developed by the American Academy of Cosmetic Surgery
and the American Society of Liposuction Surgery

American-Society-of-Liposuction-Surgery1. Credentialing
Physicians practicing liposuction surgery should have adequate training and experience in the field. This training and experience may be obtained in residency training, cosmetic surgery fellowship training, observational training programs, CME accredited postgraduate didactic and live surgical programs, or via proctorship with trained credentialed surgeons experienced in liposuction techniques. Postgraduate training should include approved completion of a comprehensive liposuction course certified for continuing medical education and sanctioned by the American Society of Liposuction Surgery or another similar organization as to satisfying requirements for initial training in liposuction surgery.

Liposuction surgery is performed by surgeons of multiple specialties. Qualified surgeons who practice cosmetic surgery will have the necessary skills to perform the procedures and the knowledge to diagnose and manage cardiovascular, surgical, or pharmacological complications that arise. Postgraduate training will not be required of physicians who receive adequate liposuction training a part of their residency training programs.

2. Preoperative Evaluation
An appropriate documented medical history, a physical examination, and appropriate laboratory work must be performed on all patient candidate for lipo-contouring procedures. Special attention should be given to bleeding diathesis, drug interactions, thrombophlebitis, and all other common complications of surgery.

Thorough clinical examination should include a detailed evaluation of the regions to be lipocontoured, including a notation of hernias, scars, asymmetries, cellulite, and stretch marks. The quality of the skin, and particularly its elasticity, the presence of stria, and dimpling, should be evaluated. The underlying abdominal musculofacial system should be evaluated for the presence of flaccidity and diastasis recti. The deposits of body fat should be recorded.

3. Body Contouring
Indications for liposuction include removal of localized deposits of adipose tissue. This would include:

Body contouring, usually of the face, neck, trunk and extremities.

Treatment of diseased, such as lipomas, gynecomastia, pseudogynecomastia, lipodystrophy and axillary hyperhydrosis.

Reconstruction of the skin and subtissues in flap elevations, subcutaneous debulking, flap movement or other conditions.

Obtaining fat for fat transfer (for such purposes as augmentation, correction of scar defects, etc.).

4. Techniques of Liposuction

Tumescent technique
The tumescent infiltration has been shown over the last nine years to be the safest for liposuction and lipocontouring, with the fastest recovery time and the least complications for the patient. not only has the use of infiltration of large volumes of dilute anesthetic (lidocaine 500 mg/L) and epinephrine (0.5 mg/L) clinically have been shown to significantly decrease blood loss and intravascular fluid loss associated with liposuction, but it may also facilitate body contouring. (The dosages and amount of the above agents may vary within recognized safe limits.)

When using the tumescent technique and other forms of infiltration of lidocaine and epinephrine, current studies recommend that the maximum dose of lidocaine when infiltrated in a dilute form prior to liposuction surgery should be in the range of 35-55 mg/kg body weight.

Ultrasonic Technique
Ultrasonic liposuction is a new, evolving technique that has previously been used in Europe and South America. Several new ultrasonic aspirators are currently being evaluated by the American Academy of Cosmetic Surgery Task Force in Ultrasonic Liposuction. Although the lay press has made anecdotal claims about ultrasonic liposuction, the effects of this technique, its uses, its safety, and its complications have not yet been established. It is for this reason that ultrasonic liposuction be considered an emerging technique that is currently under study. Until the clinical trials of ultrasonic liposuction techniques have ended and its safety and efficacy can be evaluated, its use should be limited to more experienced clinicians.

Liposuction surgery using the tumescent technique has been shown to be a safe procedure in the routine removal of volumes of up to 4000 cc. of supernatant fat. With experienced surgeons, this volume may go up to 6000 cc. Removals in this range by an experienced surgeon can be safely carried out when performed with the appropriate tumescent anesthesia with or without general anesthesia, epidural anesthesia, etc. on an outpatient basis in an office surgery facility, surgery center, or hospital setting. Lipo extractions in this range do not require the use of autologous blood.

5. Megaliposuction
The removal of volumes in excess of 8000-10,000 cc. of supernatant fat would constitute so-called megaliposuction. The indications for megaliposuction today are not clear, and many clinicians would, at the present time, prefer to do serial liposuction for the removal of large volumes of fat, rather than using megaliposuction. Until sufficient data are collected on megaliposuction, its use should be restricted to experienced surgeons doing clinical research.

The anesthetist or anesthesiologist should be aware of the differences in fluid requirements in liposuction as compared with other surgical procedures.

6. Surgical Setting
Liposuction surgery may be performed in an adequately equipped office surgery facility, in an ambulatory surgery center or in an inpatient hospital setting. The procedure should be performed under sterile technique and with routine monitoring of vital signs an oxygen saturation, EKG monitoring, and end tidal CO2 monitoring if done under general anesthesia.

The surgeons or health care provider administering anesthesia must be properly trained and qualified to provide the level of anesthesia required. It is recommended that surgeons providing liposuction services have adequate training in cardiopulmonary resuscitation techniques. In addition, the operating facility should be certified by the AAAHC (or equivalent) or function under guidelines equal to those required for such certification. Appropriate and safe management of waste products should be in compliance with OSHA regulations. In the immediate postoperative period, as long as the patient remains in the facility, there should be individuals immediately available who are trained in cardiopulmonary resuscitation.

7. Expected Sequella

Usual side effects – edema, ecchymosis, dysesthesia, fatigue, soreness, scar and minor contour imperfections are expected sequella.

Occasional side effects – persistent edema, persistent dysesthesia, hyperpigmentation, asymmetry, hematoma, seroma, drug reactions and tape reaction. Major contouring imperfections are very rare.

All of the above problems can be handled postoperatively by the surgeon in an office setting.

Rare complications – skin necrosis resulting either from infection of from technical problems is quite rare and is occasionally seen with ultrasonic assisted liposuction due to burns and with traditional liposuction. Hematomas, seromas, nerve damage and infection are rare complications. Hypovolemic shock, intraperitoneal or inthrathoracic perforation and pulmonary fat emboli are very rare but have been reported. Pulmonary fat emboli have been reported. Death is an extremely rare event.

8. Postoperative Care and Medications
Compression garments such as binders, girdles, tape, foam and other specialized equipment have been effectively used with favorable results. The use of compression is optional but appears to be most helpful in the first 7 days following surgery. Some surgeons prefer to encourage draining of tumescent fluid residuals.

Prophylactic antibiotic therapy may be indicated in cases of liposuction surgery. Some surgeons elect to provide presurgical and intraoperative steroid administration in an effort to reduce postoperative swelling. Reasonable early ambulation of liposuction patients seems advisable to avoid venous stasis and to shorten the postoperative recuperation period. There is anecdotal experience suggestive that the use of postoperative superficial ultrasound application may be helpful in the reduction of postoperative swelling, particularly the edema and induration that persist over 2 weeks. In addition, the use of lymphatic and manual massage may be helpful in the reduction of such swelling and firmness.

9. Documentation of Care
Patients undergoing liposuction surgery should have standardized pre and postoperative photographs to document results. The patient’s weight should be documented prior to the procedure. The operative report should specify the following points:

The quantities of tumescent fluid infused.

The total dosages of drugs used.

The volume of fat extracted.

The technique used.

The type of anesthesia.

The anatomical site treated.

The size of cannulas used.

Use of ultrasonic external or internal techniques.

Use of drains.

Complications encountered.

Postoperative garments used.

Review and comparison of before-and-after (6 months or longer) photographs should be used by the surgeon to objectively evaluate the quality and extent of fail results if possible. Critical outcome analysis is valuable from both the surgeon’s and the patient’s perspectives.

10. Privileging for Liposuction Surgeons
For hospital or ambulatory surgery center privileging, surgeons may complete a proctoring or preceptorship program in which a qualified, experienced liposuction surgeon oversees the applicant for a reasonable number of procedures. The proctor should have current privileges at the facility (under peer review and quality assurance) to perform such procedures and be willing to observe and evaluate the applicant surgeon without bias. The number of procedures required to be proctored, may be determined at the individual center but should be adequate to examine the pre-, intra-, and postoperative management by the applicant. The confidential case evaluations must be provided in writing to the appropriate committee or board that grants such privileges. Any conflict that may arise between proctor and applicant surgeon should be resolved according to appropriate regulations or bylaws of the individual center.

Annually, all liposuction surgeons should obtain continuing medical education (CME) specifically in the field of liposuction and related surgery through the use of current scientific publications, videotapes, scientific conferences, courses, or workshops.

11. Disclaimer
The recommendations contained in this document are not intended to establish a standard of care, but to serve only as guidelines. The ultimate responsibility for the patient’s well being rests on the clinical judgment of the physician.