does the location of the surgery or the specialty of the physician affect malpractice claims in...

© 1999 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.ISSN: 1076-0521/99/$14.00/0 • Dermatol Surg 1999;25:343–347

Does the Location of the Surgery or the Specialty of the Physician Affect Malpractice Claims in Liposuction?

William P. Coleman, III, MD,* C. William Hanke, MD,

†

Patrick Lillis, MD,

‡

Gerald Bernstein, MD,

§

and Rhoda Narins, MD

¶

*

Department of Dermatology, Tulane University School of Medicine, New Orleans, Louisiana;

†

Department of Otolaryngology, Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana;

‡

Department of Dermatology, University of Colorado Health Science Center, Denver, Colorado;

§

Department of Dermatology, University of Washington School of Medicine, Seattle, Washington; and

¶

Department of Dermatology, New York

University Medical Center, New York City, New York

background.

There is increasing national dialogue on whoshould perform liposuction and where it should be performed.

objective.

To determine the effect of the location of liposuctionsurgery and the specialty of the physician on the incidence of mal-practice claims.

methods.

Physicians Insurance Association of America mal-practice data from 1995-1997 was analyzed.

results.

Hospital-based liposuction had more than 3 times the

rate of malpractice settlements than office-based liposuction. Der-matologists accounted for less than 1% of malpractice claim settle-ments in liposuction.

conclusion.

Dermatologic liposuction education has empha-sized small volume cases performed under local anesthesia usingthe tumescent technique. The safety of this approach appears tobe validated in terms of decreased malpractice settlements.

RECENTLY, IN a number of states, fatalities thathave 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 statemedical boards, which has been driven by honest con-cern, interspecialty competition, and public outrage.In some states rules have been enacted or are plannedthat would restrict the types of procedures that couldbe performed in an office setting.

1,2

The superficial observer, whether a physician or alayman, would probably interpret these trends as goodfor the public. The prevailing view is that office surgicalfacilities are not as sophisticated as those found in thehospital. Moreover, there is less peer review in officesurgical settings and less sophisticated anesthesia sup-port is available. There is a growing assumption thatcertain types of surgery performed in unregulated officesettings are contrary to the public good. However withliposuction this assumption may be unjustified.

In order to study this issue the authors chose a con-troversial area of office surgery: liposuction. This pro-cedure was chosen because it appears to be the focusof medical board activities in large states (Florida,California, and New York). Liposuction is often cited

as a large surgical procedure that should only be per-formed in hospitals. Efforts are being made to restrictthe size of liposuction cases that can be performed inthe office environment.

Materials and Methods

Malpractice claims involving liposuction were obtainedfrom the Physicians Insurance Association of America(PIAA) Data Sharing project. Cumulative data on claims oc-curring from January 1, 1995, through December 31, 1997,were studied. This data consisted only of claims reportedfrom PIAA physician-owned malpractice insurance compa-nies and does not represent all claims reported nationally.Information was obtained as to the number of claims, themisadventure identified, the location of the surgery, and themedical specialty of the defendant physician.

In order to correlate the claims reported per specialty withthe number of procedures performed per specialty, data wasobtained from recent surveys performed by the American So-ciety for Plastic and Reconstructive Surgery and the American

Society for Dermatologic Surgery.

3,4

This information wascollated in order to obtain an approximation of the numberof liposuction procedures performed by these specialists.

Results

During the study period, 257 claims were filed. Themisadventures claimed are summarized in Table 1.

1

The overwhelming majority involved improper perfor-

Address correspondence and reprint requests to: William P. Coleman,III, MD, 4425 Conlin Street, Metairie, LA 70006.

344

coleman et al: malpractice claims in liposuction

Dermatol Surg 25:5:May 1999

mance (N

5

157), which involved approximately61% of the claims.

The location at which the liposuction surgery wasperformed is identified in Table 2. An overwhelmingmajority of the injurious liposuction procedures iden-tified were performed in the hospital 71% (N

5

179),while 21% (N

5

52) of the malpractice claims werefor surgery performed in the practitioners office. Theremaining 8% of cases occurred in hospital outpatientfacilities, surgery centers, or other outpatient facilities.

The medical specialties of the surgeons who weresued are listed in Table 3. An overwhelming majorityof these were plastic surgeons: 90% (N

5

226).Survey data was obtained from the American Soci-

ety for Dermatologic Surgery (ASDS) on liposuctionprocedures performed in 1997.

3

The survey is basedon 166 respondents for a survey of all 2400 members.This represented approximately 7% of the member-ship. In all, 7,117 cases of liposuction were reported.Extrapolating the sample would indicate that approxi-mately 100,000 cases of liposuction were performedby dermatologic surgeons during 1997.

Another survey was reported in 1998 by the AmericanSociety of Plastic and Reconstructive Surgery (ASPRS)based on a sample of 1500 members “who perform li-poplasty.”

4

In this study, 629 surveys, were returned.The 629 responding physicians indicated they had per-formed a total of 24,295 “lipoplasty” surgeries in the

past 12 months. The American Society for Plastic andReconstructive Surgery projected from this sample of7% of the total membership (8700) that plastic sur-geons had performed approximately 150,000 liposuc-tions in 1997. The responding physicians in the ASPRSsurvey reported an average of 39 liposuctions per physi-cian.

4

The responding physicians to the ASDS surveyreported an average of 42 liposuctions per physician.

3

This total estimate of 250,000 liposuction cases forboth specialties combined is in agreement with the Na-tional Statistics of the American Academy of CosmeticSurgery which in 1996 estimated 293,000 liposuctionswere performed by plastic surgeons, dermatologists,and other miscellaneous specialties (source: AmericanAcademy of Cosmetic Surgery 1996 Member Survey).

Discussion

Contrary to popular belief, the data from the PIAA in-dicates that the vast majority of liposuction claims werebased on surgery that occurred in the hospital (71%),not the office (21%) setting, in spite of the fact thatthe majority of cosmetic surgery in the U.S. is per-formed in the office setting or in ambulatory surgery

Table 1.

Reasons for Liposuction Medical Liability Claims 1995-1997 (N

5

257)

Misadventure Plastic Surgery General Surgery Ob-Gyn GP/FP Derm

Improper performance 141 11 2 1 2No medical misadventure 53 5 0 1 0Failure to recognize complication 9 0 1 0 0Failure to monitor patient 8 0 0 0 0Failure to instruct patient 6 0 0 0 0Liposuction not indicated 4 2 0 0 0Foreign body left in patient 4 1 0 0 0Patient positioning problem 2 0 1 0 0Delay in performance 1 0 0 0 0Not performed 1 0 0 0 0Delay in hospital admission 1 0 0 0 0

Source: PIAA data.

Table 2.

Site of Liposuction Surgery in 253 Liability Claims (1995-1997)

Site Number of Claims Percent

Hospital 179 71Physician Office 52 21Surgicenter 16 6Hospital Outpatient 5 2

Source: PIAA data.

Table 3.

Liposuction Liability Claims by Specialty 1995-1997 (N

5

253)

SpecialtyNumberof Claims Percent

TotalIndemnity

Plastic Surgery 226 89.7 $8,466,473General Surgery 19 7.5 594,154Ob-Gyn 4 1.6 80,000Dermatology 2 0.8 3,750Gen/Family Practice 2 0.8 0Total $9,144,377

Source: PIAA data.



345

centers (source: American Academy of Cosmetic Sur-gery 1996 Member Survey).

This aberration in the number of lawsuits from hos-pital cases may be occurring for a variety of reasons.Office and private ambulatory surgeries may offer amore personal experience for the patient, with a moreattentive atmosphere. Physicians who operate in theirown facilities tend to specialize in certain procedures.Busy liposuction surgeons usually have the latest equip-ment 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 performlarger liposuction cases in the hospital setting. Thesemay be combined with other surgical procedures. Therationale for doing these in the hospital is that larger li-posuction cases are riskier than smaller ones. Fatalityand complication data certainly support this, as doesthe PIAA data.

The question one must ask, however, is why riskylarge-volume liposuctions are performed at all? Lipo-suction is an entirely elective cosmetic procedure. It isideally performed on healthy individuals with smallaccumulations of excess fat that are resistant to dietand exercise. These patients are typically healthy, onminimal medication, and are excellent anesthetic risks.Larger liposuction cases are performed on less thanideal individuals whose accumulations of fat mayrange from excessive to obese.

Liposuction of these individuals involves the re-moval of large volumes of fat and usually the use ofsignificant anesthesia. When these cases are performedin the hospital for “safety” reasons, the physician maybe ignoring the most important fact of all: these arepoor risk patients for liposuction.

The tumescent technique for liposuction was devel-oped by dermatologist Jeffrey Klein in 1985 in an at-tempt to allow this procedure to be performed totallyand completely under local anesthesia.

5

The tumescenttechnique involves infiltration of large volumes of di-lute lidocaine and epinephrine into the targeted fat be-fore it is suctioned out. The tumescent technique hasbeen shown to dramatically decrease the amount ofbleeding during liposuction.

6,7

When compared togeneral anesthesia it also allows liposuctions of up to4 liters of fat to be performed safely and comfortablywithout general or intravenous anesthetics. In manycases, the procedures can be performed under localanesthesia alone, without any sedation.

8

The maxi-mum dose of lidocaine that can safely be employed(50–60 mg/kg) automatically limits the size of the li-posuction case. The safety profile of this form of lipo-suction has been demonstrated over and over in a se-ries of studies.

9,10,11

More recently, some physicians have been utilizingthe advantages of the tumescent technique (especially

the lack of blood loss) to push the envelope on the sizeof liposuction procedures that they perform.

12

Usingthe tumescent technique combined with general anes-thesia allows the surgeon to remove large volumes offat nearly bloodlessly. Physicians at national meetingssometimes report extractions of over 10 liters of fatduring a single case. Combining the tumescent tech-nique with general anesthesia and additional intrave-nous fluid administration causes increased risk forliposuction. Drug interactions sometimes occur, and anumber of cases of pulmonary edema have been re-ported using this practice.

12–14

In some cases, theseproblems have been blamed on tumescent anesthesia it-self, ignoring the fact in fact that an aberrant form ofthis technique was employed.

15–18

When used correctly,tumescent anesthesia as a local-anesthesia approachalone, without intravenous sedation or general anesthe-sia, is extremely safe.

9,10

Serial liposuction, or dividing the liposuction into aseries of multiple smaller cases, has been proposedsince the development of this technique in Italy in1975.

19,20

However, patient and physician interest inperforming large cases at one time, for convenience,has driven surgeons to perform larger and larger casesof liposuction. Uncomfortable with these larger casesin office facilities, some practitioners take patients tothe hospital, hoping for a secure environment.

Dermatologists and dermatologic surgeons havetypically practiced surgery in an office-based setting.As dermatology evolved in the nineteenth century, itwas always office-based, and dermatologists have al-ways been primarily trained in office-based surgery.When liposuction was developed and introduced intothe United States in late 1982, dermatologists immedi-ately developed ways of performing it on an outpa-tient basis consistent with their practice style.

21

Meanwhile, other specialists, such as plastic sur-geons, who are more comfortable in the hospital set-ting, embraced liposuction as a hospital-based proce-dure. Increased costs of performing liposuction in thehospital, however, drove many plastic surgeons intoambulatory surgical centers and office facilities as li-posuction became more popular in the late 1980s.

Although practice data from the American Society forDermatologic Surgery and the American Society of Plas-tic and Reconstructive Surgery

3,4

indicates that althoughplastic surgeons perform somewhat more liposuctionprocedures than dermatologists (a 3:2 ratio), PIAA datareveals they have an overwhelming majority of liposuc-tion malpractice claims. (a 113:1 ratio) This holds trueboth in hospital and office-based liposuction. Office-based liposuction by plastic surgeons resulted in 50 timesas many claims as office-based liposuction by dermatolo-gists. Hospital-based liposuction by plastic surgeons re-sulted in 154 times as many case as by dermatologists

346



(source: PIAA Malpractice Data). Overall losses due tothese suits were over $9 million of which dermatologistsaccounted for less than $4,000 and plastic surgeons$8,466,000 (Table 3). Interestingly, general surgeons’ li-posuction activities also resulted in a significant numberof claims (7.5% of the hospital claims) (Table 3).

The large divergence between the number of claimsagainst plastic surgeons and against dermatologistsmay be reflected in the practice styles of each of thesespecialties. In 1989, the American Academy of Derma-tology was the first medical society to release “Guide-lines of Care” for liposuction. These were later pub-lished in 1991.

22

More recently the American Societyfor Dermatologic Surgery published updated “Guid-ing Principles for Liposuction” to reflect changes inscience since the original guidelines were approved.

23

Liposuction teaching at dermatology continuing edu-cation courses has been based on these guidelines andprinciples, which emphasize the extraction of small vol-umes of fat using tumescent local anesthesia.

22–27

Plasticsurgery educational programs and articles have oftenemphasized liposuction performed in larger volumesunder intravenous sedation or general anesthesia oftenas a combined surgery with other procedures.

28–31

It isnot surprising that more malpractice claims have re-sulted from this more aggressive form of liposuction.

This study is interesting because it demonstrates thatalthough state licensing boards are focusing on thedangers of office-based liposuction, the real risks mayactually be occurring in hospitals. The risks of a proce-dure reflect largely on the physician performing theprocedure rather than the specific location of the pro-cedure itself. Regardless of the location, if the physi-cian adopts a more aggressive approach, the patient isat increased risk. As shown by the accumulated scien-tific data when using the tumescent technique with lo-cal anesthesia only, liposuction is an extremely safeprocedure. Deviating from this safer form of practicecan be dangerous. Attempts by state medical boards todrive liposuction into the hospital may in fact increasepublic risk from liposuction. State medical boardscould better increase the safety of liposuction by focus-ing on the education of the physicians who perform itand emphasizing safety above all in the performance ofthis common cosmetic procedure.

The Academy of Dermatology and The AmericanSociety for Dermatologic Surgery began a proactive ed-ucational campaign in risk management for liposuctionover a decade ago with the approval of Guidelines ofCare for Liposuction.

22

Ten years of teaching liposuc-tion as a small-volume procedure performed using tu-mescent local anesthesia has apparently paid off fordermatologists, as reflected in the low numbers of mal-practice settlements. Risk management committees ofmalpractice insurance companies could probably help

to reduce losses from liposuction lawsuits by recom-mending the safer methodology of true tumescent lipo-suction, Although some physicians may claim they areusing tumescent liposuction they are often modifyingthe procedure by adding general anesthesia.

17

This al-tered standard of care, as shown in this study, is morelikely to result in lawsuits. Large-volume liposuction(over 4000 cc) is inherently risky, but it also involvesmore aggressive anesthesia, adding to its danger. Riskmanagement for liposuction should stress smaller lipo-suction procedures and using local anesthesia, with mini-mal sedation.

Summary

Although commonly assumed to be less safe, office-based liposuction may be significantly safer than hos-pital-based liposuction, as reflected in malpractice le-gal claims. From 1995 to 1997, 71% of the studiedclaims resulted from hospital liposuction while only21% of the claims were due to office liposuction. Al-though plastic surgeons perform about approximately150,000 liposuctions annually to the 100,000 per-formed by dermatologists, their malpractice claim ex-perience in this study was 113 times as large. Thepractice styles of dermatologists, performing smallervolume liposuction with true tumescent local anesthe-sia results in less injury and consequently fewer law-suits. This results in significantly less indemnity lossesto malpractice insurance companies.

References

1. Chase M. Extreme liposuction is exposing patients to unnecessaryrisk. Wall Street Journal, January 18, 1999.

2. Landry S. Board: shorten office surgeries, St. Petersburg Times, De-cember 6, 1998.

3. Results of ASDS Member Survey on Cosmetic Surgery Procedures.November 20, 1998.

4. Survey looks at complications connected to lipoplasty. Plast SurgNews. October/November 1998.

5. Klein JA. The tumescent technique for liposuction surgery. Am JCosmet Surg 1987;4:263.

6. Lillis PJ. Liposuction surgery under local anesthesia: limited bloodloss and minimal lidocaine absorption. J Dermatol Surg Oncol1988;14:1145–8.

7. Karmo FR, Milan MF, Stein S, Heinsimer JA. Blood loss in majorlipoplasty procedures with the tumescent technique. Aesthetic SurgJ 1998;18:130–5.

8. Hanke CW, Coleman WP III, Lillis PJ, et al. Infusion rates and lev-els of premedication in tumescent liposuction. Dermatol Surg 1997;23:1131–4.

9. Hanke CW, Bernstein G, Bullock S. Safety of tumescent liposuctionin 15,336 patients. Dermatol Surg 1995;21:459–62.

10. Klein JA. Tumescent technique for local anesthesia improves safetyin large volume liposuction. Plast Reconstr Surg 1993;92:1085–98.

11. Samdal F, Armand PF, Bugge JF. Plasma lidocaine levels duringsuction assisted lipectomy using large doses of dilute lidocaine withepinephrine. Plast Reconstr Surg 1994;93:1217–23.

12. Grazer FM, Meister FL. Complications of the tumescent formulafor liposuction. Plast Reconstr Surg 1997;100:1893–6.

13. Meister F. Possible association between tumescent technique and



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life threatening pulmonary complications. Clin Plast Surg 1996;23:642.

14. Gilliland MD, Coates N. Tumescent liposuction complicated bypulmonary edema. Plast Reconstr Surg 1997;99:215.

15. Matarasso A. Superwet Anesthesia redefines large-volume liposuc-tion. Aesth Surg J 1997;17:358– 64.

16. Rohrich RJ, Beran SJ, Fodor PB. The role of subcutaneous infiltra-tion in suction assisted lipoplasty: a review. Plast Reconstr Surg1997;99:519.

17. Klein J. The two standards of care for tumescent liposuction. Der-matol Surg 1997;23:1194.

18. Coleman WP III, Lawrence N, Lillis PJ, Narins RS. The tumescenttechnique (letter). Plast Reconstr Surg 1998;101:1751–2.

19. Coleman WP III. The history of liposuction surgery. Dermatol Clin1990;8:381–3.

20. Lawrence N, Coleman WP III. Liposuction. Adv Dermatol 1996;11:19–49.

21. Coleman WP III. Liposuction and anesthesia. J Dermatol Surg On-col 1987;13:1295.

22. Drake LA et al. Guidelines of care for liposuction for the AmericanAcademy of Dermatology. J Am Acad Dermatol 1991;24:489–94.

23. American Society for Dermatologic Surgery. Guiding principles ofliposuction. Dermatol Surg 1997;23:1127–9.

24. Field L. The dermatologist and liposuction: a history. J DermatolSurg Oncol 1987;13:1040–1.

25. Coleman WP III, Letessier S, Hanke CW. Liposuction. In: ColemanWP III et al, eds. Cosmetic Surgery of the Skin. St. Louis: Mosby,1997;178–205.

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27. Coleman WP III. Liposuction. In: Wheeland R, (ed.) CutaneousSurgery. Philadelphia, WB Saunders, 1994, pp. 549–67.

28. Cardenas-Camarena L, Gozalez LE. Large-volume liposuction andextensive abdominoplasty: a feasible alternative for improvingbody shape. Plast Reconstr Surg 1998;102:1698–1707.

29. Samdal F, Birkeland KI, Ose L, Amland PF. Effect of large-volumeliposuction on sex hormones and glucose and lipid metabolism infemales. Aesth Plast Surg 1995;19:131–5.

30. Burk RW, Guzman-Stein G, Vasconez LO. Lidocaine and epineph-rine levels in tumescent technique liposuction. Plast Reconstr Surg1996;97:1379–84.

31. Courtiss H, Choucair J, Donelan MB. Large volume suction lipec-tomy an analysis of 108 patients. Plast Reconstr Surg 1992;89:1068–79.

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