Preventing Errors In The Outpatient Setting: A Tale of Three States

Elizabeth M. Lapetina and Elizabeth M. Armstrong


Health Affairs. 2002;21(4) 

In This Article

Cosmetic Surgery: A Special Case

Cosmetic surgery -- especially liposuction -- raises the brightest red flag in terms of outpatient surgery. It has certainly captured the most attention in the popular press; since 1990 there have been more than 125 newspaper stories on deaths during liposuction.[27] This surgery is entirely elective and is performed on persons in good health, so the tolerance for risk is vanishingly small. As techniques for cosmetic surgery procedures have made them less painful and less invasive, an alarming number of physicians with minimal training have developed office-based practices to perform these procedures. Nearly half of the 250,000 liposuctions performed in 1997 were done by practitioners other than plastic surgeons.[28]

The use of tumescent liposuction procedures, for example, has enabled physicians to perform cosmetic surgery in the outpatient setting but illustrates the potential dangers of allowing unqualified practitioners to perform these procedures. By 1997 outpatient liposuction under general anesthesia had become the most common aesthetic surgical procedure. Tumescent liposuction involves the subcutaneous injection of highly diluted lidocaine with epinephrine, which allows for nearly bloodless suction of fat and reduces postoperative pain, enabling liposuction to be done in physicians' offices.[29]

As patients have demanded the removal of greater volumes of fat, physicians, who sometimes have little formal training in performing liposuction, have administered higher doses of lidocaine and epinephrine. The American Academy of Dermatologists has deemed megadose concentrations of highly diluted lidocaine of up to 35 to 55 mg/kg to be safe for tumescent infiltration anesthesia, even though the Food and Drug Administration (FDA) sanctioned maximum dosage for regional anesthesia is 7 mg/kg.[30] Errors occur when physicians overlook the "highly diluted" caveat and administer large amounts of more concentrated lidocaine.

The bundling of procedures also leads to complications. If liposuction and cosmetic face surgery are performed during the same session, lidocaine is given for both procedures, which raises the risk of complications. Because only two states require the reporting of adverse events occurring in physicians' offices, it is not known how many complications result from this procedure nationwide.


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