Malpractice Claims in Liposuction
American Society for Dermatologic Surgery © 1999;25:343-347
Does the Location of the Surgery or the Specialty of Physician Affect Malpractice Claims in Liposuction
The following is worth reading in it's entirety even if you are not very technically oriented. This is a very large study using information from medical malpractice insurance companies about liposuction lawsuits. It showed that hospital-based liposuction was statistically much more dangerous (subject to massively more litigation) than outpatient liposuction. The dermatologist had almost no litigation, while the plastic surgeons had much, much more (plastic surgeons over 8 million dollars in judgements and settlements, while the dermatologist had only about 4,000 dollars total). To be fair, certainly the plastic surgeons were doing larger and more complex surgery cases. The other specialist were somewhere in between.
William P. Coleman, III,MD, C. William Hanke, MD, Patrick Lillis, MD, Gerald Bernstein, MD, and Rhoda Narins, MD
BACKGROUND: There is a national dialogue on who should perform liposuction and where it should be performed.
OBJECTIVE: To determine the effect of the location of liposuction surgery and the specialty of the physician on the incidence of malpractice claims.
METHODS: Physicians Insurance Association of America malpractice data from 1995-1997 was analyzed.
RESULTS: Hospital-based liposuction had more than 3 times the rate of malpractice settlements than office-based liposuction.
CONCLUSION: Dermatologic liposuction education has emphasized small volume cases performed under local anesthesia using the tumescent technique. The safety of this approach appears to be validated in terms of decreased malpractice settlements.
RECENTLY, in a number of states, fatalities that have occurred after liposuction in office settings have been sensationalized in the local and national press.1 This publicity has led to a great deal of action by state medical boards, which has been driven by honest concern, interspecialty competition, and public outrage. In some states rules have been enacted or are planned that would restrict the types of procedures that could be performed in an office setting.1,2.
The superficial observer, whether a physician or a layman, would probably interpret these trends as good for the public. The prevailing view is that office surgical facilities are not as sophisticated as those found in the hospital. Moreover, there is less peer review in office surgical settings and less sophisticated anesthesia support is available. There is a growing assumption that certain types of surgery performed in unregulated office settings are contrary to the public good. However with liposuction this assumption may be unjustified.
In order to study this issue the authors chose a controversial area of office surgery: liposuction. This procedure was chosen because it appears to be the focus of medical board activities in large states (Florida, California, and New York). Liposuction is often cited as a large surgical procedure that should only be performed in hospitals. Efforts are being made to restrict the size of liposuction cases that can be performed in the office environment.
Materials and Methods
Malpractice claims involving liposuction were obtained from the Physicians Insurance Association of America (PIAA) Data Sharing project. Cumulative data on claims occurring from January 1, 1995, through December 31, 1997, were studied. This data consisted only of claims reported from PIAA physician-owned malpractice insurance companies and does not represent all claims reported nationally. Information was obtained as to the number of claims, the misadventure identified, the location of the surgery, and the medical specialty of the defendant physician.
In order to correlate the claims reported per specialty with the number of procedures performed per specialty, data was obtained from recent surveys performed by the American Society for Plastic and Reconstructive Surgery and the American Society for Dermatologic Surgery.3,4 This information was collated in order to obtain an approximation of the number of liposuction procedures performed by these specialists.
During the study period, 257 claims were filed. The misadventures claimed are summarized in Table 1.1 The overwhelming majority involved improper performance (N = 157), which involved approximately 61% of the claims. The location at which the liposuction surgery was performed is identified in Table 2. An overwhelming majority of the injurious liposuction procedures identified were performed in the hospital 71% (N = 179), while 21% (N = 52) of the malpractice claims were for surgery performed in the practitioners office. The remaining 8% of cases occurred in hospital outpatient facilities, surgery centers, or other outpatient facilities.
The medical specialties of the surgeons who were sued are listed in Table 3. An overwhelming majority of these were plastic surgeons: 90% (N = 226).
Survey data was obtained from the American Society for Dermatologic Surgery (ASDS) on liposuction procedures performed in 1997.3 The survey is based on 166 respondents for a survey of all 2400 members. This represented approximately 7% of the membership. In all, 7,117 cases of liposuction were reported. Extrapolating the sample would indicate that approximately 100,000 cases of liposuction were performed by dermatologic surgeons during 1997.
Another survey was reported in 1998 by the American Society of Plastic and Reconstructive Surgery (ASPRS) based on a sample of 1500 members "who performed lipoplasty." 4 In this study, 629 surveys, were returned. The 629 responding physicians indicated they had performed a total of 24,295 "lipoplasty" surgeries in the past 12 months. The American Society for Plastic and Reconstructive Surgery projected from this sample of 7% of the total membership (8700) that plastic surgeons had performed approximately 150,000 liposuctions in 1997. The responding physicians in the ASPRS survey reported an average of 39 liposuctions per physician.4 The responding physicians to the ASDS survey reported an average of 42 liposuctions per physician.3
This total estimate of 250,000 liposuction cases for both specialties combined is in agreement with the National Statistics of the American Academy of Cosmetic Surgery which in 1996 estimated 293,000 liposuctions were performed by plastic surgeons, dermatologists, and other miscellaneous specialties (source: American Academy of Cosmetic Surgery 1996 Member Survey).
Contrary to popular belief, the data from the PIAA indicates that the vast majority of liposuction claims were based on surgery that occurred I the hospital (71%), not the office (21%) setting, in spite of the fact that the majority of cosmetic surgery in the U.S. is performed in the office setting or in ambulatory surgery centers (source: American Academy of Cosmetic Surgery 1996 Member Survey).
This aberration in the number of lawsuits from hospital cases may be occurring for a variety of reasons. Office and private ambulatory surgeries may offer a more personal experience for the patient, with a more attentive atmosphere. Physicians who operate in their own facilities tend to specialize in certain procedures. Busy liposuction surgeons usually have the latest equipment and an operating room tailored to this procedure. Hospitals on the other hand are more focused on non-cosmetic surgery. There is also a tendency to perform larger liposuction cases in the hospital setting. These may be combined with other surgical procedures. The rationale for doing these in the hospital is that larger liposuction cases are riskier than smaller ones. Fatality and complication data certainly support this, as does the PIAA data.
The question one must ask, however, is why risky large-volume liposuctions are performed at all? Liposuction is an entirely elective cosmetic procedure. It is ideally performed on healthy individuals with small accumulations of excess fat that are resistant to diet and exercise. These patients are typically healthy, on minimal medication, and are excellent anesthetic risks. Larger liposuction cases are performed on less than ideal individuals whose accumulations of fat may range from excessive to obese.
Liposuction of these individuals involves the removal of large volumes of fat and usually the use of significant anesthesia. When these cases are performed in the hospital for "safety" reasons, the physician may be ignoring the most important fact of all: these are poor risk patients for liposuction.
The tumescent technique for liposuction was developed by dermatologist Jeffrey Klein in 1985 in an attempt to allow this procedure to be performed totally and completely under local anesthesia.5 The tumescent technique involves infiltration of large volumes of dilute lidocaine and epinephrine into the targeted fat before it is suctioned out. The tumescent technique has been show to dramatically decrease the amount of bleeding during liposuction.6,7When compared to general anesthesia it also allows liposuctions of up to 4 liters of fat to be performed safely and comfortably without general or intravenous anesthetics. In many cases, the procedures can be performed under local anesthesia alone, without any sedation.8The maximum dose of lidocaine that can safely be employed (50-60 mg/kg) automatically limits the size of the liposuction case. The safety profile of this form of liposuction has been demonstrated over and over in a series of studies.9,10,11
More recently, some physicians have been utilizing the advantages of the tumescent technique (especially the lack of blood loss) to push the envelope on the size of liposuction procedures that they perform.12Using the tumescent technique combined with the general anesthesia allows the surgeon to remove large volumes of fat nearly bloodlessly. Physicians at national meetings sometimes report extractions of over 10 liters of fat during a single case. Combining the tumescent technique with general anesthesia and additional intravenous fluid administration causes increased risk for liposuction. Drug interactions sometimes occur, and a number of cases of pulmonary edema have been reported using this practice.12-14 In some cases, these problems have been blamed on tumescent anesthesia itself, ignoring the fact in fact that an aberrant form of this technique was employed. 15-18When used correctly, tumescent anesthesia as a local-anesthesia approach alone, without intravenous sedation or general anesthesia, is extremely safe.9,10
Serial liposuction, or dividing the liposuction into a series of multiple smaller cases, has been proposed since the development of this technique in Italy in 1975.19,20 However, patient and physician interest in performing large cases at one time, for convenience, has driven surgeons to perform larger and larger cases of liposuction. Uncomfortable with these larger cases in office facilities, some practitioners take patients to the hospital, hoping for a secure environment.
Dermatologists and dermatologic surgeons have typically practiced surgery in an office-based setting. As dermatology evolved in the nineteenth century, it was always office-based, and dermatologists have always been primarily trained in office-based surgery. When liposuction was developed and introduced into the United States in late 1982, dermatologists immediately developed ways of performing it on an outpatient basis consistent with their practice style.21
Meanwhile, other specialists, such as plastic surgeons, who are more comfortable in the hospital setting, embraced liposuction as a hospital-based procedure. Increased costs of performing liposuction in the hospital, however, drove many plastic surgeons into ambulatory surgical centers and office facilities as liposuction because more popular in the late 1980s.
Although practice data from the American Society for Dermatologic Surgery and the American Society of Plastic and Reconstructive Surgery3,4 indicates that although plastic surgeons perform somewhat more liposuction procedures than dermatologists (a 3:2 ratio), PIAA data reveals they have an overwhelming majority of liposuction malpractice claims (a 113:1 ratio). This holds true both in hospital and office-based liposuction. Office-based liposuction by plastic surgeons resulted in 50 times as many claims as office-based liposuction by dermatologists. Hospital-based liposuction by plastic surgeons resulted in 154 times as many cases as by dermatologists (source: PIAA Malpractice Data). Overall losses due to these suits were over $9 million of which dermatologists accounted for less than $4,000 and plastic surgeons $8,466,000 (Table 3). Interestingly, general surgeons' liposuction activities also resulted in a significant number of claims (7.5% of the hospital claims) (Table 3).
The large divergence between the number of claims against plastic surgeons and against dermatologists may be reflected in the practice styles of each of these specialties. In 1989, the American Academy of Dermatology was the first medical society to release "Guidelines of Care" for liposuction. These were later published in 1991.22 More recently the American Society for Dermatologic Surgery published updated "Guiding Principles for Liposuction" to reflect changes in science since the original guidelines were approved.23 Liposuction teaching at dermatology continuing education courses has been based on these guidelines and principles, which emphasize the extraction of small volumes of fat using tumescent local anesthesia.22-27 Plastic surgery educational programs and articles have often emphasized liposuction performed in larger volumes under intravenous sedation or general anesthesia often as a combined surgery with other procedures.28-31 It is not surprising that more malpractice claims have resulted from this more aggressive form of liposuction.
This study is interesting because it demonstrates that although state licensing boards are focusing on the dangers of office-based liposuction, the real risks may actually be occurring in hospitals. The risks of a procedure reflect largely on the physician performing the procedure rather than the specific location of the procedure itself. Regardless of the location, if the physician adopts a more aggressive approach, the patient is at increased risk. As shown by the accumulated scientific data when using the tumescent technique with local anesthesia only, liposuction is an extremely safe procedure. Deviating from this safer form of practice can be dangerous. Attempts by state medical boards to drive liposuction into the hospital may in fact increase public risk from liposuction. State medical boards could better increase the safety of liposuction by focusing on the education of the physicians who perform it and emphasizing safety above all in the performance of this common cosmetic procedure.
The Academy of Dermatology and The American Society for Dermatologic Surgery began a proactive educational campaign in risk management for liposuction over a decade ago with the approval of Guidelines of Care for Liposuction.22 Ten years of teaching liposuction as a small-volume procedure performed using tumescent local anesthesia has apparently paid off for dermatologists, as reflected in the low numbers of malpractice settlements. Risk management committees of malpractice insurance companies could probably help to reduce losses from liposuction lawsuits by recommending the safer methodology of true tumescent liposuction, although some physicians may claim they are using tumescent liposuction they are often modifying the procedure by adding general anesthesia.17 This altered standard of care, as shown in this study, is more likely to result in lawsuits. Large-volume liposuction (over 4000 cc) is inherently risky, but it also involves more aggressive anesthesia, adding to its danger. Risk management for liposuction should stress smaller liposuction procedures and using local anesthesia, with minimal sedation.
Although commonly assumed to be less safe, office-based liposuction may be significantly safer than hospital-based liposuction, as reflected in malpractice legal claims. From 1995 to 1997, 71% of the studied claims resulted from hospital liposuction while only 21% of the claims were due to office liposuction. Although plastic surgeons perform about approximately 150,000 liposuctions annually to the 100,000 performed by dermatologists, their malpractice claim experience in this study was 113 times as large. The practice styles of dermatologists, performing smaller volume liposuction with true tumescent local anesthesia results in less injury and consequently fewer lawsuits. This results in significantly less indemnity losses to malpractice insurance companies.
- Chase M. Extreme liposuction is exposing patients to unnecessary risk. Wall Street Journal, January 18, 1999.
- Landry S. Board: shorten office surgeries, St. Petersburg Times, December 6, 1998.
- Results of ASDS Member Survey on Cosmetic Surgery Procedures. November 20, 1998.
- Survey looks at complications connected to lipoplasty. Plast Surg News. October/November 1998.
- Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg 1987;4:263.
- Lillis PJ. Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption. J Dermatol Surg Oncol 1988;14:1145-8.
- Karmo FR, Milan MF, Stein S, Heinsimer JA. Blood loss in major lipoplasty procedures with the tumescent technique. Aesthetic Surg J 1998;18:130-5.
- Hanke CW, Coleman WP III, Lillis PJ, et al. Infusion rates and levels of premedication in tumescent liposuction. Dermatol Surg 1997;23:1131-4.
- Hanke CW, Bernstein G, Bullock S. Safety of tumescent liposuction in 15,336 patients. Dermatol Surg 1995;21:459-62.
- Klein JA. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg 1993;92:1085-98.
- Samdal F, Armand PF, Bugge JF. Plasma lidocaine levels during suction assisted lipectomy using large doses of dilute lidocaine with epinephrine. Plast Reconstr Surg 1994;93:1217-23.
- Grazer FM, Meister FL. Complications of the tumescent formula for liposuction. Plast Reconstr Surg 1997;100:1893-6.
- Meister F. Possible association between tumescent technique and life threatening pulmonary complications. Clin Plast Surg 1996;23:642.
- Gilliland MD, Coates N. Tumescent liposuction complicated by pulmonary edema. Plast Reconstr Surg 1997;99:215:
- Matarasso A. Superwet Anesthesia redefines large-volume liposuction. Aesth Surg J 1997;17:358-64.
- Rohrich RJ, Beran SJ, Fodor PB. The role of subcutaneous infiltration in suction assisted lipoplasty: a review. Plast Reconstr Surg 1997;99:519.
- Klein J. The two standards of care for tumescent liposuction. Dermatol Surg 1997;23:1194.
- Coleman WP III, Lawrence N, Lillis PJ, Narins RS. The tumescent technique (letter). Plast Reconstr Surg 1998;101:1751-2.
- Coleman WP III. The history of liposuction surgery. Dermatol Clin 1990;8:381-3.
Lawrence N, Coleman WP III. Liposuction. Adv Dermatol 1996;11:19-49.
- Coleman WP III. Liposuction and anesthesia. J Dermatol Surg Oncol 1987;13:1295.
- Drake LA et al. Guidelines of care for liposuction for the American Academy of Dermatology. J Am Acad Dermatol 1991;24:489-94.
- American Society for Dermatologic Surgery. Guiding principles of liposuction. Dermatol Surg 1997;23:1127-9.
- Field L. The dermatologist and liposuction: a history. J Dermatol Surg Oncol 1987;13:1040-1.
- Coleman WP III, Letessier S, Hanke CW. Liposuction. In: Coleman WP III et al, eds. Cosmetic Surgery of the Skin. St. Louis: Mosby 1997;178-205.
- Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction: peak plasma concentrations are diminished and delayed 12 hours. J Dermatol Surg Oncol 1990;16:248-63.
- Coleman WP III. Liposuction. In: Wheeland R, (ed.) Cutaneous Surgery. Philadelphia, WB Saunders, 1994, pp. 549-67
- Cardenas-Camarena L, Gozalez LE. Large-volume liposuction and extensive abdominoplasty: a feasible alternative for improving body shape. Plast Reconstr Surg 1998;102:1698-1707.
- Samdal F, Birkeland KI, Ose L, Amland PF. Effect of large-volume liposuction on sex hormones and glucose and lipid metabolism in females. Aesth Plast Surg 1995;19:131-5.
- Burk RW, Guzman-Stein G, Vasconez LO. Lidocaine and epinephrine levels in tumescent technique liposuction. Plast Reconstr Surg 1996;97:1379-84.
- Courtiss H,Choucair J, Donelan MB. Large volume suction lipectomy an analysis of 108 patients. Plast Reconstr Surg 1992;89:1068-79.