Objective: Autologous fat-grafting for the purpose of breast augmentation has gained widespread acceptance as a viable and safe alternative to classical breast implant procedures and has recently been successfully applied to buttock augmentation. Due to the numerous patient re-positionings and widely variable OR time, these procedures present unique challenges for anesthesiologists. Our goal is to discuss the current surgical methods, anesthetic methods, risks and benefits of this procedure. Methods: This is a retrospective cohort study in the setting of the operating room. Twenty-nine consecutive cases of mega-volume fat transplantation, defined as >300 cc to an individual site, performed by one surgeon, were reviewed. Age, Body Mass Index, total fat injected, total operating room time, maximum intraoperative temperature, minimum intraoperative and temperature were measured. RESULTS: Our procedure has enjoyed a 100% patient satisfaction rate. Analysis reveals high variability in age (21 - 57), total fat injected (200 cc - 1990 cc), patient Body Mass Index (18.8 - 42.2) and total operating room time (1:23:00 - 6:14:00) for our procedures. There were no instances of major complications in this cohort. Conclusions: Autologous fat transplantation for the purposes of breast and buttock augmentation is an emerging technique that shows great promise and high patient satisfaction, but providing unique challenges for anesthesiologists and surgeons.
Since the inception of breast augmentation 50 years ago and the discovery of liposuction 30 years ago, both procedures have eclipsed more classical procedures to become among the top five most performed procedures in all of plastic surgery [
Autologous mega-volume fat transplantation for breast and buttock augmentation, like any new procedure in surgery, is performed by a variety of surgeons with a wide range of expertise and technical strategies. We define mega-volume fat grafting as injecting over 300 cc to a given area, e.g. 300 cc per breast. Due to the numerous patient re-positionings and widely variable total OR times of these procedures, they represent unique challenges for anesthesiologists. Longer procedures, completely exposed patients, multiple re-positionings, large volumes of fat injected in the area of large veins, and the liberal use of local anestheticsall present a set of new and unique risks requiring careful anesthesia management.
Based on the continued success and popularity of breast augmentation and the recent rise in popularity of gluteal augmentation, the need for techniques that cater to individual preferences has never been greater. Auto- logous lipo-grafting is thus a viable alternative to standard implantation, because it provides excellent aesthetic results while minimizing negative outcomes.
The purpose of the present communication is to analyze our anesthetic experience with mega-volume fat transplantation patients at Saint Elizabeth’s Medical Center, to categorize the potential risks of these procedures and to make recommendations for proper anesthetic care.
This study was approved by Human Research Committee of St. Elizabeth’s Medical Center. After providing general written informed consent, 29 female patients (ASA physical status I-II) aged 21 to 57 years were sche- duled for a procedure of a large-volume fat transplantation for breast and/or buttock augmentations which was performed by the same surgeon at ourinstitution. Breast and buttock augmentation are first and foremost elective procedures. As such, maximal patient comfort is a priority and a goal before, during and after each procedure. The patient’s experience while having an elective cosmetic procedure done is essential, because it may influence their satisfaction with the end result. These procedures require the patient to be largely exposed throughout, and due to the numerous re-positionings and need for access to the thighs, buttocks, breasts and abdomen, it is diffi- cult to rely solely on a heating apparatus like a Bair-Hugger, which we used in 90% of our cases. In patients ex- pected to have shorter procedures who have initial temperatures above 37˚C, the Bair-Hugger is not always employed. Taking the patient’s comfort into account, the operating room is always kept between 26˚C and 28˚C, which leads to an average intra-operative patient temperature of 36.1˚C. Although AORN recommends that OR temperatures remain in the range of 20˚C to 23˚C [
Whether done on the breasts or buttocks, the procedure begins with a standing preparation of the entire body (excluding head and neck) using antiseptic solution, which is administered by the operating surgeon. Prior to entering operating room a small bore extension set was attached to the intravenous catheter so that the intraven- ous tubing can be easily disconnected from the patient. The IV is clamped to the patient’s arm this is done in order to prevent the patient from tripping over it while the antiseptic solution is being applied. After application of antiseptic solution, patient is positioned on sterile sheets. Since the patient must be able to stand on their own during this preparation, the preoperative use of sedatives such as midazolam in the holding area should be avoided (
As soon as the patient has been completely prepped, and is on the operating table, 2 mg of midazolam is ad- ministered intravenously as an anxiolytic and amnestic. Pre-oxygenation with O2 by mask is then performed while all of the appropriate monitors are applied for the procedure. As soon as all ASA standard monitors are on and connected, we administer between 100 and 250 mcg (2 - 3 mcg/kg) of fentanyl. Depending on the weight of the patient (our average patient BMI was 24.77), we then proceed to administer between 100 mg and 200 mg (2 - 2.5 mg/kg) of propofol as our primary induction agent. Simultaneously we administer between 40 mg and 60 mg (0.6 - 0.8 mg/kg) of rocuronium in order to facilitate direct laryngoscopy (DL). We do not re-dose the rocuronium in the vast majority of our cases, since muscle paralysis is not essential in what is mostly a subcutaneous surgery. The patient’s eyes are then lubricated and taped shut. The DL is performed using a MAC-3 or Miller-2 blade in approximately 95% of our procedures, routinely using a 7.0 Endotracheal Tube (ETT) followed by placement of an Orogastric (OG) Tube and OG temperature probe. We occasionally employ a Glidescope for small or questionable airway openings. Endotracheal intubation is employed for our patients because the lipo- suction and grafting procedures require significant movement and re-positioning of the patient over a long intra- operative time (average 178.3 minutes) and the procedure effectively secures the airway.
In about 90% of our cases we use O2-Air mixture with ET-FiO2 of 60% - 80% together with Desflurane 6.6% - 7.5%. In most cases this correlates with a Bispectral (BIS) monitor index of 40 - 50 and maintains the patient anesthetized. In the other 10% of patients who report smoking or have active asthma symptoms, we instead opt for Sevoflurane as it is somewhat less irritating to the airway compared to Desflurane [
tent 5 - 10 mg IV) or phenylephrine (intermittent 40 - 120 mcg IV) intra-operatively to maintain mean arterial pressure (MAP) above 55 - 60 (36.7% of cases). Since approximately 95% of our patients are scheduled to go home the day of their operation, we try to avoid the use of long-lasting narcotics and instead administer fentanyl as our narcotic of choice for post-operative pain control to maintain VAS (visual analog score) below 3 - 4 out of 10 in PACU area.
After the induction of anesthesia and placement of an endotracheal tube, the patient is essentially exposed from the neck to the knees. Venous compression boots are placed in the calf region, covered with sterile drapes, and remain in the surgical field. Tumescent solution, consisting of 30 mL of 1% lidocaine with epinephrine 1/100,000, is instilled into all areas where liposuction is to be performed. Liposuction is the initial phase of mega-volume fat transplantation, during which fat is harvested and stored in sterile canisters on the surgical field. Volumes of tu- mescent solution ranging from 2 L to 8 L are routinely used. Once the donor areas are completely tumesced, li- posuction is performed using a 3 - 4 mm multi-hole cannula. Once the fat is harvested into canisters, it is then further processed by centrifugation to dehydrate the fat and to remove unwanted blood in crystalloid. The fat is theninjected into the breast or buttock using a 14 gauge blunt tip cannulas. Access to the subcutaneous space is obtained via a small 14 gage needle stick. Volumes ranging from 200 mL to 1300 mL are routinely used. In the breast, volumes range from 200 mL to 700 mL; in the buttock, which has a larger capacity and requires a greater volume of augmentation, volumes range from 500 mL to 1300 mL of fat (
In breast augmentation, the entire procedure can be performed while the patient is in the supine position. In buttock augmentation, the patient must be placed directly prone on the operative table in order to facilitate aes- thetic contouring and shaping of the buttock region. Following these procedures, patients must be placed in a compression garment to reduce the risk of edema and postoperative hemorrhage.
Age, tumescent volume, BMI, OR time, intra-operative temperature minimum, intra-operative temperature ma- ximum, volume of fat removed, volume of fat injected, major complications.
Patient age ranged from 21 years to 57 years with mean age 37.20 and SD = 9.95. BMI also ranged dramatically from 18.8 to 42.2 with mean 24.74 and SD = 5.02. OR time ranged from 83 to 374 minutes with mean 178.3 minutes and SD = 60.3. Patient temperature maximum ranged from 35.3˚C to 37.2˚C with mean 36.1˚C and SD = 0.55. Patient temperature minimum ranged from 33.2˚C to 36˚C with mean 34.6˚C and SD = 0.67. Fat removed ranged from 1000 to 7000 cc with mean 4379 cc and SD = 1192. Fat injected ranged from 200 to 1990 cc with mean 1154 cc and SD = 400. Tumescent solution used ranged from 1000 to 9000 cc with mean 6580 cc and SD = 2001 (
We also compared the five patients with the lowest minimum intraoperative temperatures to the five patients with the highest intraoperative minimum temperatures (
There were no cases of major hemorrhage leading to significant hypotension, fat or pulmonary embolism, hy- pothermia leading to cardiac arrhythmia or other major organ system pathology, or adverse reactions to medica- tion, including lidocaine toxicity. Though vasopressors were used during 36.7% of our cases, there were no epi- sodes of hypotension resistant to small dose vasopressors, and we attribute the presence of intermittent minor intra-operative hypotension to our use of volatile anesthetic gases.
Minimum | Maximum | Mean | Standard Deviation | |
---|---|---|---|---|
Age (Years) | 21 | 57 | 37.20 | 9.95 |
BMI | 18.8 | 42.2 | 24.74 | 5.02 |
OR time | 1:23:00 | 6:14:00 | 2:59:48 | 1:00:18 |
Temperature Max (˚C) | 35.3 | 37.2 | 36.1 | 0.55 |
Temperature Min (˚C) | 33.2 | 36 | 34.6 | 0.67 |
Fat Removed (cc) | 1000 | 7000 | 4379 | 1192 |
Fat Injected (cc) | 200 | 1990 | 1154 | 400 |
Tumescent Used (cc) | 1000 | 9000 | 6580 | 2001 |
Minimum Temp | Maximum Temp | Mean Temp | Standard Deviation | Minimum BMI | Maximum BMI | Mean BMI | Standard Deviation | |
---|---|---|---|---|---|---|---|---|
Highest Minimum Temp Group | 35 | 36 | 35.3 | 0.38 | 18.8 | 42.2 | 27.14 | 9.89 |
Lowest Minimum Temp Group | 33.2 | 34 | 33.7 | 0.31 | 20.8 | 29.6 | 25.1 | 4.9 |
Patients who received autologous fat transplantation were satisfied with the outcome in 100% of our cases, which is consistent with the very positive satisfaction statistics found in the literature for this procedure men- tioned previously.
Tumescent anesthesia has been successfully used in liposuction procedures since the 1980s, and was revolu- tionary in the sense that it greatly diminished the risk of serious adverse events from the procedure, including blood loss and significant fluid shifts. The technique involves local infusion of a saline solution containing lido- caine. This technique is often used alone in the setting of liposuction, but due to the fact that we are also per- forming fat transplantation, a combination of GA and tumescent anesthesia is required for our patients. In 1988, Klein demonstrated that tumescent anesthesia provides a relatively low risk of systemic lidocaine toxicity [
Lidocaine toxicity often presents with CNS or cardiovascular symptoms. A moderate or severe overdose can result initially in CNS excitation, in the form of seizures [
which is active on cardiac tissue, lidocaine toxicity can often present with reentrant arrhythmias, or diminished blood pressure and heart rate. Injecting lidocaine as a tumescent solution into fatty tissue does not appear to cause the same effects because of the relatively poor absorption of this solution into systemic circulation when administered in this manner. Klein reported doses of 35 mg/kg to be safe when used for liposuction [
Preparation and surgeon administration of the tumescent solution must be very carefully performed. Martinez et al. report a 2008 fatality due to lidocaine toxicity in a patient receiving tumescent anesthesia for an elective liposuction procedure [
Proper management of our patients’ temperature is an essential component of safe anesthesia. Though un- common, there are case reports of patients who have become hypothermic under GA, and have subsequently suffered cardiovascular collapse. In one such case report, Nishikawa et al. describe a patient who suffers pro- gressive hypothermia despite placement of a warming blanket and use of warm IVF; with the patient ultimately requiring continuous veno-venous hemofiltration (CVVH) intraoperatively for rewarming [
Another significant risk while injecting large volumes of adipose tissue is the possibility of fat embolism syn- drome (FES). Most often FES is seen as a result of long-bone trauma, but it has also been reported secondary to both orthopedic surgery and liposuction [
Autologous fat transplantation for the purposes of breast and buttock augmentation is an emerging technique showing great promise, providing natural volume enhancement and leaving patients very satisfied with the result. This technique may be an ideal, safe solution for patients who want to have both liposuction and breast/buttock augmentation, but do not want the extra difficulty and risk of two separate procedures or artificial implants. Anesthesiologists, confronted with such otherwise healthy patients electing to undergo such cosmetic procedures, must be keenly aware of the potential pitfalls of hypothermia, lidocaine toxicity, and airway management during patient repositioning, and must work with the increasing number of surgeons beginning to perform such proce- dures.