Abstract
Background:
Liposuction and/or abdominoplasty is one of the most common procedures in plastic surgery. Safety is a primary concern for both patients and surgeons. In this study, we aimed to more accurately estimate perioperative blood loss to prevent and manage early decreases in hemoglobin percentage (HB%).
Methods:
A prospective study was conducted between March 2022 and March 2024, involving 12 patients, both men and women, who underwent liposuction and/or abdominoplasty under general anesthesia. Samples were taken from aspirated fluid, fat, and drain, and a manual hematocrit calculation method was used. The volume of blood in the lipoaspirate was calculated based on the loss in the supernatant, fat, and drain fluids. Blood was replaced according to the study formula. Patients were assessed for postoperative decreases in HB% and stability of vital signs.
Results:
The mean aspirate volume was 7400 mL, with a nontrivial volume of blood loss, and the mean postoperative decrease in HB% was 1.8 g/dL. After correcting for blood loss through transfusion according to the study formula, all patients were vitally stable, with no postural hypotension and normal pulse rates.
Conclusions:
This study introduced a new method for intraoperative hematocrit calculation of blood loss in large-volume liposuction, allowing for accurate estimation of the volume of blood loss that may need to be replaced. This method improves the safety of the procedure, predicts postoperative decreases in HB%, and supports the decision to continue or halt the procedure safely.
Takeaways
Question: What is the amount of blood loss in large-volume liposuction?
Findings: By calculating the hematocrit of the aspirated fluid, fat, and drain fluid, we were able to predict the amount of blood lost during surgery. Blood loss during surgery was significant, and it needs replacement according to the formulated equation.
Meaning: We formulated an equation to replace the blood loss to make liposuction safer.
INTRODUCTION
Lipoabdominoplasty is a body-contouring procedure aimed at functional and aesthetic improvement, addressing deformities caused by excess skin, fat, and musculofascial laxity while leaving a natural-appearing umbilicus.1 Liposuction and/or abdominoplasty are among the most common aesthetic procedures performed, with advances enabling the removal of considerable amounts of adipose tissue in a short period.
In 2012, the American Society for Aesthetic Plastic Surgery reported that liposuction was the second-most common surgical aesthetic procedure worldwide.2 According to the British Association of Aesthetic Plastic Surgeons Audit Results 2019, there was a sharp increase of 9% in the total number of men and women who underwent liposuction in the United Kingdom in 2018 compared with 2017.3
Adipocytes are in direct contact with 1 or more capillaries. When comparing the ratio of capillary surface area to cellular volume in adipocytes with that in striated muscle, the capillary bed of adipose tissue appears richer than that of muscle.4
In humans, blood flow in resting adipose tissue, in the absence of vasodilation, ranges from 2 to 14 mL/min/100 g of tissue. In maximally dilated adipose tissue, blood flow can reach 20 to 50 mL/min/100 g of tissue. With profound vasoconstriction produced by tumescent injection, the blood flow must be less than 1 mL/min/100 g of tissue.5
Although liposuction was originally intended for minor contour irregularities, advances in liposuction surgical technique and a better understanding of its consequences have enabled recontouring of large regions and multiple body areas. These advances have transformed liposuction from the realm of minor surgical procedure to that of major surgery.6
Liposuction is a highly effective surgical intervention designed to treat excess fat deposits. Although initially intended for minor contour adjustments, advancements in technique and a better understanding of its outcomes have enabled surgeons to recontour large areas and multiple body regions. These improvements have elevated liposuction from a minor to a major surgical procedure.6
Adipose tissue is a metabolically active organ that affects energy balance, diabetes risk, and cardiovascular disease risk. Thus, the removal of a significant amount of subcutaneous adipocytes via liposuction could directly impact an individual’s metabolism.7
Decreasing overall subcutaneous fat mass with large-volume liposuction may measurably improve overall health. Studies have indicated that large-volume liposuction may offer health benefits beyond aesthetic improvements. For instance, research has shown significantly reduced fasting plasma insulin levels among obese women following the procedure, suggesting enhanced insulin sensitivity.8 Additionally, a meta-analysis reported notable decreases in fasting plasma insulin, indicating potential metabolic advantages.9 These findings suggest that large-volume liposuction could positively impact metabolic health, potentially reducing the risk of obesity-related complications.10 To minimize blood loss, liposuction techniques have been modified extensively.
Blood constitutes approximately 20%–45% of the lipoaspirate collected during dry liposuction. In the wet technique, blood loss is reduced to 10%–30% of the aspirate without epinephrine and to 15% with epinephrine.
The super-wet technique uses larger volumes of subcutaneous infiltrate in which 1–2 mL of solution is used for each 1 mL of fat to be removed. Using this method, blood loss is generally 2%–4% of the aspirated volume.11
The tumescent technique uses the largest volume (3–4 mL) of infiltration solution for each 1 mL of fat to be removed. Estimated blood loss is approximately 1% of the aspirate.12
Patient safety remains the prime concern; therefore, the main focus in lipoabdominoplasty has always been on ensuring patient safety first, followed by outcomes. Safety is paramount at all stages of the procedure and involves the participation of all members: the surgeon, anesthesiologist, therapist, and nurses.
Most research publications focus on the techniques and complications of liposuction rather than on safety measures, which involve attention to blood loss, metabolic changes, and their possible complications. Another important safety parameter related to blood loss during liposuction is the aspirate volume.
The American Society of Plastic Surgeons defines large-volume liposuction as the removal of 5000 mL or greater of total aspirate during a single procedure.13 Most studies in the literature define large volume as the removal of 3500 mL or more of total aspirate during a single procedure,14 but there is significant variation worldwide in the exact amount of fat aspiration that defines large volume. Given the increasingly large volume of infiltration used in large-volume liposuction, careful attention must be paid to all fluids infused, whether as part of the infiltration solution or as intravenous fluids administered during the procedure.
It is essential that all remaining fluid be accounted for when assessing total output, including the total volume of aspirate, any additional blood loss from concomitant procedures, and urine output. Immediate postoperative care should include an assessment of the need for replacement fluids as needed.
In addition, red blood cell loss must be assessed, and replacement transfusions should be given if needed. Klein12 claimed that vasoconstriction is so complete that there is virtually no blood loss with liposuction.15
Is this regulatory concern about aspiration volume justified? Clinical experience with large-volume wet liposuction suggests nontrivial blood loss.16
Depressed hemoglobin (HB) and hematocrit (HCT) levels 1 week after surgery confirm that blood loss is as real as if it had occurred externally and is not simply an artifact of hemodilution.17 Knowledge of the expected blood loss from liposuction and combination procedures today is useful for surgeons planning combined procedures to lessen postoperative anemia, a common cause of morbidity.
Observational studies indicate that findings from relevant preoperative laboratory tests, such as HB, HCT, and clotting tests, may predict perioperative blood loss and transfusion needs. In this study, a manual method was used to calculate intraoperative and postoperative blood loss in large-volume liposuction instead of automated machine methods due to the technical difficulties of automated sample processing, which carries a high risk of machine damage from suspended fat particles, even when the sample is filtered.
The rationale for developing a new method to calculate blood loss after major surgery stems from the limitations and inaccuracies of current methods. Traditional techniques, such as asking the surgeon to rank the efficacy of hemostasis subjectively,18 estimating blood loss based on the quantity of blood in lipoaspirate on visual inspection,19 monitoring HCT drop postoperatively, or measuring the HCT of aspirated fluid from frozen samples only after surgery, lack precision. Previous studies have overlooked the importance of measuring blood contained within the aspirated fat, which constitutes a significant portion of the aspirate. Additionally, no studies have attempted to estimate third-space loss, despite its recognized significance in surgical outcomes. There is also a lack of formulas that integrate HCT measurements or blood loss calculations to effectively guide fluid and blood replacement.20 This study introduces a structured protocol to help surgeons calculate perioperative blood loss more accurately, specifically focusing on third-space loss. Furthermore, a new formula is proposed to improve fluid and blood replacement calculations, offering flexibility for surgeons to decide whether a correction should prioritize HB levels or the patient’s hemodynamic stability.
The aim of this study was to calculate perioperative blood loss in large-volume liposuction. This method can estimate the amount of blood transfusion that a patient may need through an intraoperative manual method, allowing for measurements at any time during the surgery. This enables the determination of whether it is safe to continue the procedure and harvest additional fat or to stop at the current level. Additionally, the results of the manual intraoperative method calculation can help ascertain whether the preoperatively prepared blood is sufficient or may need more blood preparation for achieving optimal postoperative hemodynamic safety and stability. All this can be accomplished through accurate calculation of blood loss intraoperatively at any time during the surgery, as well as at the end of the procedure.
PATIENTS AND METHODS
In this prospective study between March 2022 and March 2024, a total of 12 patients were selected for liposuction and/or abdominoplasty. Patient ages ranged from 18 to 40 years (mean age, 30 y).
All patients were healthy adults without any chronic disease. The benefits and drawbacks of the procedure were discussed with each patient. The inclusion criteria were as follows:
Patients aged between 18 and 40 years.
Patients with a body mass index of 34 or less.
Both men and women were included.
Patients who had undergone liposuction and/or abdominoplasty.
The exclusion criteria were as follows:
Patients with ischemic heart disease or uncontrolled cardiac arrhythmias.
Patients with poorly controlled diabetes and elevated glycated HB levels.
Patients with vascular disease.
Patients using antiplatelet and anticoagulant drugs.
Patients were admitted to the hospital on the day of surgery. Routine preoperative blood work was performed 2–3 days before surgery, including a complete blood count, bleeding profile, random blood sugar, viral screening, chest x-ray, and abdominal ultrasound.
For all patients, vital sign parameters were recorded, including preoperative, intraoperative, and postoperative blood pressure, pulse rate, pre- and postoperative HB levels (HB%), and preoperative patient HCT. Records also included total infiltration and total aspiration volumes (divided into total fluid and total fat volumes).
In this study, we calculated blood loss in the lipoaspirate (including both fat and fluid) and in the drain on day 0 (which reflects third-space blood loss) by taking samples from them and determining the HCT of fat, fluid, and drain using a manual method performed intraoperatively. We then applied a mathematical equation (Klein equation),21 as described in the following section. We found the amount of blood loss during the liposuction procedure.
Initially, we began calculating aspirated fluid HCT for 10 patients using an automated complete blood count machine, and samples were transferred to the laboratory for HCT calculation. Unfortunately, the results were often unrealistic, yielding false-positive and false-negative readings due to suspended fat and other particles, even after centrifugation. Consequently, these cases were excluded from the study, and the method was changed for the next 12 patients to a manual HCT calculation performed intraoperatively. For all patients, liposuction and/or abdominoplasty surgery was performed under general anesthesia, using the wet technique with standard infiltration.
Infiltration solution was prepared using the standard formula: 10 mL of 2% lidocaine and 1 mL of 1:1000 epinephrine added to 1000 mL of normal saline. The solution was injected into the desired area of aspiration using an infiltration cannula with a diameter of 1.5 mm.
After a delay of 20–30 minutes, power-assisted liposuction was performed using a cannula with a diameter of 3–5 mm and a blunt tip cannula. The procedure may or may not have been combined with abdominoplasty, as previously decided.
The total volume of lipoaspirate (including total fat and fluid volume) was recorded before taking samples. At the end of the procedure, the lipoaspirate fluid was allowed to settle in canisters for 30–60 minutes, allowing the aspirate to separate into 2 layers: a lower layer of fluid and an upper layer of fat before taking samples (Figs. 1–3).
Fig. 1.
Canisters containing the aspirated fat and fluid from a single surgery.
Fig. 3.
Fluid samples collected from the central part of supernatant fluid to avoid sedimentation effect.
Fig. 2.
Fluid and fat samples collected using a liposuction cannula.
We used an aspirating cannula with a size of 4 mm and a syringe to collect samples from the fat, fluid, and drain. We aspirated fluid samples from the bottom of the canister and fat samples from the center of the fat mass in the canister, necessitating the use of a cannula for this purpose. For the collected samples, we measured the aspirated fat HCT, aspirated fluid HCT, and drain HCT using the manual HCT calculation method (Fig. 4).
Fig. 4.
Manual HCT ruler.
Sometimes, this calculation method was used to estimate blood loss during the liposuction procedure, not necessarily at the end, whenever the surgeon had doubts about the volume of blood loss during the procedure based on the bloody appearance of the aspirate fluid or any alterations in vital signs recorded by the anesthesiologist.
Methods
To estimate HCT, a micro-HCT tube (75 mm in length/1.2 mm inner bore) was used, which could hold approximately 0.05 mL of blood. Blood entered the tube by capillary action until it was about three-quarters full. One end of the tube was then sealed with bone wax by placing it vertically at a 90-degree angle into the wax, ensuring a plug length of 4–6 mm to prevent blood leakage. The sealed tubes were placed in a centrifuge and spun at a speed of 5000–10,000 rpm for 5–6 minutes. After centrifugation, the blood separated into 3 distinct layers: plasma at the top, a thin buffy coat layer of white blood cells and platelets in the middle, and packed red blood cells at the bottom. The HCT value, which represents the percentage of red blood cells in the blood, was then determined using an HCT-reading ruler by measuring the packed red cell volume and comparing it against a standard scale (Fig. 5).
Fig. 5.
Manual calculation of HCT.
For fat HCT, we first centrifuged samples in blood tubes to separate fat particles from the sample and then continued with the same steps described earlier (Figs. 6 and 7).
Fig. 6.
Preparation to measure blood content in fat.
Fig. 7.
Drawing blood from fat samples after centrifugation.
Two to 3 readings were obtained for each sample, and the average of the results was taken to minimize any errors. The volume of blood loss was then calculated using the Klein equation.21 (See equation, Supplemental Digital Content 1, which displays the Klein equation, https://links.lww.com/PRSGO/E250.)
Summing the volume of blood loss in both the fluid and fat yields the total blood loss in the aspirated fluid. Intraoperatively, we initiated fluid and blood transfusion simultaneously with liposuction. The amount of fluid and blood administered was determined according to the volume of aspiration using the following equation:
Input (maintenance fluid + infiltration fluid + blood transfusion + 2 L Ringer or normal saline) = output (aspiration + urinary output).
To maintain ±10 mm Hg changes in resting blood pressure, we considered 1 unit of blood for every 3000 mL of aspirated fluid, following the method described by Hetter22 (1 pint of blood for each 3000 mL of aspiration).
At the end of the surgery, we compared the amount of blood loss in the aspirate calculated by the manual HCT method with the amount of blood the patient had already received intraoperatively (following the method of Hetter). (See equation, Supplemental Digital Content 2, which displays the total volume of blood loss that was replaced, https://links.lww.com/PRSGO/E251.) In our study, we found that giving the patient a blood volume equal to the estimated amount calculated by our method, plus 1 additional pint of blood (to cover third-space loss), prevented patients from experiencing anemia-related symptoms.
In comparison to our previous experience with large-volume liposuction, where we used to administer blood according to the volume of aspiration only (Hetter method), patients exhibited a significant drop in HB% levels and a subjective appearance of paleness. Blood transfusion volume was based on the findings, and replacement of blood could occur intraoperatively (day 0) and on day 1, depending on vital signs and the patient’s general condition.
Actually, it is not necessary to administer to the patient the whole amount of blood loss calculated by the manual method; this remains a decision of the surgeon depending on clinical experience and other vital sign parameters and clinical evaluations. This provides insight into the patient’s limits and values, clarifying what to expect next and allowing for the early possibility of managing any complications related to postoperative decrease in HB%. Evaluation of the patient was conducted by measuring HB% within 24 hours and monitoring vital signs, including heart rate and blood pressure, to ensure that the patient received the accurate amount of blood according to the findings and to maintain stable hemodynamic status and correct postural hypotension.
During the operative time and shortly after surgery, intermittent compression devices were used on the lower limbs for all patients as active prophylaxis against deep venous thrombosis. Patients were hospitalized for 24–52 hours, with an average stay of 34 hours.
Admission was for fluid rehydration, blood transfusion (if needed), blood pressure control, pulse monitoring, and assessment of urinary output, along with the administration of antibiotics and analgesia. Injectable third-generation cephalosporin was administered during hospitalization and then switched to oral antibiotics for the first week after surgery.
Patients began ambulation early (4–6 h postoperatively), and drains were removed on the fifth to seventh postoperative day. Regular follow-ups for patients were scheduled at 1, 2, and 3 weeks, and at 2–6 months postoperatively.
RESULTS
This study included 12 patients (7 women and 5 men; 58% and 41.6%, respectively) who underwent liposuction and/or abdominoplasty between 2022 and 2024 under general anesthesia using the wet technique (infiltration-to-aspiration ratio [1:1] as standard infiltration). The age range was 18–40 years, with a mean of 30.8 years. Infiltration fluid ranged from 4000 to 13,000 mL, with a mean of 7000 mL.
The volume of aspirate ranged from 3500 to 10,000 mL, with a mean of 7400 mL, which included a total fluid range of 2000–3700 mL (mean 2670 mL) and a total fat range of 1900–7100 mL (mean 4700 mL). For all patients, preoperative laboratory tests for HB% were routinely conducted, with results ranging from 10.5 to 17 g/dL (mean 12.7 g/dL). On postoperative day 1, HB% for all patients in the study ranged from 8.8 to 14.5 g/dL (mean 10.8 g/dL), with a pre- and postoperative decrease ranging from 0 to 3.9 g/dL and a mean decrease of 1.8 g/dL.
Estimated blood loss by the manual method ranged from 350 to 3000 mL (mean 1100 mL), whereas the actual blood volume given to patients intra- and postoperatively ranged from 450 to 1800 mL (mean 1000 mL) (Tables 1–6). The preoperative patient HCT ranged from 32.7% to 48.4%, with a mean of 39.9%. At the time of aspiration, HCT was 48.4% (mean 39.9%). The aspirated fluid HCT to fat ranged from 3% to 12% (mean 5.8%), fluid HCT ranged from 4% to 15% (mean 6.2%), and drain HCT ranged from 7% to 30% (mean 13.4%) (see Tables 1–6).
Table 1.
Age and Sex Distribution and BMI
| Patient No. | Age, y | Sex | BMI, kg/m2 |
|---|---|---|---|
| 1 | 23 | Female | 30 |
| 2 | 25 | Male | 33.8 |
| 3 | 18 | Male | 31.3 |
| 4 | 33 | Male | 33 |
| 5 | 35 | Female | 31.2 |
| 6 | 40 | Female | 30 |
| 7 | 38 | Female | 31.6 |
| 8 | 24 | Male | 28 |
| 9 | 32 | Female | 31.6 |
| 10 | 39 | Female | 32 |
| 11 | 27 | Male | 34 |
| 12 | 36 | Female | 33 |
BMI, body mass index.
Table 6.
Preoperative Blood Pressure, and Postoperative Blood Pressure and Pulse Rate
| Patient No. | Preoperative Blood Pressure, mm Hg | Postoperative Blood Pressure, mm Hg | Postoperative Pulse Rate, bpm |
|---|---|---|---|
| 1 | 120/80 | 125/85 | 90 |
| 2 | 130/90 | 130/80 | 83 |
| 3 | 110/70 | 110/ 60 | 89 |
| 4 | 120/80 | 110/70 | 110 |
| 5 | 130/80 | 100/60 | 80 |
| 6 | 120/80 | 110/65 | 88 |
| 7 | 120/80 | 110/70 | 102 |
| 8 | 130/ 60 | 120/80 | 87 |
| 9 | 130/80 | 130/70 | 98 |
| 10 | 120/65 | 110/ 60 | 90 |
| 11 | 130/90 | 120/70 | 85 |
| 12 | 110/70 | 100/70 | 92 |
Table 3.
Patient, Fluid, Fat, and Drain HCT%
| Patient No. | Patient HCT% | Fat HCT% | Fluid HCT% | Drain HCT% |
|---|---|---|---|---|
| 1 | 40 | 3 | 4 | 12 |
| 2 | 39.1 | 4 | 4 | 12 |
| 3 | 40 | 8 | 9 | 30 |
| 4 | 42 | 12 | 15 | 20 |
| 5 | 32.7 | 4 | 5 | 10 |
| 6 | 34.8 | 8 | 5 | 19 |
| 7 | 39.7 | 8 | 10 | 10 |
| 8 | 43 | 3 | 4 | 10 |
| 9 | 40.6 | 3 | 4 | 7 |
| 10 | 40 | 4 | 4 | 10 |
| 11 | 48.4 | 6 | 5 | 10 |
| 12 | 38.4 | 5 | 5 | 11 |
Table 5.
Drain Volume and Blood Loss in Drain on Day 0 (in mL)
| Patient No. | Day 0 Drain, mL | Blood Loss in Day 0 Drain, mL | Day 0, Day 1 Drain + Day 2 Drain, mL |
|---|---|---|---|
| 1 | 400 | 120 | 1000 |
| 2 | 500 | 155 | 1000 |
| 3 | 400 | 300 | 1100 |
| 4 | 500 | 238 | 1350 |
| 5 | 400 | 122 | 800 |
| 6 | 350 | 191 | 850 |
| 7 | 400 | 100 | 1100 |
| 8 | 450 | 104 | 1100 |
| 9 | 500 | 86 | 900 |
| 10 | 500 | 125 | 950 |
| 11 | 450 | 93 | 940 |
| 12 | 400 | 115 | 950 |
For all patients, vital sign parameters were recorded, including preoperative blood pressure (mean 120/80 mm Hg) and postoperative blood pressure (mean 150/70 mm Hg), with no instances of postural hypotension. The mean pulse rate was 91 bpm.
DISCUSSION
This study proposed a method and new protocol for calculating and managing fluid and blood replacement in patients undergoing large-volume liposuction. The resolution of the Federal Medical Council of Brazil determines that the volume of aspiration should not exceed 7% of body weight, and the total liposuction area should not exceed 40% of the body surface area.23 Gilliland et al24 and Gilliland and Coates25 defined large volume as an aspiration of 5000 mL, mega-volume liposuction as an aspiration of 8000 mL, and giganto-volume as an aspiration of 12,000 mL per single session.
The safety committee of the American Society of Plastic Surgeons, in 2009, published the “Evidence-based Patient Safety Advisory: Liposuction” by Haeck et al,26 providing evidence on patient safety before, during, and after the procedure, revealing that there was no scientific data available to support a specific maximum volume at which liposuction is no longer safe, especially when performed in an inpatient setting.16,27,28 Commons and Halperin29 conducted a study performing large-volume liposuction with total aspirate volumes as high as 16,000 mL.
Choudry et al19 published a study in which the mean volume of total aspirate was 8 L (5–11.7 L). Cubillos30 reported an average volume of aspiration of 13.77 L (women, 13.9 L; men, 15.3 L), placing most procedures performed in this study into the categories of mega-volume and giganto-volume liposuction.
Dhami and Agarwal31 reported aspiration volumes ranging from 5000 to 22,000 mL (mean 13,500 mL). Some authors have even documented aspiration of 25 L per case.32,33
In large-volume liposuction procedures, blood loss is a fundamental concern regarding total lipoaspirate volume. Increased aspirated volume and longer surgery duration have not been reported to necessarily increase the complication rate.32
The key to successful and safe outcomes in large-volume liposuction patients is proper preoperative preparation and adequate fluid replacement. There are several controversies surrounding the estimation of blood loss in large-volume liposuction, primarily divided into 2 schools of thought.
First are the plastic surgeons who report very low levels of blood loss when using super-wet or tumescent techniques, assuming that blood loss in lipoaspirate fluid is trivial.17 Klein12 claimed that vasoconstriction is so complete that there is virtually no blood loss with liposuction.
Tsai et al34 reported similar results, with blood loss in the range of 1%. The second school of thought posits that clinical experience with large-volume super-wet liposuction suggests nontrivial blood loss.16,24,35
Although minimal visible blood loss may occur during liposuction, extravascular third-space blood loss is substantial.36–38 If that loss were truly trivial, there would be no basis for state medical boards and the American Society of Plastic Surgeons imposing limits on aspirated volumes.
Swanson17 concluded that the estimated blood loss is higher than previously estimated. His study showed that an estimated blood loss of 217 mL was the standard amount, with an additional 187 mL for each liter of aspirate. He also noted that if abdominoplasty was performed in the same procedure, an additional 290 mL of blood loss should be considered.17 Rosique et al39 found that the average volume of liposuction was approximately 4.1 L, with expected blood loss volumes ranging between 965 mL for liposuction alone and 1255 mL when associated with abdominoplasty.
According to Pitman and Holzer,40 blood loss is significant and not trivial; patients’ HCT levels checked before and after surgery presented about 20% blood loss on average for an average of 1800 mL. Subjective methods in studies have also determined blood loss and the manner in which replacement occurs during and immediately postoperatively, such as the study by Sagiv et al,18 which asked surgeons to rank the efficacy of hemostasis as excellent (1), good (2), moderate (3), or poor (4).
Choudry et al19 estimated blood loss based on the quantity of blood in lipoaspirate through visual inspection or by blood loss in the surgical field if associated with abdominoplasty. Many studies have shown that substantial third-space blood loss may account for about 98% of blood loss.36,41
Third-space loss cannot be exactly estimated and may be higher than expected; in some studies, such as the theory proposed by Courtiss et al,42 it was revealed to be as high as or equal to the amount of blood loss during aspiration. On the other hand, it is difficult to accept that such a small amount of blood loss occurs during the liposuction procedure, with the well-documented drops in HB levels after liposuction.
Swanson17 demonstrated that depressed HB and HCT levels after surgery confirm that blood loss is as real as if it had occurred externally and is not simply an artifact of hemodilution. The study by Swanson43 found that the average reduction in HB level was 1.9 g/dL on the first postoperative day and 2.0 g/dL 1 week after the procedure.
Campos44 estimated blood loss by calculating the difference in pre- and postoperative HB levels, with decreases ranging between 2 and 6 g/dL, with an average of 3.01 g/dL. He accepted the reduction in HB% without the use of blood transfusion, despite patients developing clinical symptoms postoperatively. Criteria for blood transfusion indicated that transfusion should occur only if HB levels were between 6 and 7 g/dL; instead, he used an iron supplement in the immediate postoperative period to minimize undesirable clinical symptoms and return HB to normal levels.44
Ali Eed45 found that the average drop in HB postoperatively was approximately 3 g/dL. According to the study by de Jesus Carrascal-Navarro et al,46 which reviewed the impact of tranexamic acid on blood loss by measuring the decrease in HB% preoperatively and 12–20 hours postoperatively, the average difference reported was −2.8, and transfusion criteria include an HB level less than 8 g/dL postoperatively or between 8 and 9 g/dL in symptomatic patients.
Karmo et al47 found that the mean blood loss during aspiration was 250 mL for a mean total aspirate volume of 3 L, whereas the mean decrease in HB on the seventh postoperative day was as high as 4.3 g/dL, indicating that more blood may have been lost than was recorded. In our study of large-volume liposuction of the flank, abdomen, and back, alone or in combination with abdominoplasty, the drop in postoperative HB was found to be between 0 and 3.9 g/dL, with a mean HB% drop of 1.8 g/dL, which is lower than the results reported in other studies.
Our findings are also similar to those of Albin and de Campo,48 which show no real correlation between aspirated volume and blood loss, as bleeding from third-space loss is not accurately recorded. The study by Cantarelli49 also found that the total volume of aspirated fat and HB levels were not correlated, with a mean decrease in HB% of 3 g/dL 6 hours postoperatively.
We measured blood loss in the drain intraoperatively, with volumes ranging from 86 to 300 mL (mean 145 mL), whereas the amount of fluid in the drains postoperatively was nearly the same (350–500 mL, mean 440 mL). The significant range of difference in drain blood loss reflects considerable patient variability and necessitates evaluation on a patient-by-patient basis.
In all cases, no blood transfusion complications occurred, including allergic reactions, anaphylactic reactions, fever, or reported infections. Similarly, no major complications occurred in these patients, such as deep venous thrombosis, fat embolism, or flap necrosis.
In our study, we found that administering a blood volume equal to the estimated amount calculated by our method, plus 1 additional pint of blood (to cover third-space loss), prevented patients from experiencing anemia-related symptoms. Our study shows a mean postoperative HB of 10.7 g/dL. In comparison to our previous experience with large-volume liposuction, where we administered blood according to the volume of aspiration only (Hetter22 method), patients exhibited a significant drop in HB% levels and a subjective appearance of paleness. Some studies have attempted to avoid blood transfusion and find alternative ways to deal with blood loss, accepting decreases in HB levels to 6–7 g/dL, and considering blood transfusion only when patients develop anemia-related symptoms, even if this delays the recovery period.
The study by Mandel50 used autologous blood donation, calculating that blood transfusion was necessary for the removal of each 1500 mL of aspiration, whereas aspiration amounts greater than 2500 mL necessitated 2 units of blood transfusion. In this study, the author used autologous blood donation harvested 1 or 2 weeks before surgery, with a minimum of 7 days between the last unit harvested and the day of surgery, and initiated iron supplement (ferrous sulfate 300 mg 3 times daily) 5 days before blood donation, continuing for at least 2 weeks after surgery. The study also mentions that in the nontransfused patient group, significant drops in HB were observed despite pre- and postoperative iron supplementation.50
The study by Hetter22 used the same methodology as Mandel,50 except that donation occurred 3 days before operation. Rosique et al39 found that postoperative erythropoietin administration was not effective in preventing blood transfusion for hemodynamic instability in patients undergoing major liposuction.
The manual method of blood loss calculation can be performed at any time during the surgery, not just at the end. This allows the surgeon to assess blood loss whenever there are doubts based on the bloody color of aspirate fluid or any alterations in vital signs recorded by the anesthesiologist. This awareness can guide the decision to continue the procedure safely or to stop and prepare for additional blood if necessary.
One of the most important parameters in our study was patient vital signs, alertness, and postural hypotension. On day 0 and day 1 postoperatively, all patients exhibited stable vital parameters, with blood pressure and pulse rates within normal levels (mean blood pressure, 115/70 mm Hg; mean pulse rate, 92 bpm), good urine output, and drain removal between days 4 and 6, with a mean of 5 days.
This study challenged the traditional focus on aspirate volume as the primary determinant of patient safety in liposuction. Instead, we prioritized blood loss, especially third-space loss, as the crucial factor influencing hemodynamic stability and HB levels. Our findings, supported by drain measurements and analysis of aspirate volume versus blood loss (Tables 2 and 4), demonstrate the following:
Table 2.
Infiltration and Aspiration (Fluid and Fat) Volume (in mL)
| Patient No. | Total Infiltration Fluid, mL | Total Aspiration, mL | Total Aspirated Fat, mL | Total Aspirated Fluid, mL |
|---|---|---|---|---|
| 1 | 8000 | 10,800 | 7100 | 3700 |
| 2 | 6000 | 7500 | 5200 | 2300 |
| 3 | 6000 | 8000 | 4500 | 3500 |
| 4 | 11,000 | 10,000 | 7300 | 2700 |
| 5 | 6000 | 7500 | 4700 | 2800 |
| 6 | 6500 | 7500 | 5200 | 2300 |
| 7 | 5000 | 4500 | 2500 | 2000 |
| 8 | 3500 | 4000 | 1900 | 2100 |
| 9 | 4000 | 3500 | 1500 | 2000 |
| 10 | 13,000 | 10,000 | 6500 | 3500 |
| 11 | 9000 | 9000 | 6000 | 3000 |
| 12 | 6500 | 6200 | 4000 | 2200 |
Table 4.
Estimated and Real Blood Given to Patient and the HB% Change
| Patient No. | Estimated Blood Loss, mL | Real Blood Given, mL | Different, mL | HB Preoperatively, g/dL | HB Postoperatively, g/dL | Decrease in HB, g/dL |
|---|---|---|---|---|---|---|
| 1 | 900 | 1350 | 450 | 12.5 | 12 | 0.5 |
| 2 | 770 | 1350 | 580 | 12.5 | 12.5 | 0 |
| 3 | 1690 | 1800 | 110 | 13.2 | 9.5 | 3.7 |
| 4 | 3000 | 1800 | −1200 | 14.9 | 11 | 3.9 |
| 5 | 1000 | 1350 | 350 | 10.6 | 8.6 | 2 |
| 6 | 1500 | 900 | −600 | 11.3 | 9 | 2.3 |
| 7 | 1000 | 450 | −550 | 11.9 | 9.3 | 2.6 |
| 8 | 350 | 450 | 100 | 14 | 12 | 2 |
| 9 | 400 | 450 | 50 | 10.5 | 10 | 0.5 |
| 10 | 1000 | 900 | −100 | 12 | 10 | 2 |
| 11 | 800 | 900 | 100 | 17 | 14.5 | 2.5 |
| 12 | 810 | 900 | 90 | 12.3 | 10.9 | 1.4 |
No correlation between aspirate volume and blood loss: Cases with lower aspirate volumes (4.5 and 4 L) had blood losses of 1000 and 350 mL, respectively; conversely, higher volume aspirates (8 and 10 L) had blood losses of 1690 and 3000 mL, respectively.
The significance of third-space loss: Drain volumes, although limited (350–500 mL), revealed substantial blood loss (86–300 mL), highlighting the importance of third-space loss.
Therefore, relying solely on aspirate volume for safety assessment is insufficient. Accurate measurement of blood loss in each patient is essential for maintaining hemodynamic stability and guiding appropriate fluid and blood replacement. Furthermore, accurate blood loss assessment is critical for surgical decision-making:
Determining whether to proceed or terminate surgery: Excessive blood loss may necessitate terminating the procedure to ensure patient safety.
Planning combined procedures: Accurate blood loss evaluation is crucial when combining liposuction with other procedures (eg, abdominoplasty) to avoid exceeding safe limits.
Our study emphasizes the need for the following:
Shifting focus from aspirate volume to blood loss as the critical safety parameter in liposuction.
Implementing a standardized protocol for blood loss measurement, including third-space loss assessment.
Using this information to guide individualized fluid and blood replacement strategies, ensuring patient safety and optimal outcomes.
Incorporating blood loss assessment into surgical decision-making, particularly when planning extensive or combined procedures.
By adopting this approach, surgeons can move beyond volume-based assessments and provide more personalized and effective care for liposuction patients, enhancing both safety and surgical outcomes.
Our formula for blood transfusion may guide surgeons in determining the amount of blood that may be needed during and after surgery. Although it is flexible, allowing surgeons to choose whether to administer the total amount of blood lost or only what makes the patient hemodynamically stable, the decision ultimately depends on the surgeon’s clinical experience, vital sign parameters, and other clinical evaluations. This calculation method can serve as a scientific objective approach for calculating blood loss during liposuction, allowing for comparisons among various devices, techniques, and instruments, and demonstrating which ones can lower blood loss, ultimately improving overall practice and advancing it toward new horizons.
Limitations of the Study
The small sample size hinders the conclusion of the full patterns of relation among various parameters, especially the volume of aspirate and the volume of blood loss. However, this does not preclude the general assumption of the lack of relation and the importance of patient-to-patient evaluation.
CONCLUSIONS
This study introduces a new method for intraoperative HCT calculation of blood loss in large-volume liposuction, allowing for accurate estimation of the exact volume of blood loss that may need to be replaced. This method can guide surgeons in determining whether it is safe to continue the procedure and harvest additional fat or to stop at the current level. Additionally, the results of the manual intraoperative method calculation can help ascertain whether the preoperatively prepared blood is enough or whether more blood preparation is needed, ultimately achieving optimal prediction of postoperative decrease in HB% for achieving the best postoperative hemodynamic safety and stability.
RECOMMENDATIONS
Blood loss and replacement in large-volume liposuction are critical to patient safety and must be carefully considered in each procedure.
Manual HCT calculation is simple, predictive, and effective and can be performed intraoperatively to support surgeons’ decisions related to aspiration.
Third-space blood loss is an important measure in decreasing postoperative HB%. It needs further evaluation and more studies for a more accurate estimation of blood loss.
Large-volume liposuction is a safe procedure; however, additional studies related to metabolic changes in the body and responses to large-volume liposuction are recommended.
DISCLOSURES
The authors have no financial interest to declare in relation to the content of this article. This study was self-funded.
ETHICAL APPROVAL
The study was approved by the ethical committee of the Arabian Board of Health Specialties.
Supplementary Material
Footnotes
Published online 26 September 2025.
Disclosure statements are at the end of this article, following the correspondence information.
Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.
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