Troubling reports of adverse outcomes after liposuction prompted a census survey of aesthetic plastic surgeons. All 1200 actively practicing North American board-certified ASAPS members were polled by facsimile, then mail, regarding deaths after liposuction. Patient initials together with case summaries precluded data replication yet assured patient anonymity and preserved surgeon privacy. Incomplete returns or ambiguous findings were authenticated, where feasible, by direct follow-up. Total number of lipoplasties performed by plastic surgeons was interpolated from the ASPRS procedure database for the survey time frame of 1994 to mid-1998. Lacking reliable annual case volume estimates, deaths from lipoplasties performed by non-ABPS surgeons were excluded from the actual mortality rate computation but were included in cause-of-death ranking statistics.
Responding aesthetic plastic surgeons (917 of 1200) reported 95 uniquely authenticated fatalities in 496,245 lipoplasties. In this census survey, the mortality rate computed to 1 in 5224, or 19.1 per 100,000. A virtually identical 20.3 per 100,000 mortality rate was obtained in a 1997 random survey commissioned by the parent society. Pulmonary thromboembolism remains as the major killer (23.4 ± 2.6 percent); lacking consistent medical examiners' toxicology data, the putative role of high-dose lidocaine cardiotoxicity could not be ascertained. Where so stated, many deaths occurred during the first night after discharge home; prudence suggests vigilant observation for residual "hangover" from sedative/anesthetic drugs after lengthy procedures.
Taken together, these two independent surveys peg the late 1990s mortality rate from liposuction at about 20 per 100,000, or 1 in every 5000 procedures. Set beside the 16.4 per 100,000 fatality rates of U.S. motor vehicle accidents, liposuction is not an altogether benign procedure. We do not have comparable mortality data for lipoplasties performed by non-ABPS-certified physicians.
Lipoplasty, body contouring by removing unsightly subcutaneous fat, has come far since its bloody beginnings in the early 1970s, when intraoperative autologous transfusion was more the rule than the exception. The introduction of wetting-distending and softening fat cells with saline solution-lessened surgical trauma by permitting suction aspiration through small diameter percutaneous cannulas. Gradual incorporation of local anesthetic (lidocaine) and/or vasoconstrictor (epinephrine) into wetting solution, the "superwet" technique, further refined liposuction into an even less daunting procedure.1,2 Subsequent modifications such as "tumescent anesthesia" have transformed modern liposuction into a virtually bloodless and largely painless office procedure for removing several liters of ungainly subcutaneous fat.
Seductive simplicity, reputed safety, convenient office setting, not to mention direct payment, have drawn nonplastic surgeons to liposuction as a welcome second income generator-at times with little more physician training than a weekend hands-on seminar. Little surprise then that, in the competition for patients, liposuction has become trivialized and commercialized into a routine ambulatory office procedure, holding out to the American public gratifying cosmetic benefits at minimal risk. As liposuction is performed largely outside the hospital-distant from peer review, incident reporting and medical examiner scrutiny-the extent of complications from the 293,000 (estimated) lipoplasties performed in 19963,4 may well be underreported.
Adverse national media publicity about liposuction-disfiguring outcomes, dubious ethics, and even deaths-has raised the profession's concern about the safety of the procedure.5 Even so, the few highly visible cases6 may represent just the tip of an iceberg, for the authors have personal knowledge of several-score deaths after liposuction. The recent worrisome rise in deaths and near-deaths associated with liposuction1 spurred us to determine whether these represent tragic but random incidents or a troubling national trend.
As we shall show, liposuction is not trivial surgery, is not always benign, and is not quite as safe as intimated in glossy office brochures.