“Secrets” for performing tumescent liposuction without conventional anesthesia

In tumescent liposuction, a subcutaneous infiltration of large volumes of very dilute lidocaine and epinephrine is used to produce dramatic local vasoconstriction and profound local anesthesia. Because it reduces the amount of surgical blood loss, the tumescent technique has become a worldwide standard of care for liposuction.

Yet many surgeons do not appreciate how easily liposuction can be accomplished completely with local tumescent anesthesia—without general anesthesia or heavy intravenous (IV) sedation. In this article, I will present previously unpublished details of my technique for performing liposuction exclusively with local anesthesia.

The first published description of the tumescent liposuction technique that included the concept of tumescent local anesthesia (TLA) appeared in 1987.1 In it, patients were given intramuscular (IM) meperidine and IM diazepam to supplement the dilute lidocaine and epinephrine. By 1993, when I introduced tumescent liposuction to plastic surgeons,2 virtually all of my liposuctions were performed with TLA—without IM or IV sedation.

Over the ensuing years, the term “tumescent liposuction” has come to denote three distinct forms of liposuction surgery, each defined by the degree of anesthesia used. Tumescent liposuction is now performed using:

• general anesthesia or heavy IV sedation, which must be administered by an anesthesiologist;

• small IM or IV doses of narcotic analgesics, sedatives, or both that require pulse-oximetry but do not require an anesthesiologist; or

• local anesthesia with oral sedatives and anxiolytics that do not require pulse-oximetry.

Surgeons Versus Dermasurgeons

Most liposuction surgeons whose residency training involved the use of general anesthesia prefer to perform liposuction using general anesthesia or heavy IV sedation. These surgeons use TLA merely for surgical hemostasis.

In contrast, dermasurgeons, whose train­ing is usually limited to the use of local anesthesia, tend to perform liposuction en­tire­ly with TLA. This technique is now known as “dermalipo.” The ability to ac­­complish liposuction totally with local anesthesia requires knowledge and skills that have not been published and are therefore not well-known to nondermatologists.

Surgeons who perform liposuction with general anesthesia often use the “superwet” technique, in which the volume of infiltrate is 50% less than in the true tumescent technique preferred by dermasurgeons. Although the local anesthesia and hemostasis of the superwet technique are suboptimal, this degree of hemostasis is usually sufficient to avoid excessive surgical blood loss.

I offer the following descriptions to clarify the terminology before I reveal my “secrets.”

• TLA uses exceptionally large volumes of very dilute lidocaine (usually 1 g/L) and epinephrine (usually 1 mg/L). Com-mercial solutions of lidocaine (1%) with epinephrine (1 part per 100,000) contain 10 g/L of lidocaine and 10 mg/L of epinephrine. The maximum dosage of tumescent lidocaine I recommend is 45–50 mg/kg.

• Tumescent liposuction is a liposuction technique in which TLA is used with or without any additional form of anesthesia.

• Dermalipo is tumescent liposuction performed totally with TLA; no general anesthesia, no IV or IM narcotic analge­sics, and no IV or IM sedatives are used. Typical oral sedatives and anxiolytics include lorazepam (1 mg), clonidine (0.1mg), or both.

Eight “Secrets”

I will now describe the eight most im­portant unpublished “secrets” of dermalipo.

1) Allow time for detumescence. Perhaps the most important secret of dermalipo is that dermasurgeons allow significant time for detumescence to occur after tumescent infiltration. Lipo­suction is more difficult to perform if it is begun too soon after infiltration has been completed.

When liposuction is initiated immediately after infiltration, as is usually the case when general anesthesia is used, the aspirate will contain a relatively large proportion of tumescent fluid. Tumescent liposuction is more effective if the surgeon waits at least 30–60 minutes after infiltrating an area before initiating liposuction of that area. I prefer to wait 60 minutes.

2) Use a gentle infiltration technique. There is a paradox in the use of general anesthesia for tumescent liposuction. Surgeons who do not know how to perform tumescent infiltration without causing excessive pain must rely on general anesthesia to facilitate local anesthesia. Knowing how to avoid painful tumescent infiltration is vital for performing liposuction totally by TLA.

The pain from tumescent in­fil­tration is the result of at least three factors:

• The most important determinant of painful infiltration is the acidity of the tumescent anesthesia solution. An acidic solution causes a burning or stinging sensation upon infiltration. Commercial solutions of lidocaine and epinephrine are intentionally acidic to maximize their shelf lives. 

Adding 10 milliequivalents of sodium bicarbonate to each liter of TLA solution neutralizes its acidity and eliminates the burning–stinging sensation. It should be noted that bicarbonate is required regardless of whether the solvent for the tumescent anesthetic solution is physiologic saline or lactated Ringer’s solution. The lactate in Ringer’s solution is converted to bicarbonate only after it has been absorbed systemically and metabolized in the liver.

• A second factor that determines infiltration pain is the rate of fluid infiltration into localized volumes of subcutaneous fat. As the infiltration rate increases, so do the rate of localized tissue distension and the degree of discomfort.

Using a well-designed infiltration cannula can minimize this effect. A cannula with only a few distal openings causes more pain than a cannula with holes distributed along 50–90% of its distal length. For a given rate of fluid infiltration, a cannula with only a few holes will cause more rapid local tissue distension and, therefore, more pain, than a cannula with openings distributed along most of the cannula (Figure 1).

• A third cause of painful tumescent infiltration is the repeated thrusting of a blunt-tip cannula through subcutaneous fat that has not been anesthetized. An infiltration cannula with holes restricted to 15% of its distal length must be pushed repeatedly back and forth throughout the targeted compartment of fat to distribute the tumescent solution widely.

In contrast, a cannula with holes distributed along most of its length needs to be moved much less frequently. It can be placed in one position and allowed to remain there while local tumescence is achieved, and only then is it moved to another position.

In fact, for many anatomic areas, such as the abdomen, hips, and lateral thighs, one operator can use two of these cannulas simultaneously to accelerate the rate of infiltration. While one cannula is in place and infiltrating, another cannula can be withdrawn and reinserted into a new position. This coordinated infiltration technique can provide relatively rapid infiltration with minimal discomfort (Figure 2).

A little-appreciated aspect of tumescent infiltration is that registered nurses (RNs) can be trained to do the infiltration in a setting outside the operating room. Thus, the surgeon can attend to other patients while an RN is doing the tumescent infiltration and while detumescence is proceeding.

The detailed aspects of this infiltration technique, including the training of RNs to do infiltration, have been taught for many years,3 but they have not been published in the peer-reviewed literature.

3) Tumescent anesthesia is remarkably long-lasting. Surgeons mistakenly believe that TLA has a relatively short effective half-life. With proper technique, TLA provides at least 10–12 hours of effective surgical anesthesia and hemostasis. Proper technique requires a sufficient volume of tumescent local anesthesia and then sufficient time to allow for detumescence.

Many liposuction surgeons who rely on general anesthesia are probably unaware of the maximum duration of TLA because they tend to use less-than-optimal volumes of anesthetic solution. The volume of TLA used by surgeons who perform liposuction under general anesthesia is typically less than half of the volume used by dermasurgeons.

4) Small-diameter cannulas are less pain­ful than larger cannulas. By definition, microcannulas have an outside diameter of less than 3 mm. The largest cannula that I use is 12-gauge, which has a 2.8-mm outside diameter. Sur­geons who use only larger cannulas will find it difficult to perform tumescent liposuction totally with local anesthesia.

5) Use smaller microcannulas initially. The initial use of a smaller (16-gauge or 14-gauge) cannula with subsequent use of a larger (14-gauge or 12-gauge) microcannula significantly reduces the pain associated with larger cannulas. Smaller cannulas create an initial pattern of small tunnels throughout the targeted fat compartment. Subse­quently, less resistance and less pain result from passing a larger microcannula through the adipose tissue.

6) Hold the fat with a special grip. In terms of the volume of fat removed per minute, microcannulas can be surprisingly effective. In this regard, optimal microcannula technique requires that the surgeon’s hand that is not holding the cannula grips the patient’s skin and fat in a certain way.

This grip should be both gentle and efficient. The goal of the grip is to gently immobilize the fat while maximally increasing the interstitial pressure within the targeted fat. The rate of fat aspiration is proportional to the pressure gradient between the interstitial space within the targeted fat and the lumen of the aspiration cannula.

With the finger flexed only at the metacarpophalangeal joints, and with the proximal and distal interphalangeal joints fully extended, the grip can maximally augment the interstitial pressure of the adipose tissue held between the fingers and the thumb. The resulting rate of aspiration can be remarkable.

7) Clonidine and lorazepam are effective oral sedatives. The administration of clonidine (0.1 mg) and lorazepam (1 mg) by mouth provides excellent anxiolysis and sedation without respiratory depression. “Bizarre” is the word most patients use to describe the sensation of having liposuction while fully awake under local anesthesia.

It is to be expected that conscious patients will experience anxiety during liposuction. Clonidine and lorazepam provide sufficient anxiolysis for more than 90% of my patients. Fewer than 10% of the remaining patients require at most 1–2 mg of IV midazolam.

Caution: Do not administer clonidine if the patient’s systolic and diastolic blood-pressure readings are less than 100 mm Hg and 60 mm Hg, respectively, and if the pulse rate is less than 60 beats per minute.

8) Use atropine to prevent vasovagal syncope. Intraoperative syncope and near-syncope are not rare during surgery under local anesthesia. Atropine is very effective for preventing vasovagal syncope. Any patient who has a history of fainting or sudden light-headedness is given 0.3 mg of IV atropine preoperatively as soon as an IV access is established.

It is my hope that this article will help surgeons who want to learn to perform liposuction totally by local anesthesia. PSP

Jeffrey A. Klein, MD, is a dermasurgeon at the Capistrano Surgery Center in San Juan Capistrano, Calif. His professional training includes board certification in internal medicine and dermatology, 2 years as a National Institutes of Health research fellow in clinical pharmacology, and master’s degrees in public health and mathematics. He is a clinical associate professor of dermatology at the University of California, Irvine. He can be reached at (949) 248-1632 or [email protected]

Drainage Following Liposuction
An open-drainage technique minimizes postoperative pain, swelling, and bruising.

References

1. Klein JA. The tumescent technique for liposuction surgery. J Am Acad Cosmetic Surg. 1987;4:263–267.

2. Klein JA. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg. 1993;92:1085–1098.

3. Welcome to Liposuction 101. Available at: http: //[removed]www.liposuction101.com/body[/removed]_nurse_s_ course.html. Accessed December 13, 2005.