being made by
the main surgeon. The demographic data, weight, body mass index (BMI),
hemoglobin, serum iron, and total protein levels of all patients were collected
pre-operatively, and also between 7 and 10 post-operative days. The patients
were evaluated post-operatively at 7 days and 10 days as part of the
post-operative surgery control, and notes were made on their clinical
evaluation, and on the hemodynamic status. The laboratory tests were done in the
same laboratory and tabulated.
All surgeries were performed in a specialized plastic surgery clinic (Plastic
Surgery center). All patients received, read, and signed in advance, the
informed consent form, the authorization for photographs, and the service
contract. All patients were administered epidural anesthesia and sedation.
Prophylactic antibiotic therapy (cephalothin 2 g) was also administered
during anesthetic induction, and replicated after 3 hours.
In general, we used a super wet technique for tissue infiltration, respecting
the safety limit of 0.07 mg/kg of adrenaline, using 1 ampoule of adrenaline
(1: 1000) for every 500 mL of saline solution, without lidocaine. In all
cases, a classic liposuction was performed, either alone, or in conjunction
with other surgical procedures.
We used intermittent compression of the lower limbs for active prophylaxis
against intraoperative deep venous thrombosis. Preheated solutions (37ºC)
were used to replace intravenous fluids. In the immediate post-operative
period, all patients were hospitalized for fluid replacement, blood pressure
control, monitoring of the pulse, assessment of urinary output
(spontaneous), intermittent compression of the lower limbs, and for
analgesia by the intravenous or oral route. Pharmacological prophylaxis
against thrombosis was also instituted with enoxaparin 20 mg SC on the day
of surgery, and with enoxaparin 40 mg SC from the next post-operative day
All patients were released on the following day, after having met all the
clinical parameters mentioned in resolution CFM 1886/2008 (spontaneous
walking, urination without difficulty, normal sensitivity in the perineal
region after spinal block, enlightened companion, etc.)7.
Thirty patients underwent classical liposuction between 2016 and 2017 (Table 1). The mean age of the patients was
39.2 years (range: 23-57 years), with a predominance of female patients (n = 25,
89%). The mean pre-operative weight of the patients was 72.18 kg (range: 55-105
kg), and the mean BMI was 27.03 kg/m2 (range: 20.6-37.4
kg/m2). A total of 6 patients were categorized as grade I
obesity; grade II obesity was noted in 1 patient. The patients are still on
follow-up, and have maintained weight loss after surgery.
Table 1 - Data summary.
||Hb pre-operative (g/dL)
||Hb post-operative (g/dL)
|Serum Iron pre-operative (mcg/dL)
||Serum Iron post-operative (mcg/dL)
All 30 patients underwent classical liposuction. Additional surgical procedures
were performed in 20 patients (66%), while 10 patients underwent liposuction as
a single procedure. Additional procedures included abdominal dermolipectomy, and
fat grafting on the buttocks. An average of 2,500 ml of intravenous fluids were
given. The mean duration of the surgical procedure was 4 hours.
The volume of the aspirate in all cases was less than both, 7% of the body
weight, and 40% of the total body area. No patient had severe complications.
Fifteen complained of symptoms such as dizziness, dyspnea, tachycardia, and
orthostatic hypotension, but no patient needed blood transfusion.
All our patients had pre-operative values of hemoglobin above 12 g/dL, except 3
female patients, who had values between 11.3 and 11.8 g/dL.
The fall in hemoglobin levels was between 2 and 6 g/dL, with a mean of 3.01 g/dL,
corresponding to 22.16% of the pre-operative hematocrit. Our cohort had a
hemoglobin level of 7.8 g/dL for up to 10 days in the post-operative period. The
serum iron levels had reduced between 44 μg/dL and 122 μg/dL, with a mean
reduction of 45.15 μg/dL (39.32%).
Two patients had pre-operative serum iron levels below the lower limit of normal.
These two patients experienced a fall in hemoglobin by 3.5 and 4.0 g/dL,
respectively. The total protein levels varied between 0.1 and 3.1 g/dL, with a
mean of 1.06 g/dL, representing a mean variation of 14.6 g/dL.
With refinement in techniques, liposuction has become one of the most performed
surgical procedures in plastic surgery. A look at the liposuction techniques
used in the evolutionary phases, since being described in the 1970s, it is
evident that the main objective of the technical refinements was to minimize
blood loss during the procedure. The initial “dry method” used general
anesthesia without injecting any vasoconstricting solutions.
This method was abandoned in favor of wet infiltration techniques, reducing blood
loss from 20-45%, to 15-30%, in wet techniques8. The use of the super-infiltration technique
(superwet) or 1: 1 has been recommended by most authors to
be the most suitable for safe liposuction6.
By definition, in the super wet technique, 1-2 mL of solution is infiltrated for
every 1 mL of aspirate, presenting a blood loss of 1-2% of the total aspirate.
The tumescent technique, described by Klein in 1985, uses saline solution,
epinephrine, sodium bicarbonate, and lidocaine in an infiltrated volume:
aspirate volume ratio equal to, or greater than 2-3: 1; the incidence of
bleeding is approximately 1%.
According to the Brazilian Society of Plastic Surgery and the Federal Council of
Medicine (SBCP/CFM), 3 major variables are to be analyzed in order to define the
safe limits of liposuction: the volume of the aspirate, which should not be
greater than 7% of the body weight, the aspirate composition, and the aspirated
body surface, because the larger the area, the greater the damage; it is also
not recommended to aspirate more than 40%, as exceeding the limits of each item
will increase the surgical risk considerably9.
In 2009, the American Society of Plastic Surgery (ASPS) safety
committee published the Evidence-Based Patient Safety Advisory:
Liposuction by Haeck et al.6.
This was a complete review of the scientific literature on liposuction,
providing evidence on the relevant aspects of patient safety before, during, and
In this advisory, the supporting literature was critically evaluated in terms of
study quality. Most of the recommendations were classified as Grade D. The notes
in this recommendation correspond to the levels of evidence provided by the
supporting literature. This review of scientific literature showed that there
was no scientific data available to support a specific maximum volume at which
liposuction is no longer safe, especially when performed in a hospital
The risk of complications may increase as the volume of aspirate, and the number
of anatomical sites treated, increase.
Among the patients studied, neither the aspirated volume limit, nor the maximum
aspirated body surface exceeded the limits determined by the SBCP and the
Cupello, and the liposuction committee of SBCP10, reported that the number of deaths in combined surgeries is 4
times higher than that of non-combined surgeries, and reports of serious
complications were increased when high-volume liposuction was combined with
procedures like abdominoplasty.
The restriction of liposuction in combination with various procedures has been
the subject of many discussions, mainly because the actual volume of liposuction
aspirate that can be safely removed during a combined procedure is still
Pre-operative anemia is an important issue because it is the strongest predictor
of blood component transfusions, which carry many risks, and is likely to
increase morbidity and mortality. In addition to the increased risks related to
the higher need for transfusion, anemia has been associated with deleterious
effects, per se11.
The prognostic value of anemia in surgery has been studied in many populations,
including cardiac and non-cardiac surgery. These studies have shown that anemia
is an important risk factor for short- and long-term outcomes in the general
Only 3 of our patients had pre-operative anemia as defined by the criteria of the
World Health Organization (WHO), which identifies anemia as hemoglobin
thresholds of 12.0 g/dL for children aged 12.0 to 14.99 years and non-pregnant
women aged 15 years or older, and a threshold of 13.0 g/dL for men older than 15
As detailed earlier, blood loss in liposuction is considerably decreased (1% of
total aspirate) when super wet or tumescent infiltration techniques are
employed. However, this does not consider the “hidden” bleeding that occurs in
the tissues, which is not “registered”13.
Many variables affect this data, so this makes it difficult for the surgeon to
predict the exact blood loss of an individual. There are formulas for the
calculation of blood loss, but they depend on post-operative measurements of
hematocrit and/or hemoglobin. The most suitable moment for collection is not
known, because in the first 24 to 72 hours, there are changes caused by
hemodilution, and it is not exactly known when it ceases. Additionally, the
organism is producing new red blood cells for replacement, which may also
interfere with the results.
In our sample of 30 patients, we observed that in both the sexes, the changes in
hemoglobin and serum iron levels after liposuction of the abdomen, flanks, and
back, alone, or in conjunction with classic abdominoplasty, were superior to the
expected values. The expected values are based on the knowledge of 1% of blood
loss with super wet infiltration, and follow the standards of aspirated volume,
and treated body surface. These blood losses were directly related to the
post-operative clinical symptoms.
The changes in total protein levels did not appear to be important, since
post-operative hypoproteinemia was not noted in any patient. The indication of
transfusions is based on the laboratory results of the clinic that the patient
attended in the post-operative period. Transfusions are needed only in
exceptional conditions, and there is no formal indication for its routine
prophylactic use. In cases where maximum aspirated volume equals 5% of body
weight, and a super wet liposuction has been performed without other concomitant
surgeries, neither auto-, nor normo-dilution volume transfusions are
According to the Carson and Kleinman14
criteria, transfusion is always recommended with hemoglobin levels less than 6
g/dL, and is usually indicated with hemoglobin levels between 6 and 7 g/dL. None
of our patients required blood transfusion.
Twenty (66%) of the patients underwent other procedures in conjunction with
liposuction, which is contrary to the ASPS Advisory
recommendations of 2009.
We noted no major complications.
In the cases studied, we determined that the reduction in levels of hemoglobin
was responsible for the patients’ clinical symptoms. We therefore avoided the
procedures that require blood transfusion when performed in patients with
hemoglobin levels below 12 g/dL.
Iron supplementation was necessary in the immediate post-operative period, to
return hemoglobin to normal levels and to minimize undesirable clinical
Analysis and/or interpretation of data, statistical analysis, final
approval of the manuscript, data collection, conceptualization,
methodology, completion of operations and/ or experiments, writing -
preparation of the original, writing - review and editing,
supervision, validation, visualization.
Analysis and/or interpretation of data, statistical analysis,
conceptualization, conception and design of the study, research,
completion of operations and/or experiments, writing - review and
Research, performing of operations and/or experiments, writing -
review and editing, supervision
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consultórios médicos e dos complexos cirúrgicos para procedimentos com
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15-year experience. Ann Plast Surg. 2008;61(3):230-4.
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blood cell transfusion in the adult. UpToDate. 2018. [acesso 2018 Out 17].
Disponível em: https://www.uptodate.com/contents/indications-and-hemoglobin-thresholds-for-red-blood-cell-transfusion-in-the-adult
1. STK Núcleo de Cirurgia Plástica, Belo
Horizonte, MG, Brazil.
Corresponding author: Roney Campos, Avenida João César de Oliveira,
nº 1298, sala 605 - Eldorado - Contagem, MG, Brazil, Zip Code: 32310-000.
Article received: April 18, 2018.
Article accepted: October 1, 2018.
Conflicts of interest: none.