New York, NY (February 9, 2004) — The American Society for Aesthetic Plastic
Surgery (ASAPS) presents the following guidelines developed to assist physicians
in clinical decision-making. The guidelines were developed in conjunction
with plastic surgery organizations participating in a Lipoplasty Task Force.
This document is not intended to establish a standard of care, but to spell
out recommendations that can help to ensure the highest level of patient
satisfaction. As such, it is subject to periodic review, updating and revision.

Background

Nearly two decades of clinical experience in the United States and Canada have demonstrated that lipoplasty (liposuction) is safe and produces effective therapeutic outcomes when performed by a trained surgeon in accordance with accepted standards of surgical practice. Lipoplasty is generally recommended for patients of normal weight who have localized fat deposits that are resistant to diet or exercise or have areas of fat deposits that are disproportionate. Lipoplasty to remove a greater volume of fat is sometimes performed on patients who exceed their ideal body weight but who otherwise are appropriate candidates for fat suctioning. Lipoplasty is not a surgical treatment for obesity.

Lipoplasty is the single most requested aesthetic (cosmetic) surgical procedure
in the United States, with 372,831 procedures performed in 2002 (statistics
from the American Society for Aesthetic Plastic Surgery). From its introduction
in the U.S. in 1982 until the early 1990s, lipoplasty had among the lowest
complication rates of all aesthetic surgical procedures. However, as new techniques
were introduced, and physicians found they could remove larger amounts of fat,
the incidence of major complications, including fatal outcomes, rose.

Data on Lipoplasty Safety
While data prior to 1994 showed a very low rate of lipoplasty complications,
surveys examining procedures performed between mid-1994 and mid-1998 suggested
mortality rates as high as 1 in 5,000. Educational efforts conducted to alert
plastic surgeons to lipoplasty risk factors have produced a dramatic effect
on the procedure's safety record since 1998, according to results of a major
survey published in Aesthetic Surgery Journal (ASJ) , ASAPS' peer-reviewed
journal. Survey respondents reported a total of 94,159 lipoplasty procedures
performed from September 1998 through August 2000. Based on the results, the
estimated risk of death from lipoplasty performed as an isolated procedure
(not in combination with any other surgeries) was found to be 1 per 47,415
procedures. For more information on this research, see: Major Survey Reports
Turnaround in Lipoplasty Safety (May, 2001).

The educational efforts that led to these significant improvements in lipoplasty
safety focused on data from earlier studies showing that the following factors
contribute to increased risk:

1) administration of excessive amounts of fluid and local anesthesia, 2) excessive
fat removal, 3) performance of multiple unrelated procedures in the same surgical
session and 4) poor patient selection/patient health. All these factors can
be avoided.

Training

It is ASAPS' position that since lipoplasty is a surgical procedure, physicians
performing lipoplasty should be trained as surgeons. Such training is absolutely
necessary to ensure the highest standard of care, to ensure patient safety,
and to minimize potential complications. Physicians who perform liposuction
without having had the customary surgical training, including fluid management,
may not be prepared to prevent or handle unexpected complications. Yet no current
state laws prohibit any physician, including those without appropriate specialty
training, from performing lipoplasty and other cosmetic surgery. Physicians
may use titles such as “plastic surgeon,” “cosmetic surgeon,” or similar names
without actually being certified in the specialty of plastic surgery or even
being formally trained in surgery.

Medical education is comprised of three components: undergraduate medical
education (“medical school”), graduate medical education (“residency training”),
which prepares a physician to practice a specialty, and continuing medical
education (CME), which continues throughout a physician's professional life.
Following medical school, doctors performing lipoplasty should either have
completed a general surgery residency program approved by the Accreditation
Council on Graduate Medical Education (ACGME); a plastic surgery integrated
residency program approved by the ACGME; or a surgical specialty residency
program approved by the ACGME in a specialty recognized by the American Board
of Medical Specialties (ABMS). The physician should also have specific training
in lipoplasty. The American College of Surgeons has stated that qualification
of a surgeon as a specialist implies that practice will be conducted within
specialty limits.

The American Board of Plastic Surgery (ABPS) is recognized by the ABMS to
certify doctors in the specialty of plastic surgery. Plastic surgeons certified
by the ABPS have successfully completed a minimum of 5 years of surgical training
including approved residency training specifically in plastic surgery .
All ASAPS members are ABPS certified.

Hospital Privileges and Outpatient Surgical Facilities

Credentials to perform specific surgical procedures within an acute care hospital
setting are a form of physician accreditation. Hospital surgical privileges
to perform specific procedures are granted only after a hospital review committee
evaluates a surgeon's training and competency. This involves peer review and
monitoring of results and complications. Permission to perform new surgical
techniques may be granted upon documentation of additional training.

ASAPS maintains that cosmetic surgical procedures and treatments may be safely
performed in facilities outside of a hospital. Published data regarding complications
associated with a variety of plastic surgery procedures performed in accredited office-based
facilities showed a complication rate of less that ½ of 1 percent (0.47%)
in over 400,000 operations. This number compares favorably with the rate of
complications for similar procedures performed in hospitals.

It is recommended that out-of-hospital facilities, including office-based
surgical facilities, meet strict quality standards, peer review, and external
quality assurance assessment, such as accreditation by the American Association
for Accreditation of Ambulatory Surgery Facilities (AAAASF) or equivalent agency.
All facilities should be adequately staffed and equipped to monitor patients
and deal with potential complications. All facilities should have appropriate
resuscitation equipment, and be required to report morbidity and mortality
data.

Beginning in July 2002, ASAPS required its membership of ABPS-certified plastic
surgeons to perform operations requiring anesthesia (other than local anesthesia
and/or minimal oral or intramuscular tranquilization) only in accredited surgical
facilities.

It is ASAPS' position that the performance of cosmetic surgical procedures
and treatments in any venue requires ABMS board certification in a surgical specialty
and hospital privileges, based on documented training and peer review. The
hospital privileges should be for the aesthetic procedure to be performed whether
the procedure is performed in the hospital or an approved outpatient setting.
Issues of patient safety must be addressed when planning procedures, wherever
they may be performed. The common denominator is prudent surgical judgment
with respect to patient evaluation, risk disclosure, amount/length of surgery
planned, and postoperative care.

Patient Selection

Lipoplasty is well suited for women and men who are within 30 percent of
their ideal body weight and have adequate skin elasticity to ensure good cosmetic
results, but who have localized fat deposits that are resistant to diet or
exercise. It is not an indicated treatment for obesity. Appropriate patient
selection should include candid discussion of any pre-existing medical conditions,
and any current medications, including dietary or herbal supplements. An appropriate
physical examination, including laboratory work based on the patient's general
health and age, is necessary; the American Society of Anesthesiologists (ASA)
has set general standards for preoperative testing. Special attention should
be given to possible drug interactions.

Lipoplasty should be considered a major surgical (not a “lunch time”) procedure,
with the need for accurate disclosure of risk and potential complications to
patients electing to undergo this procedure using any of the currently performed
techniques.

Preinjection of Fluids (Wetting Solutions)

Lipoplasty is based on the principle of the aspiration of subcutaneous fat
through an inserted cannula that is attached to a vacuum pump or syringe. A “superwet” technique
has become the one most surgeons choose, wherein a small volume dilute solution
of local anesthetic and a vasoconstrictor is infiltrated into the surgical
areas prior to beginning the procedure. Significant medical complications are
rare, although the risk of significant complications and fatalities has been
shown to increase with larger volume infusion and removal.

Preinjection of fluids containing local anesthetics and vasoconstrictors in
a volume equal to the expected volume of fat to be removed has enabled lower
morbidity and has decreased blood loss, swelling, bruising, and discomfort.
Prior to the use of preinjection techniques, most fat removals of greater than
1500-2000 cc required blood transfusions to replace intraoperative blood loss.

Fluid Management

It is recommended that patients undergoing moderate (greater than 2000 cc)
and large volume lipoplasty (greater than 5000 cc) have extended postoperative
monitoring of vital signs and urine output. Only experienced surgeons should
consider volumes of aspirate above 5000 cc, and they should monitor all intake
and output fluids. Patients undergoing removal of significant amounts of fat
may require additional intravenous fluid replacement and monitoring by an overnight
stay in a hospital or an accredited extended outpatient care facility.

Fluid management is a fundamental part of surgery. A physician possessing
core knowledge in surgery is best equipped to manage fluid and electrolyte
balance in patients undergoing lipoplasty. Physicians who perform lipoplasty
without having received thorough surgical training may be unable to prevent,
identify, or treat potential complications should they occur.

Anesthesia

Some patients and their doctors prefer local anesthesia, or epidural anesthesia
(with or without conscious sedation), while others prefer general anesthesia.
A board-certified/board-eligible anesthesiologist or a certified registered
nurse anesthetist should administer general anesthesia.

Techniques
Over time, several techniques have evolved as modifications of standard lipoplasty
(Suction-Assisted Lipoplasty [SAL]), including Power-Assisted Lipoplasty (PAL),
and Ultrasound-Assisted Lipoplasty (UAL) and using terms such as superwet or tumescent to
refer to the ratios of injected fluid to aspirate (including fat) removed during
lipoplasty. It is ASAPS' position that the technique used is subject to the
determination of the operating surgeon and is of less consequence than the
training of the surgeon and the accreditation of the facilities.

General Recommendations

Lipoplasty is a serious surgical procedure that has been demonstrated to be safe and effective when safety guidelines are in place. Among the risks are those associated with all surgery, such as wound infection, scarring, bleeding, deep vein thrombosis (DVT), and pulmonary embolism.

General recommendations include:

• Physicians performing lipoplasty in any facility should be required to
  have surgical privileges/ accreditation to perform this procedure in an acute
  care hospital.

• Physicians should be qualified for examination or certified by an ABMS-recognized surgical board.

• Facilities outside of acute care hospitals should possess a peer-review system, should report morbidity and mortality data, and should be accredited by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), or an equivalent agency such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or the Accreditation Association for Ambulatory Health Care (AAAHC).

• Appropriate patient monitoring and resuscitation equipment and medication
  are essential, regardless of who is performing the procedure and how much
  fat is being removed.

• Precise records of fluid intake and output should be maintained during
  the perioperative period.

• Communications to patients seeking cosmetic surgery should properly represent
  the risks of these procedures, so that fully informed consent can be given.

• In addition to the standard discharge criteria, patients and their caregivers
  should be provided with written information on the symptoms of drug reactions
  and fluid overload and with instructions on how to respond if these symptoms
  occur.

• Duration of care should include close monitoring 2-4 hours post operative
  and physician follow-up in 24 to 48 hours, with outcome reviews scheduled
  at intervals from a week to a year.

This document was updated from November 20, 2000.