INTRODUCTION
Improvement of body contour is popular in the clinics of plastic surgeons. Flaccidity
and localized fat in the abdomen are often associated with fat accumulation in other
areas, such as thighs, flanks, back, and arms. For this reason, treating only the
abdomen does not lead to satisfactory results in terms of body contouring, which also
occurs when it is association with liposuction in other areas of the body. Patients
usually seek treatment to improve their body silhouette by tapering the waist and
increasing and shaping the buttocks in addition to reducing flaccidity and abdominal
fat. Thus, lipoabdominoplasty associated with body liposuction and buttock fat grafting
is currently the most appropriate treatment to achieve the results desired by most
patients (Figure 1 to 9).
Figure 1 - Clinical case: preoperative, front.
Figure 1 - Clinical case: preoperative, front.
Figure 2 - Clinical case: preoperative, profile.
Figure 2 - Clinical case: preoperative, profile.
Figure 3 - Clinical case: preoperative, posterior.
Figure 3 - Clinical case: preoperative, posterior.
Figure 4 - Clinical case: marking of the surgical planning, front.
Figure 4 - Clinical case: marking of the surgical planning, front.
Figure 5 - Clinical case: marking of the surgical planning, profile.
Figure 5 - Clinical case: marking of the surgical planning, profile.
Figure 6 - Clinical case: marking of the surgical planning, posterior
Figure 6 - Clinical case: marking of the surgical planning, posterior
Figure 7 - Clinical case: Six months postoperatively, front.
Figure 7 - Clinical case: Six months postoperatively, front.
Figure 8 - Clinical case: Six months postoperatively, profile.
Figure 8 - Clinical case: Six months postoperatively, profile.
Figure 9 - Clinical case: Six months postoperatively, posterior.
Figure 9 - Clinical case: Six months postoperatively, posterior.
Although plastic surgery is considered a safe procedure, it requires a rigorous preoperative
evaluation of the patient and trans and postoperative control, including the use of
risk assessment tables for plastic surgery1. Associated surgeries increase patient risk and require even greater attention. Iverson
(2002)2 indicates liposuction associated with other surgical procedures as one of the main
transoperative factors generating physiological fatigue, along with blood loss, hypothermia,
and duration of surgery, among others2. For this reason, investigating and realizing safe limits for the anticipated amount
of surgery is extremely important for physicians. Resolution No. 1,711 of 2003 of
the Federal Medical Council states that liposuction should be limited to a maximum
of 40% of the body surface area and the aspirated volume should not exceed 5% of the
patient's body weight using the dry technique and 7% of the patient's body weight
when using the infiltration technique3. However, when other surgeries are associated with liposuction, common sense tells
us to reduce these values. There is no common consensus on the volume limit that can
be safely aspirated.
In liposuction, accurately determining the amount that requires aspiration to achieve
appropriate results is not an easy task. There is possibility of exceeding safe limits
in some cases. Cupello (2015)4 reported 1.76% of complications were due to hypovolemia as a result of excessive
liposuction. Sozer (2018)5 reported that 1% of patients in his series required blood transfusions. Thus, having
an estimate of the expected reduction in hemoglobin (Hb), by aspirated volume, would
assist surgeons in surgical planning and clinical management of patients, thus reducing
risks and avoiding blood transfusions.
Few studies correlate the decrease in Hb to liposuction associated with lipoabdominoplasty.
This information is crucial as it provides parameters to guide surgeons on postoperative
anemias and how they evolve throughout the patient's recovery.
OBJECTIVE
To examine the postoperative changes in Hb and the clinical recovery of patients undergoing
body liposuction associated with lipoabdominoplasty.
METHODS
This cross-sectional, prospective, and descriptive study was conducted from December
2017 to March 2018 in the Spani Vendramin clinic. The inclusion criteria were patients
who underwent body liposuction associated with lipoabdominoplasty and was performed
by the primary author of this study. The exclusion criteria were patients who did
not want to participate in the study, those who underwent bariatric surgery, and those
who could not be followed up as required by the surgical methodology. All patients
signed an informed consent form (ICF), and the research project was approved by the
Research Ethics Committee of the João de Barros Barreto University Hospital under
Opinion No. 2,735,756.
Patients underwent CBC tests before the induction of anesthesia, at the end of the
surgery, on the morning of the day before hospital discharge, and at the 1st, 2nd, and 4th postoperative weeks. A questionnaire was completed at the patients' clinical follow-up
requesting information on lipothymia, fainting, and duration of weakness. The decrease
in Hb post-surgery, after hospital discharge, and its recovery over the 1st, 2nd, and 4th weeks were evaluated. During this period, oral iron replacement (120 mg BID) was
administered. The association between the frequency of complaints of weakness and/or
lipothymia and the reduction in hemoglobin were examined. The reduction in hemoglobin
and the percentage of aspirated volume were also evaluated. In the transoperative
period, the aspirated volume, the percentage of area treated with liposuction, and
the quality of the aspirate were measured. We used the relative percentages of the
Lund-Browder chart to establish the percentage of treated area, similar to Matos Júnior
(2005)6. The volume of supernatant fat was divided by the total aspirated volume, including
the fluid with solution and blood, to determine the quality of liposuction. The closer
the value was to 1, the better the quality of the aspirate.
Surgical technique
The infiltration technique for liposuction was used, with an approximate ratio of
1:1 between the infiltrated volume and the aspirated volume (superwet). A physiological
solution was prepared with adrenaline 1:500,000. The surgery began with the patient
in prone position, and liposuction and fat grafting were performed in the planned
areas, such as the thighs, buttocks, back, and arms, with a 3.5 mm and a 4.0 mm cannulae.
After this step, the patient was placed in a supine position, and the abdomen was
aspirated followed by plastic surgery. Dissection was performed from the central region
up to the xiphoid appendix to perform aponeurosis plication of the rectus abdominis
muscles with inverted "X" sutures using polypropylene 0 threads. The excess flap was
removed, and some adhesion sutures were made between the flap and the muscle aponeurosis
using 2.0 polyglactin thread. Umbilicoplasty, vacuum drainage, and suturing by planes
with polyamide 3.0, 4.0, and 5.0 threads, as well as poliglecaprone 4.0 sutures were
completed. The patient wore a modeler in the postoperative period, which was kept
open in the abdomen area for the first 5 days and then closed after this period. She
also received daily lymphatic drainage from the 2nd PO day forward. Prophylaxis for
deep vein thrombosis with 40 mg of enoxaparin was administered once a day for 7 days.
RESULTS
Sixteen patients, all female, aged between 33 and 45 years (average 36.2 years) participated
in the study. The average of aspirated volume, the percentage of aspirated volume
in relation to the patient's weight, and the percentage of body surface area treated
were 4.26 liters, 6.5%, and 33.1%, respectively. The average Hb at the end of surgery
and at hospital discharge was 10.4 g/dL and 8.92 g/dL, respectively. The percentage
of the reduction in Hb between the beginning and end of surgery was, on average, 19.7%,
and between the beginning of surgery and discharge was 30.2%. Table 1 summarizes the main results.
Table 1 - Data Overview
| Variable |
Average |
Standard Deviation |
| Age (years) |
36,2 anos |
4,64 |
| Aspirated volume (ml) |
4.260ml |
1.451 |
| Percentage of aspirated volume in relation to body weight (%) |
6,5% |
1,86 |
| Quality of the aspirate |
0,7
70% supernatant fat:
30% fluid with blood
|
0,08 |
| Percentage of BS treated with liposuction (%) |
33,1% |
3,99 |
| Hb in IPO (mg/dl) |
10,4mg/dl |
0,76 |
| Percent reduction of Hb in IPO (%) |
19,6% |
3,31 |
| Percent reduction of Hb in IPO per liter(%) |
4,95% |
1,9 |
| Percent reduction of Hb at discharge per liter aspirated (%) |
8,3% |
4,26 |
| Hb in hospital discharge (mg/dl) |
8,92mg/dl |
0,86 |
| Percent reduction in Hb at hospital discharge compared to preoperative Hb (%) |
30,2% |
4,93 |
| Percent reduction in Hb at hospital discharge compared to Hb in IPO (%) |
13,3% |
5,3 |
Regarding laboratory results and the evolution of Hb, at the end of 1 week 37.5% of
patients had an average reduction of 15.6% compared to HB levels at hospital discharge.
However, the overall average of HB recovery was 2.4% (SD 18.07) in the first week
compared to the decrease in the initial Hb and in relation to hospital discharge.
In the second week, there was a recovery of 41.6% (SD 18.4), on average. At 4 weeks
postoperatively, 12 of the 16 patients had Hb levels normal or very close to normal
(Hb ≥ 11.5 g/dL). The average Hb of the patients in this study period was 11.85 g/dL,
which corresponded to a recovery of 74% (SD 15.2) compared to the initial decrease
in Hb after hospital discharge. Table 2 summarizes the laboratory results and the evolution of Hb of the patients in the
postoperative period.
Table 2 - Clinical and laboratory evolution of Hb
Hb at
hospital
discharge
(mg/dl)
|
Percent Hb reduction (%) |
No complaints |
1 day |
1 day |
Hb after 1
week (mg/dl)
|
Hb after 2
weeks (mg/dl)
|
Hb after 4
weeks (mg/dl)
|
| Lipothymia + |
Lipothymia + |
| 1 day |
2 days |
| Weakness |
weakness |
| 8.6 |
33.3 |
|
|
X |
9.4 |
11.9 |
12.6 |
| 8.8 |
37.1 |
|
|
X |
8.6 |
9.8 |
12.2 |
| 8.0 |
33.3 |
|
X |
|
9.1 |
10.3 |
11.7 |
| 8.5 |
32.4 |
X |
|
|
7.5 |
9.6 |
10.9 |
| 10.8 |
20.0 |
X |
|
|
11.1 |
11.7 |
12.4 |
| 9.5 |
29.6 |
X |
|
|
10.2 |
11.0 |
12.1 |
| 9.6 |
27.6 |
X |
|
|
10.8 |
11.5 |
12.8 |
| 8.5 |
34.6 |
X |
|
|
7.2 |
9.1 |
10.5 |
| 8.2 |
32.2 |
|
X |
|
8.2 |
11.2 |
11.8 |
| 8.9 |
29.9 |
|
|
X |
8.4 |
10.7 |
12.0 |
| 9.1 |
22.4 |
X |
|
|
9.5 |
9.8 |
11.8 |
| 7.9 |
35.8 |
|
|
X |
7.6 |
9.4 |
11.1 |
| 8.4 |
31.7 |
|
X |
|
8.6 |
10.2 |
11.5 |
| 10.6 |
26.5 |
X |
|
|
11.3 |
12 |
13.2 |
| 9.3 |
29.1 |
X |
|
|
9.6 |
11.4 |
12.3 |
| 8.1 |
30.9 |
X |
|
|
7.9 |
9.5 |
10.7 |
Table 2 - Clinical and laboratory evolution of Hb
Clinically, symptoms of lipothymia and weakness were observed in 43.75% (7 out of
16) of the patients who passed out within 2 days post-surgery (Table 2). There were no cases of fainting. There was no statistically conclusive correlation
between the symptoms and the drop in Hb at hospital discharge nor between the symptoms
and the percentage of aspirated volume.
DISCUSSION
Liposuction associated with abdominoplasty is one of the plastic surgeries most frequently
performed 7. Although several authors show safe and consistent results5,8, few studies define safety parameters on aspirated volume and the evolution of Hb
in the postoperative period. Oliveira Junior (2018)9 investigated the change in Hb and hematocrit in the immediate postoperative period
and at hospital discharge in patients undergoing lipoabdominoplasty, without associating
it with liposuction in other areas of the body. He reported a 20% reduction in the
Hb level, with most patients being discharged from the hospital with Hb values above
10 g/dL, and the lowest value being 9.3 g/dL9. However, Campos (2018)10 conducted a study with patients undergoing liposuction and/or abdominoplasty and
compared the decrease in hemoglobin between the preoperative period and 7 to 10 postoperative
days and reported a 22.16% reduction of Hb, with a minimum value of 7.8 g/dL10. These studies did not report the clinical complaints of patients in the postoperative
period.
In our study, the decrease in Hb at the immediate postoperative period was 19.6% (SD
3.31), with an average Hb of 10.4 g/dL and a minimum Hb of 9.3 g/dL. There was no
hemodynamic instability in any patient. Patients remained hospitalized until the following
day and received hydration and analgesia, prophylaxis for infection, and prophylaxis
for deep vein thrombosis. Hb decreased even further in patients' pre-discharge exams.
The average Hb reduction between pre-surgery and discharge was 30.2% (SD 4.93), with
an average Hb of 8.92 g/dL and a minimum Hb of 7.9 g/dL (Table 1). At the time of writing, 7 of the 16 patients demonstrated symptoms of lipothymia
and weakness, however without hemodynamic instability. All patients were discharged
for recovery at their homes with oral iron supplementation. Of the 7 patients with
clinical complaints, only 4 continued to report symptoms on the following day, and
on the third day, no patient showed symptoms of weakness or lipothymia. These complaints
generally occurred in patients who experienced larger volumes of aspirate and/or had
greater reductions in Hb, although statistically this was inconclusive. We noted that
other individual factors may be associated with the presence of symptoms of weakness
and lipothymia in patients. Some patients who had below-average volumes of aspirate
reported clinical complaints and others with larger volumes of aspirate and lower
Hb levels did not report symptoms.
The maximum safe volume for liposuction is a controversial issue in the literature2,11,12. The limit established by the CFM in Brazil, although consensual, was not obtained
by Evidence-Based Medicine criteria13. Chow (2015)11, demonstrated that a greater volume can be aspirated in liposuction in patients with
a higher body mass index (BMI). We noted that the quality of the aspirate of obese
patients is higher, which would allow for aspirating a larger volume. Thus, we agree
that BMI is a superior reference than the patient's weight, (as currently occurs in
Brazil), in order to establish the maximum volume that can be aspirated,
In an abdominoplasty surgery with circumferential liposuction, Sozer (2018)5 aspirated an average of 2,540 mL (1,650 to 6,200 mL) and reported that 1% of patients
required blood transfusion5. Sanza performed megaliposuctions with a volume ranging from 6 to 10 liters and reported
Hb values between 6 and 9 g/dL, with an average of 8.2 g/dL on the 1st PO day. However, he did not report information on blood transfusions12. In the study by Leão (2010)14, the aspirated volume in lipoabdominoplasty associated with liposuction was 800 to
6910 mL, with an average of 2,524 mL14. In our study, the average aspirated volume was 4.26 liters, corresponding to 6.5%
of body weight, and no patient had hemodynamic instability or received blood transfusions
(Table 1).
The balance between the possible risks and the need for transfusion should always
be considered. Transfusions always imply potential risks to the patient. Symptoms
of weakness, lipothymia, and fainting, and signs such as tachycardia, hypotension,
and reduced diuresis should be observed before deciding the need for a transfusion13.
According to the criteria of Carson and Kleinman (2017)15, in patients without active bleeding and that are hemodynamically stable, a transfusion
should only be performed in cases with Hb less than 6 g/dL. A transfusion is usually
indicated in cases with a Hb between 6 and 7 g/dL, and a transfusion is recommended
only if the patient has symptoms such as orthostatic hypotension, tachycardia, and
myocardial ischemia that do not respond to fluid replacement in cases with an Hb between
7 and 8 g/dL15.
Formulas determining the reduction in Hb value after surgery would be useful to estimate
the Hb levels in patients undergoing liposuction. It is estimated that the blood lost
during a superwet liposuction corresponds to 1 to 2% of the aspirated volume11,13,16. The average Hb reduction per liter aspirated in this study was 4.95% between the
beginning and the end of the surgery. The reduction was even greater on the following
day, with an average reduction in Hb between the preoperative period and hospital
discharge of 8.3% per liter aspirated (Table 1). This information may be used for calculating the Hb expected at the end of the
surgery and patient's discharge. Being aware of the patient's initial Hb, in order
to estimate the volume that can be safely aspirated is a more personalized approach
to surgery.
Clinical and laboratory recovery with only oral iron administration is considered
satisfactory. In 2 weeks, the Hb of our patients had recovered 41.6%, on average,
in relation to its value at hospital discharge. This is considering that the preoperative
Hb, reached 74%, on average, at the end of the 4th week (Table 2). It is important to note that at the end of the 1st week, the Hb decrease was even greater, on average 15.6%, in 37.5% of the patients.
Thus, special attention is required to monitor patients who are predicted to have
an Hb between 7 and 8 g/dL. The percentage of reduction of Hb at discharge compared
to preoperative Hb should be calculated. In these patients Hb can decrease even more
during the first week. It would be prudent to request a CBC before hospital discharge
for these patients.
CONCLUSION
The implementation of liposuction and lipoabdominoplasty within the limits of liposuction
established by the CFM is safe. The patient may have a Hb reduction of approximately
20% to 30% between the immediate postoperative period and hospital discharge the next
day. Even with an average Hb value of approximately 8.92 g/dL, hospital discharge
was safe, and home recovery with oral ferrous sulfate supplementation was satisfactory.
COLLABORATIONS
|
FSV
|
Analysis and/or data interpretation, Conception and design study, Data Curation, Final
manuscript approval, Formal Analysis, Methodology, Project Administration, Realization
of operations and/or trials, Supervision, Writing - Original Draft Preparation, Writing
- Review & Editing
|
|
DRF
|
Analysis and/or data interpretation, Data Curation, Methodology
|
|
MGC
|
Analysis and/or data interpretation, Data Curation, Methodology
|
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1. Universidade Federal do Pará, Belém, PA, Brazil.
2. Sociedade Brasileira de Cirurgia Plástica, Belém, PA, Brazil.
3. Clínica Spani Vendramin, Belém, PA, Brazil.
Corresponding author: Fabiel Spani Vendramin Rua Municipalidade, 985, Sala 2112, Umarizal, Belém, PA, Brasil. Zip code: 66050-350.
E-mail: drfabiel@gmail.com
Article received: May 12, 2019.
Article accepted: October 20, 2019.
Conflicts of interest: none.
