TY - JOUR
AU - Hunstad, Joseph P
AB - As a 3-physician aesthetic surgery practice performing a large number of liposuction procedures, we have never experienced pneumothorax (PTX) associated with liposuction of any anatomic region. We appreciate the authors acknowledging their experience with PTX associated with axillary liposuction.1 We also congratulate them on apparently eliminating this complication from their series, presumably through acquiring a greater understanding of potential occurrence and by adopting a wider-diameter and stiffer infiltration cannula. We appreciate the authors’ efforts in highlighting PTX as a rare but potentially devastating complication of liposuction. They report having performed 16,215 liposuction procedures, 0.0432% of which resulted in PTX. It is of particular interest that no further cases of PTX were noted after the adoption of a wider-diameter and stiffer infiltration cannula. Awareness of the surgeon’s cannula, particularly the relatively narrow-diameter infiltration cannula, is key in the avoidance of visceral and parenchymal injuries when performing liposuction.2-7 Many surgeons report that fatigue and loss of proprioception during large-volume liposuction with or without power-assisted handles contribute to these injuries. There is evidence that surgeon fatigue is similarly associated with an increased complication rate.8 The authors propose, however, that many of these injuries occur not at the end of a lengthy case but at the beginning, with infiltration of tumescent solution. Scarred tissue planes or secondary procedures increase the risk of these problems, as they increase resistance to cannula passage, leading to uncontrolled and forceful movements on the part of the surgeon. The authors also note the importance of considering that some areas of liposuction are prone to these types of injury. As previously stated, we have never experienced a symptomatic or clinically evident PTX in our practice. Liposuction is a safe procedure when performed by a well-trained, board-certified plastic surgeon. Complications are rare but should be respected. Steps should be taken to minimize the occurrence of any complications in any elective procedure such as this. In our clinical experience tumescent liposuction is very safe. We continue to use a 1.5-mm infiltration cannula in our practice and have yet to experience the devastating complication of intraperitoneal or intrathoracic injury. If PTX is identified as occurring during infiltration, a critical analysis of the techniques performed is necessary. We think there are 2 important methods to ensure safety in tumescent liposuction. The first is to take advantage the hydrodissection effect of the tumescent solution. Tumescent infiltration is a process of rapid infiltration of crystalloid solution with careful cannula manipulation.2-4 The tip of the liposuction cannula needs to be in the subcutaneous space, but once this is achieved it is possible to use the hydrodissection properties of the tumescent solution to expand the safe subcutaneous space in a front ahead of the cannula. Hydrodissection magnifies the deformity, hydrates the tissues, and allows for more accurate positioning of the cannula. This technique decreases the force required to push the cannula through scarred or previously dissected tissue planes and allows pressurized fluid to “find” safe planes of dissection. Achieving a truly tumesced state of the soft tissues to be liposuctioned pushes compliant abdominal wall musculature and fascia towards the abdominal cavity and away from the infiltration cannula. Although this hydrodissection is not under sufficient pressure to push the thoracic cage out of the way, a combination of manual compression of the chest wall and allowing a fluid front to hydrodissect over the costal margin or other bony anatomy helps maintain the cannula in a safe plane. The second important point highlighted by this article is incision placement. We find that the axilla is an area of frequent complaint by patients seeking contour improvement. Access to the axilla and supracostal abdomen is fraught with hazard, however. Liposuction from traditional abdominal access sites directs the cannula in a cephalic orientation with the risk of pushing the cannula under the costal margin and into the chest. The apex of the axilla or preaxillary chest is very difficult to reach from the abdomen without a very long cannula. Even with a long cannula, coursing this over the costal margin is technically demanding. Similarly, certain axillary incisions direct the cannula toward the chest wall because of interference by the shoulder and brachium. The surgeon must be particularly cognizant of the location of the cannula tip under these circumstances, and use his or her nondominant hand to ensure appropriate placement. We commend the authors of this study for suggesting safe approaches to the axillary region. In our practice we, like them, use a hydrodissection technique to ensure tumescence and to increase the volume of the safe subcutaneous plane. We also advocate a carefully considered incision placement, particularly within the inframammary fold (IMF). The IMF approach allows for safe tumescence of the upper abdomen, lateral chest, and axilla. The cannula begins superficial to the rib cage and is not directed under the costal margin at any point during tumescence. As the cannula is directed laterally and cephalically it is parallel to the skin surface and not directed towards the chest wall at any time. This approach has the further advantage of being performed from a supine position, not requiring a lateral decubitus positioning as the authors advocate. Our practice continues to use a relatively small-diameter infiltration cannula for the vast majority of our axillary infiltration. We use a larger, stiffer cannula only for large-volume liposuction, typically in the trunk areas. A narrow-diameter cannula can be safely used when careful incision placement and appropriate tumescent technique is utilized. This article is a welcome addition to the literature, increasing awareness of this rare but avoidable potential complication. It provides a service to aesthetic surgeons, highlighting that although liposuction is common and very safe, there remain significant risks that can be mitigated with thoughtful application of technical principles. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Mentz JA , Mentz HA, Nemir S. Pneumothorax as a complication of liposuction . Aesthet Surg J . 2020 ; 40 ( 7 ): 753 - 758 . OpenURL Placeholder Text WorldCat 2. Hunstad JP . Addressing difficult areas in body contouring with emphasis on combined tumescent and syringe techniques . Clin Plast Surg. 1996 ; 23 ( 1 ): 57 - 80 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 3. Hunstad JP . The tumescent and syringe techniques and body contouring. A historical perspective and techniques for their combined usage . In: Gonzalez-Ulloa M, Meyer R, Smith JW, Zaoli G, eds. Aesthetic Plastic Surgery. Padova : Piccin-Nuova Libraria ; 2002 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 4. Hunstad JP , Aitken ME. Liposuction: techniques and guidelines . Clin Plast Surg. 2006 ; 33 ( 1 ): 13 - 25, v . Google Scholar Crossref Search ADS PubMed WorldCat 5. Hunstad JP , Aitken ME. Liposuction and tumescent surgery . Clin Plast Surg. 2006 ; 33 ( 1 ): 39 - 46, vi . Google Scholar Crossref Search ADS PubMed WorldCat 6. Abboud MH , Dibo SA, Abboud NM. Power-assisted liposuction and lipofilling: techniques and experience in large-volume fat grafting . Aesthet Surg J. 2020 ; 40 ( 2 ): 180 - 190 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 7. Wall SH Jr, Lee MR. Separation, aspiration, and fat equalization: SAFE liposuction concepts for comprehensive body contouring . Plast Reconstr Surg. 2016 ; 138 ( 6 ): 1192 - 1201 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Janhofer DE , Lakhiani C, Song DH. Addressing surgeon fatigue: current understanding and strategies for mitigation . Plast Reconstr Surg. 2019 ; 144 ( 4 ): 693e - 699e . Google Scholar Crossref Search ADS PubMed WorldCat Author notes Dr Isakson is an aesthetic surgery fellow at a private practice in Huntersville, NC. © 2020 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Commentary on: Pneumothorax as a Complication of Liposuction
JF - Aesthetic Surgery Journal
DO - 10.1093/asj/sjaa047
DA - 2020-06-15
UR - https://www.deepdyve.com/lp/oxford-university-press/commentary-on-pneumothorax-as-a-complication-of-liposuction-C5GFSJj3Fu
SP - 759
EP - 760
VL - 40
IS - 7
DP - DeepDyve
ER -