Tumescent Liposuction

Liposuction and lipotransfer are invaluable techniques in the practice of cosmetic surgery. These techniques have evolved with the help of many surgeons and physicians practicing a variety of specialties. However, cosmetic surgeons are indebted to the contributions of a handful of practitioners who have made seminal contributions to this area.

A brief history of liposuction

Liposuction did not have an auspicious start. In the late nineteen-twenties, a French surgeon by the name of Dujarrier used a uterine curette to remove localized adiposity (fat) from the knees and ankles of a ballerina in the late twenties. Tragically, one of her legs had to be amputated as a result of complications of the procedures.

In the late 60's and early seventies, Pitanguy developed methods of resecting blocks of skin and adipose to reduce the abdomen, thighs, and buttocks. However, these surgeries were associated with extensive and disfiguring scars.

In the mid seventies, a father and son team of Italian surgeons, the Fishers, began experimenting with a motor driven suction cannula for the removal of unwanted subcutaneous fat. The instrument had an internal cutting device that severed fat that was then suctioned into the cannula. The severed fat was then aspirated by vacuum into a collection container. This was the so-called "cellulosuctionatome" This technique was published in 1976 in the Bulletin of the International Academy of Cosmetic Surgery. The technique was not ideal and complications included prolonged drainage, capsule formation, and skin necrosis.

The Fishers demonstrated their new technique in the Paris operating room of Pierre Fournier. The operation enjoyed notoriety and was covered with a photo spread in the Paris Match. The Fishers claim to be the inventors of modern liposuction and feel that Yves Gerard Illouz, a Paris based gynecologist, who also claims to have invented modern liposuction, developed his technique after seeing the article in the Paris Match. For his part, Illouz claims to have innovated a tunneling technique for suction lipoplasty. The Fishers dispute this. What is not in dispute is the importance of Illouz's contributions in developing a blunt tip liposuction cannula that utilized suction aspiration. His basic cannula design is still in use today. He also introduced the use of a "wetting solution." His original solution was 100 cc of normal saline, 20 cc of distilled water, and 100 I.U. of hyaluronidase.

American dermatologists were introduced to these methods at the 1977 International Academy of Cosmetic Surgery meeting in Paris. However, it was not until 1982 that liposuction was more broadly introduced to American plastic, cosmetic, and dermatologic surgeons. That year a 14 member panel of from the American Society of Plastic and Reconstructive Surgeons and a group of seven cosmetic surgeons, primarily dermatologists, the nucleus of the American Society of Liposuction Surgery, separately visited Illouz and Fournier in Paris to learn their techniques for liposuction with Illouz's blunt tip suction cannula. This was the origin for what has been referred to as the “two standards of care” for liposuction in the United States.

Illouz advocated a hypotonic wetting solution, which was thought to break up fat cells. Fournier favored a "dry" technique. Both techniques were performed under general anesthesia. These techniques were associated with significant blood loss when the aspiration volume exceeded 1.5 liters. Fournier found that the motion of the cannula with the vacuum of the aspirator at the aperture of the cannula provided adequate force to severe pieces of fat without the need for the cutting action found in the cellulosuctionatome designed by the Fishers. Fournier favored the dry technique because it saved time over Illouz's wet technique and there was no tissue distortion caused by the infiltrated wetting solution. Fournier himself noted that too rapid a procedure with his method could lead to a fall in blood pressure and shock necessitating a blood transfusion. Typically, he left a drain in place for 24-48 hours. An elastoplast dressing was placed at the end of the procedure.

Influential American dermatologists adopted and adapted Illouz's method to perform liposuction of lipomas, chin and limited body areas. These procedures were primarily performed under general anesthesia or deep IV sedation. Dilute lidocaine solutions were introduced in 1983 and 1984 to facilitate liposuction under narcotics and IV diazepam. Early in 1985, Jeff Klein began his initial work that lead to the development of tumescent liposuction. The first article describing this method of liposuction was published in the American Journal of Cosmetic Surgery in 1987. This method will be discussed at length in the next section.

In contrast, American plastic surgeons adopted liposuction under general anesthesia using either a dry or wet method. Dry implied that surgery was performed without infiltration of any fluids into the tissues. Unfortunately, blood loss associated with the dry technique tended to be significant with an 11 to 18% drop in hematocrit following a 2-liter liposuction. Men seemed to be prone to a higher blood loss than women. Courtiss and Gragan (Clinics in Plastic Surgery, 1984;11:457-463) reported that as a rule of thumb, one third of the aspriated material was blood. To avoid hematomas, drains were often placed. Pitman and Teimourian (Plastic and Reconstructive Surgery, 1985;76:65-69) reported a survey of 1573 liposuctions performed by 107 plastic surgeons. Twenty-five (2%) of these patient required post-operative blood transfusion. In the general plastic surgery literature, liposuction trauma was equated to a crush injury (Hetter GP, Clinics in Plastic Surgery; 1989; 16:245-248). Hetter introduced the use of wetting solutions containing epinephrine (1:400,000). However even with an epinephrine containing wetting solution, blood transfusion after a 1500 ml aspirate was still advocated. Where as Illouz's solution was referred to as the wet technique, Hetter's solution was wet with epinephrine. An additional term used in relation to wetting solutions is the superwet technique where approximately 1 ml of dilute epinephrine containing solution is infiltrated for each milliliter of planned aspirate.

Tumescent Anesthesia

Liposuction continues to be performed predominantly by two very different standards. At one end of the spectrum is pure low volume (2 liters or less of total aspirate) tumescent technique with surgery performed following infiltration of tumescent anesthesia and the patient is only medicated by a mild anxiolytic. This is unquestionably the safest form of liposuction. At the other extreme, is large volume liposuction (greater than 5 liters of total aspirate) performed with minimal or significant tissue wetting and general anesthesia. This technique is associated with the highest risk of morbidity and mortality. Alternatives to tumescent liposuction are described so that the reader understanding how they differ from pure tumescent technique and not as an endorsement for less safe technique.

Until the mid eighties, liposuction was performed either under general or epidural anesthesia or deep IV sedation supplemented with small volume local anesthesia. At the time large diameter cannuals were the norm. These varied in size from 6-10 mm with blunt tips and various suction port designs. Passing cannulas of these sizes through subcutaneous tissues resulted in significant tissue trauma, skin irregularities, blood loss, and prolonged recovery. It was the dermatologists who innovated a less traumatic method for performing liposuction.

In 1985, Jeffrey Klein evolved an early form of tumescent liposuction involving diluted local anesthetics, IM diazepam and meperidine analgesia. The initial case involved a nurse on his staff infiltrated with a liter of solution containing 2,000mg of lidocaine and 2 mg of epinephrine. This produced a solution of 0.2% lidocaine with 1:250,000 epinephrine. This produced profound anesthesia and significant hemostasis. A total of 550 ml of aspirate was removed consisting of 450 ml of blood free fat and 100 cc of lightly blood tinged anesthetic solution.

Klein later reported that he exceeded the then accepted maximum dose of infiltrated lidocaine (7mg/kg) under the incorrect assumption that much of the infiltrated lidocaine would be removed with the fat aspiration. Subsequently, Klein analyzed sequential lidocaine levels following infiltration of large doses of dilute solution to establish a maximal safe dose of lidocaine. Initial studies on blood levels of lidocaine following liposuction with a dilute solution of lidocaine increased linearly with the peak blood level occurring 9-15 hours after surgery. It is thought that a safe maximal dose of lidocaine is one that keeps the peak plasma lidocaine concentration below 5 micrograms/ml. By performing a linear regression analysis on peak plasma lidocaine levels, a maximal safe dose of lidocaine with tumescent anesthesia was estimated by Klein to be 35 mg/kg. More recent studies suggest that higher dose of lidocaine given as tumescent anesthesia is safe. Ostad, Kageyama, and Moy have reported that 55 mg/kg is safe. These dosages of lidocaine are safe from the standpoint of not causing significant complications. However, a patient receiving 35-55 mg/kg of lidocaine is likely to experience lidocaine "intoxication." Symptoms will include tingling in the fingers and periorally, metal confusion and dysphoria.

Klein also experimented with buffering the tumescent solution with sodium bicarbonate to neutralize the acid pH of lidocaine. Epinephrine in a dose as low as 0.65 mg/liter was found to provide adequate vasoconstriction for many hours. Triamcinolone (10 mg/L) was also tried in the tumescent solution but later abandoned because it was found not to provide any benefit. More fibrous body regions required higher concentrations of lidocaine for adequate anesthesia. Areas that are being done for a second time benefit from higher concentration of lidocaine.

In addition to tumescent anesthesia, several other techniques complete the method of tumescent liposuction. The dilute anesthetic is introduced into the area to be aspirated using a motor driven peristaltic pump. The rate of infusion is controlled by the operated and generally limited by patient tolerance. The pump makes it possible to infuse the local anesthetic initially through a 25-gauge needle. The aspiration itself is performed using microcannulas with internal diameters of 1.2 to 2.7 mm. There are various configurations of tip openings. The actual technique will be described in the next section. Once the liposuction is complete, absorbent pads are placed next to the patient's skin and lycra compression garments are used to provide gentle compression.

Body liposuction

Generally, liposuction can be performed in any adequately equipped procedure suite, ambulatory surgery center, or hospital setting. Low volume liposuction such as neck liposuction and small regional liposuctions under tumescent anesthesia can be safely performed in properly equipped procedure suite, accredited or not. However, many states have specific requirements for performing general anesthesia or IV sedation. Liposuction performed under this type of anesthesia is generally performed in an accredited office based operating room, accredited surgery center or hospital. It is generally well accepted that liposuctions above 4-5 liters of total aspirate are associated with an increased morbidity and mortality and must be performed in an accredited center where sufficient personnel and resources are available to manage complication. Generally, we restrict office-based liposuction procedures performed under tumescent anesthesia to ASA class 1 individuals and discharge to a responsible adult is mandated by the State of California.

Preoperatively, patients have a history and physical exam. A great deal of emphasis is placed on screening patients for the use of over the counter medications, and herbal products. It is our practice to ask patients to stop all aspirin and nonsteroidal anti-inflammatories, and herbal products three weeks prior to surgery. In addition, consumption of red wine is curtailed during this period. We generally have the patient sign their consent at the preoperative visit so they have an opportunity to have any remaining questions answered well before surgery.

Routine preoperative testing should be dictated by the medical history of the individual patient. As a routine, a baseline hematocrit, metabolic panel, screening for Hepatitis C, and HIV may be performed. The practices of universal precautions make viral testing less pressing. Blood loss is not a factor in tumescent liposuction so it is not necessary to prepare the patient for a blood transfusion. Like all cosmetic procedures, before and after pictures are a must. It is helpful to have an area where full-length photography can be performed. A full-length mirror facilitates the consultation.

On the day of surgery, the patient changes into disposable underwear and a gown. Generally, women can wear a sports bra to help maintain decorum. We perform skin marking in a photo lane. The patient removes the gown and photos are then made. Using a skin marker, the areas to be addressed by liposuction are carefully marked. With experience, we have found that it is possible to estimate the volume to be extracted within about 10%. This is helpful in performing the actual procedure. Once the patient is marked, they are given diazepam 5 mg p.o. although many doctors prefer lorazepam due to its shorter half-life. An IV is started and the patient may also receive a small dose of Versed IM. For the torso and extremities, Hebiclens is used as a skin prep. For the neck and face, an iodine prep is used to avoid the risk of keratitis.

The local anesthetic is infiltrated at the rate of 25 to 100 cc/minute depending on the patient comfort level. The infiltration is facilitated using a peristaltic pump that draws the tumescent anesthetic from an IV bag of normal saline into which the lidocaine, sodium bicarbonate, and epinephrine has been added in the appropriate quantities. The specialized tube that passes through the peristaltic pump has a leur lock at its distal end. At this site, a 25-gauge spinal needle is attached. This needle is used for the initial infiltration of the tumescent solution. Once the tissues are minimal numbed, a 20-gauge spinal needle is the used to infiltrate the tissues until they are firm. Just prior to performing the fat aspiration, the adequacy of the anesthesia is checked with an 18-gauge needle, which is just slightly smaller than the cannulas that are actually used for aspirating fat.

The target fat spaces are infiltrated with a volume of anesthetic solution that is 1.5 to 2.5 times the total estimated aspirate. This renders the fat space densely numb and minimizes the blood space. Aspiration of the fat is then carried out using various sized microcannulas that are inserted using 2 mm stab incisions. The liposuction cannula is connected by disposable suction tubing, which in turn connects to a high-powered aspiration machine. At the completion of the procedure, the incisions are left open to drain, the wounds are dressed with antibiotic ointment and absorbent pads are then placed over the treated areas. The patient is then dressed with compression garments that are then worn for 5-6 days with the absorbent pads being changed on a daily basis. Patients typically meet discharge criteria within minutes of completing the procedure.

In performing tumescent liposuction, it is critical to be aware of the maximal dosage of lidocaine that will be administered. This effectively limits what can be safely extracted and therefore places limits the number of areas can undergo liposuction in a given operative session. For a 60 kg adult, if a total dosage of lidocaine was to be limited to 35 mg/kg, 2100 mg of lidocaine could be given. If there were 800 mg of lidocaine in 1 liter of normal saline, a total volume of 2.6 liters would be available for infiltration. This would be enough tumescent solution to extract 1 to 1.5 liters of supernatant fat. For the same 60 kg adult, if a total dosage of lidocaine was to be limited to 50 mg/kg, a total of 3000 mg of lidocaine could be give. Again if there is 800 mg of lidocaine in 1 liter of normal saline, a total volume of 3.75 liters could be infiltrated. This could feasibly be used to extract 2 liters of supernatant fat. It is critical to document the total quantity of tumescent fluid infused and the total dosage of lidocaine given during the course of the liposuction.

Complications from responsibly performed liposuction are rare. The usual and expected side effects include soreness, pain, fatigue, edema, ecchymosis, and minor contour irregularities. Less commonly there may be persistent dysesthesia (i.e. abnormal sensation on the skin), pruritis (itchiness), asymmetry, seroma, drug reactions. Major contour irregularities are very rare. Rare complications include skin necrosis which can be seen with ultrasonic liposuction, or using the aspiration port of the lipocannula as a rasp on the subdermal plexus. This aggressive technique virtually always damages the skin integrity and does nothing to enhance the liposuciton. Serious nerve damage, seromas, and infection are also very rare. Life threatening problems are extraordinarily rare and could include thromboembolism, fat embolism, intraperitoneal and intrathoracic perforation. Fatalities are very rare. The fatality rate for pure tumescent liposuction appears to be less than 1 in 500,000 cases. This stands in stark contrast to the death rate associated with liposuction performed under general anesthesia by board certified general plastic surgeons. A survey of board certified plastic surgeons revealed a death rate of 1 in 5000 liposuction cases. Plastic surgeons like to perform liposuction under general anesthesia because it is very fast compared to the same procedure performed under tumescent liposuction. However, these numbers clearly show that no one should have liposuction under general anesthesia.