Complications of Stem Cell-Assisted Fat Transfer

Rate

Risk factor

Minor surgery (under 60 min)

Age between 41 and 60 years

History of prior major surgery (less than 1 month)

Varicose veins

Inflammatory bowel disease

Swollen legs (current)

Obesity (20 % over BMI normal range)

Oral contraceptive or hormone replacement therapy

Pregnancy or postpartum (under 1 month)

Age between 61 and 74 years

Malignancy present or within the past 6 months

Major surgery (over 60 min)

Laparoscopic surgery (over 60 min)

Confinement to bed (more than 72 h preoperative and postoperative)

Immobilizing cast (less than 1 month)

Previous myocardial infarction

Central venous access (less than 1 month)

Congestive heart failure

Severe sepsis

History of deep venous thrombosis (DVT) or pulmonary embolism (PE)

Family history of thrombosis

Age 75 years or older

Major surgery with additional risk factors (myocardial infarction, congestive heart failure, sepsis, chronic obstructive pulmonary disease)

History of increased clotting time

Stroke (less than 1 month)

Multiple trauma (less than 1 month)

Myeloproliferative disorder

Lupus anticoagulant

Heparin-induced thrombocytopenia

Table 54.2

Risk factor points and prophylactic measures

Total points	Risk level	Prophylactic measures
1	Low	Early ambulation
		Anti-embolism stockings
		Sequential compression device
2	Moderate	Early ambulation
		Anti-embolism stockings
		Sequential compression device
		May use Lovenox 40 mg subcutaneously every day or 30 mg subcutaneously every 12 h
3–4	High	Early ambulation
		Anti-embolism stockings
		Sequential compression device
		Use Lovenox 40 mg subcutaneously every day or 30 mg subcutaneously every 12 h for several days
5 or over	Very high	Early ambulation
		Anti-embolism stockings
		Sequential compression device
		Use Lovenox 40 mg subcutaneously every day or 30 mg subcutaneously every 12 h for several days

Lovenox (enoxaparin) is a low molecular weight heparin and has a low risk of causing bleeding (1–2 % in the perioperative period). Do not use if the patient is allergic to heparin or pork products or has a low platelet count or bleeding tendency

Obese patients should be warned that obesity increases the risk of thromboembolism and should be encouraged to lose weight before elective surgery.

Estrogens, both oral contraceptive and hormonal replacement therapy, are known causes of thromboembolism [74]. Patients on estrogens should be advised about the increased risk of thromboembolism if the estrogens are not stopped at least 4 weeks before surgery and 2 weeks after surgery. If the patient refuses to stop the estrogens, whatever the reason, the surgeon must decide as to whether or not to do the cosmetic procedure. A written statement that the patient refuses to stop estrogens and the reasons for the refusal should be entered into the medical records.

54.20.4 Physicians’ Desk Reference

The Physicians’ Desk Reference (PDR) states that for Ortho Evra (norelgestromin/ethinyl estradiol transdermal system) [75] and Ortho Tri-Cyclen tablets and Ortho-Cyclen tablets (norgestimate/ethinyl estradiol) [76], “an increased risk of thromboembolism and thrombotic disease associated with hormonal contraceptives is well established” and that “if feasible, hormonal contraceptives should be discontinued at least 4 weeks before and 2 weeks after elective surgery of a type associated with an increase in risk of thromboembolism and during and following prolonged immobilization.” Under Premarin [77] (conjugated estrogen tablets) in the PDR, it is stated that with “… estrogen-alone … the risk of VTE (venous thromboembolism), DVT (deep venous thrombosis) and pulmonary embolism (PE), was reported to be increased for women taking conjugated estrogens …” and that “if feasible, estrogens should be discontinued at least 4–6 weeks before surgery of the type associated with an increased risk of thromboembolism, or during periods of prolonged immobilization.”

Rosendaal [74] stated that immobilization is a known factor for causing thromboembolism as well as prolonged travel in airplanes, deficiencies in protein C and proteins, and heritable thrombophilia. Sandler and Martin [78] noted that there was a 10 % incidence of thromboembolism in 2,388 autopsies as a cause of death in the general hospital population. The incidence of thromboembolism following liposuction is about 1 % [79], abdominoplasty is 1.5–2 % [80, 81], and the combination of liposuction and abdominoplasty has an incidence of 2.9 % [82].

All patients having cosmetic surgery over 60 min should have graduated compression stockings (anti-embolism stockings) or intermittent compression device (sequential compressive device) during and after surgery until ambulatory as a routine measure to prevent thromboembolism. The sequential compressive device has fibrolytic effects [83] and reduces the risk of thromboembolism by 60 % [84]. The pneumatic compression device is much better than anti-embolism stockings and probably should supplant its use.

The use of the venous foot pump is for the prevention, treatment, and management of venous disease in the lower extremities [85]. Charalambous et al. [86] concluded that the venous foot pump had questionable efficiency in deep venous thrombosis prophylaxis in the context of a true clinical setting.

The use of low molecular weight heparin (Lovenox, enoxaparin) should be considered in patients with moderate risk for thromboembolism, and it should be used in all patients with high risk for thromboembolism [87–90].

54.21 Conclusions

Patients should be assessed preoperatively for elective cosmetic surgery as to the risks of thromboembolism and preventive measures to be taken. Attention should be paid to the specific risk of the use of estrogens before and after surgery. This includes birth control pills and replacement estrogen therapy. Estrogens should be stopped at least 4 weeks before and 2 weeks after surgery.

Patients having surgery should have some type of compression garments during surgery. Intermittent compression devices are better than anti-embolism stockings. These garments should be used until the patient is ambulatory after surgery. Lovenox should be considered for those patients who have moderate risk for thromboembolism and definitely used in all patients with a high risk of thromboembolism.

54.22 Tumorigenesis

Qian et al. [88] concluded that there was no evidence to indicate the malignant transformation of adipose-derived stem cells (ASCs). Rigotti et al. [91] found that autologous lipoaspirate transplant combines striking regenerative properties with none or marginal effects on the probability of postmastectomy locoregional recurrence of breast cancer.

54.23 Discussion

There are very few serious complications of autologous fat transplantation. Since it is the patient’s own tissue, there is no rejection phenomenon and there should not be a scar capsule surrounding the fat or autoimmune reaction.

The harvesting of large amounts of fat using liposuction techniques is prone to any of the complications of liposuction surgery. If small amounts of fat (under 50 mL) are retrieved, then one may expect the possibility of bruising or infection in the donor site.

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