by Bernard A. Burton, MD

Tumescent liposuction surgery has enjoyed a meteoric rise in popularity since its introduction to the United States in 1982. It is presently the most commonly performed cosmetic procedure in this country. By 1989, an estimated 250,000 cases had been performed that year. The large number of potential candidates, the relative ease of performance, and the high patient satisfaction rate with liposuction were the primary reasons for its popularity.

Despite this, a significant problem still existed with liposuction at that time period, as well documented by Courtiss, Choucair, and Donelan in their article "Large-Volume Suction Lipectomy: An analysis of 109 patients." (1) When the aspirate removed exceeded 1500 ml. of material, the blood loss was tremendous. In their study the average patient had a total of 2755 ml. of material removed. Of this, 964 ml. was blood. Adding the blood into dead space and sponges, drapes and dressings, the average 64 kg. patient within this survey lost 43% of her blood volume. The average patient in this study then received 2.1 units of autologous blood with an average post operative hematocrit of 31.2%, which was 4.4% below the average pre-operative hematocrit, which was 35.6%. Thus, despite 2.1 units of autologous blood, the average post operative hematocrit dropped 4.4%.

Despite the significant blood loss, the authors of the above study felt that liposuction surgery accomplished in this manner with removal of over 1500 ml. of material was safe and effective. They felt they had no serious complications and that the undesired side effects were few and responded to simple measures. They performed a double blind study with use of epinephrine solution and saline and with no injections at all. Their conclusion was that epinephrine in no way caused any decrease in the amount of blood from liposuction. They challenged the advocates of epinephrine injection with liposuction surgery to show their result using a prospective double blind study subjected to statistical analysis.

Dr. Jeffrey Klein, the developer of the tumescent local anesthesia technique, lists seven fallacious assumptions about local anesthesia, many of which still persist today, which convinced most anesthesiologists and surgeons that it was impossible to do moderate volume liposuction by local anesthesia. These include: (2)

Fallacy 1: Lidocaine is only effective as a local anesthetic for a relatively short time; and the higher the concentration, the longer the duration of anesthesia.

Fallacy 2: Peak plasma lidocaine levels occur within 60 to 90 minutes after subcutaneous infiltration.

Fallacy 3: Most of the lidocaine infiltrated for tumescent liposuction is removed along with aspirated fat.

Fallacy 4: Minimally effective concentrations of lidocaine for local anesthesia of skin is 0.4%.

Fallacy 5: Lidocaine dosage restrictions 7 mgs. per kg. with epinephrine should be the same for all forms of local anesthesia including epidural, axillary of intercostal nerve block, and subcutaneous and intradermal infiltration.

Fallacy 7: Rate of absorption is independent of the concentration of the infiltrated lidocaine.

Although it could be discussed in much great detail, Dr. Klein summarized that: (1 ) Lidocaine is effective as a local anesthetic for approximately 24 to 96 hours in most patients and the lower the concentration, the longer the duration of anesthesia; (2) Peak plasma lidocaine levels occur at approximately 12 to 15 hours after subcutaneous infiltration; (3) Most of the lidocaine infiltrated for tumescent liposuction remains in the body with the local infiltrate; (4) The minimally effective concentration of lidocaine for local anesthesia is 0.05%; (5) Lidocaine dosage restrictions for the tumescent technique can be as high as 60 mgs. per kg. with epinephrine; (6) The rate of absorption is dependent on the concentration of infiltrated lidocaine, the higher the infiltrated concentration the higher the rate of absorption.

There are two fundamental premises in the tumescent technique,(4) the use of the Klein formula and the injection of large volumes of the total solution until true tumescent is obtained, that is until the tissue it swollen and firm as wood or rock. Only in this manner can profound and enduring local anesthesia and vasoconstriction be achieved. The Klein solution that is now used generally consists of Xylocaine in either 0.05%, 0.075%, or 0.1%. Epinephrine 0.65 mgs. per liter is added for its hemostatic effect, as well as sodium bicarbonate, 10 mgs. per liter. The sodium bicarbonate significantly eliminates the burning, stinging pain associated with the acidic pH of normal commercially available lidocaine preparations. It has also been shown to massively enhance the antibacterial action of Xylocaine. To this mixture many surgeons using the tumescent technique add 10 mgs. per liter of Triamcinolone to the anesthetic solution. This has been shown to decrease post operative inflammation and soreness in many cases. (3)

In addition to inventing and naming the tumescent technique, Dr. Klein has also defined tumescent liposcution. In Dr. Klein's words, tumescent liposuction is defined as a combination of the tumescent technique for local anesthesia and a specific method for liposuction. In addition to the tumescent technique, tumescent liposuction methods include the use of micro-cannulas inserted through multiple small incisions, non-closure of these incisions with sutures, and the use of specially designed post operative dressings and garments to speed up the drainage of the blood tinged anesthetic solution and to maximize healing rate.

Tumescent liposcution improves the safety of large volume liposuction (i.e. greater than 1500 ml of fat) by virtually eliminating surgical blood loss and by completely eliminating the risk of general anesthesia. In a study involving 112 patients the mean volume of aspirated material was 2657 ml and the meal volume of supernatant fat was 1945 ml. The mean volume of whole blood aspirated by liposuction was 18.5 ml.

Thus for each 1000 ml.of fat removed, 9.7 ml. of whole blood was suctioned. Compared with the previously mentioned study's 35% blood loss within the aspirate, the tumescent technique virtually eliminates surgical blood loss and the risks of transfusion.

With the tumescent technique, patients are discharged ambulatory 30 minutes after the liposuction procedure is completed. Because of residual local anesthesia, most patients experience no significant soreness for the first 10-16 hours after surgery. Tylenol is most frequently recommended for post-operative analgesia because of its anti-inflammatory affects on post-operative trauma. The patients are encouraged to go for a walk on the evening of surgery. There is no post-operative restriction on physical activity; normal exercise may be resumed as soon as it is tolerated. Virtually every patient can return to work at a desk type job 48 hours after liposuction surgery by the tumescent technique.

The tumescent technique permits large and small volume liposuction totally by local anesthesia. The advantages of using tumescent local anesthesia rather than general anesthesia for liposuction surgery include virtual elimination of surgical blood loss, elimination of the dangers of general anesthesia, elimination of heavy IV sedation, elimination of narcotic analgesics, quicker recovery, and improved esthetic results.

References

1.Courtiss, EH, Choucair, RJ and Donelan, MB "Large-Volume Suction Lipectomy: An analysis of 108 patients." Plast. Reconstr. Surg. 89:1068, 1992.

2.Klein, J.A. "Tumescent Technique for Local Anesthesia LA improves safety in large-volume liposuction." Plast. Reconstr. Surg. 91:1085, 1993.

3.Lillis, PJ "Dermatologic clinics" volume 8 number 3 page 439, July 1990.

4.Hernandez-Perez, E.,Henriquez, A., Guiterrez, J. "Clarifying concepts in Modern Liposuction" International Journal of Esthetics, volume 2 number 1 page 65.

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