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Journal of Clinical Anesthesia (2006) 18, 379 – 387

Special article

Liposuction: contemporary issues for the anesthesiologist
Ian J. Kucera MD, PharmD (Medical Director)e, Thomas J. Lambert BA (Research Associate)b, Jeffrey A. Klein MD (Associate Clinical Professor)c, Randy G. Watkins MD (Attending Staff)a, Jason M. Hoover MD (Assistant Professor)b, Alan D. Kaye MD, PhD (Professor and Chairman)d,*

Cooks Children’s Hospital, Ft. Worth, TX, USA Department of Anesthesiology, Louisiana State University, School of Medicine, New Orleans, LA 70112, USA c Department of Dermatology, University of California, Irvine, CA, USA d Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA e Pain Management Clinic Sormont-Vail HealthCare, Anesthesia Associates of Topeka, KS, USA

Received 13 September 2004; accepted 13 July 2005

Liposuction; Lidocaine; Tumescent liposuction; Anesthesia; Epinephrine

Abstract Liposuction is a procedure that has emerged over the last 30 years as a method to remove subcutaneous fat for cosmetic purposes. Numerous liposuction techniques have been developed and the purpose of this article is to examine one such technique: btumescent liposuction.Q Tumescent liposuction involves using large volumes of dilute local anesthetic and epinephrine to facilitate anesthesia and decrease blood loss. Questions remain about the appropriate dose of local anesthetic, the use of general anesthesia in liposuction, and the setting in which the chosen liposuction method is used. This article also attempts to shed light on this burgeoning field. D 2006 Elsevier Inc. All rights reserved.

1. Introduction
Liposuction has become one of the most commonly performed cosmetic surgeries in the United States [1]. Clinical anesthesiologists have variable involvement in the care of patients undergoing liposuction depending on the practice setting of the surgeon performing the procedure. With a significant number of cases being performed, it is
* Corresponding reviewer. Department of Pharmacology, Louisiana State University School of Medicine, T6M5, New Orleans, LA 70112, USA. Tel.: +1 504 568 2315; fax: +1 504 568 2317. E-mail address: (A.D. Kaye). 0952-8180/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2005.07.003

not surprising that recent reports have brought to light potential complications arising from some of these procedures [2,3]. Often, these are based in offices of plastic surgeons or dermatologists. The clinical anesthesiologist should be well-acquainted with issues related to obesity, fluid management, and concomitant disease states of this population of challenging patients.

2. History of liposuction
The first modern attempts at liposuction were pioneered in Italy in the 1970s [4]. Arpad Fischer and Giorgio Fischer

380 [4] were cosmetic surgeons who used a blunt hollow cannula attached to suction. Their technique also involved multiple incision sites with a crisscross pattern of suctioning; this technique tended to decrease the amount of scar tissue and complications arising from the procedure [5]. Before this employment, others had tried various methods of removing undesirable fat deposits, including en bloc resection and subcutaneous use of curettes. Both of these methods resulted in significant complications, namely, hematoma and seroma formation. A French physician named Illouz became interested in the Fischers’ work and augmented the procedures. The result came to be known as the bwet technique.Q This involved injecting saline and hyaluronidase into the fatty tissue before suctioning. The theory behind this modification was to decrease bleeding and facilitate removal of fatty tissue [6]. Liposuction was introduced into the United States in the early 1980s. Immediate disagreement arose as to which medical specialties were qualified to perform the procedure. For example, plastic surgery initially claimed that their specialty was the one qualified to perform the developing technique. However, training courses soon became available for physicians from a variety of specialties [6]. Dermatologists were also involved in the development of liposuction. They were trained to use local anesthetic techniques because of the emergence of the technique as an office-based procedure. This led to the development of the tumescent technique of liposuction by Klein [7] in the mid-1980s, making it possible for the opening of numerous outpatient liposuction clinics. The change was based on three primary advantages to this method: (1) decreased blood loss as a result of epinephrine in the tumescent solution, (2) improved pain control because of large volumes of lidocaine infused, thus negating the need for general anesthesia or significant sedation, and (3) removal of large volumes of fat because of decreased fluid shifts secondary to infused epinephrine. Before the advent of tumescent technique in the early 1980s, liposuction was only done with general anesthesia and it was complicated by frequent major blood loss. In fact, surgical blood loss during liposuction was the limiting factor in terms of patient safety. During the procedure, the surgeon was forced to aspirate very expediently, only stopping when more blood than fat was in the aspirate. A study published in 1992 described 108 cases of nontumescent blarge-volumeQ liposuction in which 25% of the aspirate was blood, necessitating blood transfusions for all 108 patients [8]. Shortly thereafter, another article described tumescent liposuction (TL) totally by local anesthesia in 112 patients with a blood loss of less than 20 mL [9]. Thus, the development of the tumescent technique provided liposuction totally by local anesthesia, with minimal surgical blood loss. Unfortunately, many surgeons and anesthesiologists, due to their limited training in tumescent anesthesia, still believe that modern general anesthesia is the safest route for

I.J. Kucera et al. liposuction. Consequently, many do not make the effort to learn the new technique that allows liposuction totally by local anesthesia. Although modern general anesthesia is considered safe when administered by a competent anesthesiologist, it may expose the patient to unnecessary risk given that a safer alternative is available. Now that many surgeries can be performed totally by local anesthesia, it might be considered that general anesthesia is often abused in the world of cosmetic surgery. To fully illustrate the benefit of TL over the alternative, some of the controversies regarding the safety of this method must be addressed.

3. Definition of TL
There are a number of controversies surrounding TL. The most fundamental disagreements concern the very definition of TL. The term btumescent techniqueQ is applied to liposuction that is performed by infiltrating large volumes of very dilute lidocaine (see Lidocaine considerations below) and epinephrine into subcutaneous tissue to achieve widespread local anesthesia. If the infiltration is performed correctly, the tissue will assume a swollen, firm, or btumescentQ consistency. Once detumescence takes place after approximately 30 minutes, the area is sufficiently anesthetized and liposuction may proceed. The definition of btumescent liposuction,Q on the other hand, can assume one of two forms [10]. The first and original form of TL uses the tumescent technique as described above. The original form also assumes that supplemental intravenous (IV) fluids are unnecessary and that the amount of aspirate is less than 3 to 4 L per surgery. Because this procedure is performed completely during local anesthesia, there is minimal risk of respiratory depression. Therefore, one of the key advantages of this form is the avoidance of dangers involved with significant sedation and general anesthesia. The second form of TL, also known as the super wet technique, involves the use of general anesthesia or heavy IV sedation, thus carrying with it a more significant risk of respiratory depression. It also uses infiltrative fluid volumes of dilute epinephrine, with or without lidocaine, that may achieve less than tumescent results in the subcutaneous tissue. In addition, the protocol allows for very large (N4 L) of aspirate to be removed in one session. Because of the potential for large fluid shifts secondary to the volume of tissue removed, this type of liposuction is considered to be significantly more dangerous than the original form of TL. A final caution is that use of supplemental IV fluids is not an absolute contraindication during this procedure, and they may be used by some surgeons. Owing to the risk of pulmonary edema, significant volumes of IV fluids should be used with extreme caution in any TL procedure. Newer procedures such as power liposuction, ultrasound-assisted liposuction, and high-pressure infusion, have been developed in recent years that involve modifications of

Liposuction: contemporary issues for the anesthesiologist the original form of TL to enhance results. Power liposuction uses a reciprocating cannula to remove fat [11], whereas ultrasound-assisted liposuction is a modified procedure that uses ultrasonic energy delivery to enhance traditional liposuction [12]. High-pressure infusion has been investigated with pressures near 300 mmHg in the subcutaneous tissues during injection of the solution, but this method has not been shown to affect systemic lidocaine absorption [13]. However, these procedures are beyond the scope of this paper.

381 tized path. In the ideal procedure, infiltration continues uninterrupted because the cannulas are repositioned through the adits in an alternating fashion, allowing the target area to become tumescent more quickly and with less pain. This stage is completed when most of the target tissue has become sufficiently tumescent. Because a few areas may still require touch-up infiltration due to incomplete tumescence, the fourth and final stage is directed at providing supplemental infiltration with a smaller cannula. After infiltration of tumescent solution, a 16-gauge cannula is used to remove the unwanted adipose tissue. Subsequently, a larger 14-gauge cannula is used to remove larger volumes of tissue. Occasionally, a 12- or 11-gauge cannula may be used with significant cases. The technique of starting with small cannulas followed by slightly larger cannulas for subcutaneous fat removal is the secret to being able to do 100% of liposuction cases totally by local anesthesia.

4. The tumescent technique
As mentioned above, TL involves infiltration of fatty tissue with large volumes of dilute lidocaine and epinephrine. Many different techniques have been established to achieve this result. However, the optimal technique is one that minimizes discomfort, volume of anesthetic solution required, and the time required to complete the infiltration. The method that approaches this ideal more than any other is called the Monty technique for tumescent infiltration, which can be divided into a four-stage infiltration process. When using the true tumescent technique, preprocedure sedation depends on the extent of liposuction. Procedures involving only one body area require no preoperative sedation. In more extensive procedures involving more than one body site, or lasting longer than one hour, it is suggested that 2.5 to 5.0 mg of intramuscular midazolam be administered [14]. Alternatively, patients may receive one mg lorazepam per mouth (PO) and 0.1 mg clonidine PO before tumescent infiltration, but this decision is left to the discretion of the practitioner. The first stage involves making a series of round openings, called adits, that will allow both subcutaneous access for the surgical cannulas and permit efficient drainage of residual tumescent anesthetic solution after surgery. After injecting small 0.2- to 0.5-mL blebs of local anesthetic solution into the dermis and superficial subcutaneous fat, a one-mm skin punch biopsy is used to make an adit within each bleb. Alternatively, a 1.5- or 2.0-mm punch biopsy may be used if the adits are to provide access for the surgical cannulas. In the second stage, a small amount of tumescent anesthetic is injected with an 18- or 20-gauge spinal needle along a few paths in a slightly deeper plane of subcutaneous tissue. These paths will provide painless insertion of the larger-diameter 16- or 14-gauge infiltrators required for the third stage of infiltration. The third stage, also known as the tumescent infiltration phase, represents the most critical step in the patient causing only minimal discomfort during the liposuction session. This procedure is accomplished using a combination of newly developed Monty infiltration cannulas (US Patent Pending), 2X-Infiltration Tubing, and a Klein infiltration pump. Two cannulas are positioned into the subcutaneous fat through adits and advanced along a previously anesthe-

5. Lidocaine considerations
Much controversy has arisen because of the large doses of lidocaine administered during liposuction, as there have been reports of deaths of unclear origin associated with liposuction. Historically, the maximum dose of lidocaine was considered to be 7 mg/kg according to the package insert of Xylocaine (brand name of lidocaine). However, there appear to be only minimal data regarding how this level was ascertained. With the advent of tumescent anesthesia, the maximum dose of lidocaine, when delivered in a tumescent solution, may be considerably larger. Several factors are responsible for this increased dosage, including epinephrine-induced vasoconstriction, dilution of lidocaine resulting in slowed absorption, decreased vascularity of adipose tissue, and the lipophilicity of lidocaine with potential sequestration in adipose tissue [10]. The literature indicates that the maximum dosage of lidocaine in tumescent anesthesia may be as high as 55 mg/kg [14-16]. However, these studies were small and used multiple dosages, with no controls. The commercial concentration of lidocaine is 10 g/L (1%), with epinephrine 10 mg/L (1:100 000). In contrast, a btypicalQ solution of tumescent local anesthesia is diluted by a factor of 10 to 20 and thus contains lidocaine at 0.5 (0.05%) to one g/L (0.1%) and epinephrine 0.5 (1:2 000 000) to one mg/L (1:1 000 000). It is clear that the maximum dose of lidocaine that can safely be administered is greater than the 7 mg/kg listed in the package insert; however, the dose that should be used as an upper limit has not been appropriately studied [17,18]. The initial recommendation of 7 mg/kg was based on minimal data as published in the original package insert of lidocaine. There are no exact bofficial concentrationsQ of lidocaine or epinephrine used when performing TL. The concentrations of lidocaine added to normal saline (NS)

Table 1 Drugs that inhibit 3A4 and cytochrome P450 system

I.J. Kucera et al. There are multiple classes of agents that act to inhibit the action of the 1A2 and 3A4 families. These drug interactions can be clinically significant, particularly when the sizeable doses of lidocaine used with the tumescent technique are infused. A large group of drugs have been identified that inhibit either the 3A4 or 1A2 families of P450. Significant interactions have been reported with sertraline, nifedipine, and clarithromycin; however, all of the drugs listed in Table 1 have the potential to affect the metabolism of lidocaine [23,24]. Prilocaine and articaine are two other drugs that are being used in tumescent anesthetic mixtures in Europe, and they may be superior to lidocaine for TL. One study with prilocaine found that the patients involved did not experience elevated plasma levels of prilocaine or methemoglobinemia when liposuction involving less than 2 L using a 0.05% prilocaine solution was performed [25]. Regarding articaine, one investigation revealed that at the dose of articaine used, there were no cardiac side effects or symptoms of central nervous system (CNS) intoxication. Therefore, the authors concluded that articaine may provide a safe analgesic alternative for TL [26]. As with any medication, each drug has its own side effect profile and choice of medication used should be individualized to the patient.

Alfentanil Aprazolam Amitryptiline Amlodipine Atorvastatin Carbamazepine Cyclosporine Diltiazem Erythromycin Fentanyl Losartan Lovastatin Metronidazole Pravastatin Sildenafil Simvastatin Tetracycline Valproic acid Verapamil

vary according to the site of liposuction. In most vascular or sensitive areas, such as the breasts and abdomen, it has been suggested that up to 1500 mg of lidocaine be added to each liter of NS. This concentration is decreased to as low as 500 mg/L in less sensitive areas such as the thighs [19]. Likewise, the concentration of epinephrine added to the solution varies. In more sensitive or vascular tissue, up to one mg of epinephrine may be used and decreased to 0.5 mg/L in less vascular tissue. Regarding pharmacokinetics, lidocaine is cleared from the body by deethylation in the liver by the cytochrome P450 system [20]. The P450 system is a large group of proteins embedded in the lipid bilayer of the endoplasmic reticulum. This group of proteins is responsible for most phase I oxidative reactions in the liver. As research continues into the mechanisms of hepatic metabolism, more isoenzyme families of P450 are characterized. Lidocaine metabolism results from reactions with the 1A2 and 3A4 isoenzyme groups of the cytochrome P450 families [21]. A major active metabolite of lidocaine, monoethylglycinexlidide, is similar in activity to the parent compound and can cause seizures at elevated levels. Approximately 10% of lidocaine is excreted unchanged in the urine. Because lidocaine is primarily eliminated by a system in the liver that is susceptible to inhibition, potential interactions exist. In a study investigating the effect of erythromycin on plasma lidocaine levels, it was found that peak lidocaine levels were essentially unchanged. However, peak plasma levels of the active metabolite monoethylglycinexlidide were 40% higher in the presence of erythromycin [22], suggesting that solely measuring plasma lidocaine levels may not be sufficient to determine safe doses of lidocaine. Regardless, current practice is still confident that peak plasma concentration is a much better predictor than metabolite concentration.

6. Safety of TL
In any surgical procedure, including liposuction, the risk of complications is a multivariate function of surgical factors (eg, trauma, number of procedures performed at one time, and the choice of technique), patient-specific factors (see Preoperative assessment below), and pharmacological/anesthetic factors (see Lidocaine considerations above). With regard to TL, safety is primarily dependent upon which of the two TL techniques is used and the number of unrelated cosmetic procedures performed at one time. The latter factor represents a possible financial conflict of interest in the world of cosmetic surgery (see Liposuction safety controversies below). Over the past several years, the media has focused attention on safety issues involved with liposuction. There have been several published reports regarding patients who died after undergoing liposuction, and two independent surveys from the late 1990s had pegged the mortality rate from liposuction at approximately 20 per 100 000, or one in every 5000 procedures [27,28]. Virtually every reported death related to liposuction has been associated with surgeons who traditionally do liposuction exclusively by general anesthesia. However, to date, there have been no published reports of any deaths associated with TL when performed totally by local anesthesia. Perhaps the most important reason for the concern over liposuction safety is the lack of convincing evidence suggesting the benefits of TL performed totally by local

Liposuction: contemporary issues for the anesthesiologist anesthesia. One study that has been used to verify the safety of tumescent anesthesia used a survey mailed out to practicing physicians. Only 3.7% responded to the questionnaire and yet these data have been widely quoted as proving that the tumescent technique is devoid of adverse outcomes [29]. In addition to poor outcome data, the tumescent technique uses doses of lidocaine up to 8 times the widely recognized maximum dose. There are several studies supporting this increased dose, but unfortunately, there are still no controlled studies investigating this increase in dose [14,30,31]. Another study including 60 patients used subjective interviews to assess lidocaine toxicity and assessed objective criteria by evaluating plasma lidocaine levels in 10 patients [27]. An additional study investigating the rate of delivery of tumescent anesthetic found that delivery rates of anesthetic solution did not influence lidocaine plasma levels. However, it also indicated that doses of tumescent lidocaine also did not correlate with plasma lidocaine levels within the first two hours of the procedure [15]. With the problems regarding poor outcomes, data are not specific to liposuction. There are minimal morbidity/ mortality data on most procedures performed on an outpatient basis [32]. Given this information, three concerns have arisen regarding the safety of the tumescent technique: (1) doses used in this procedure are up to 8 times the previously recommended maximum doses; (2) no welldesigned studies have been conducted examining the pharmacokinetic and pharmacodynamic effects of tumescent lidocaine/epinephrine; and (3) no well-designed studies have been conducted investigating the outcome of officebased tumescent anesthesia. These concerns do not necessarily imply that tumescent anesthesia is not a safe procedure. They identify that more data from well-designed clinical studies are needed regarding the outcomes of patients undergoing liposuction totally by local anesthesia. Results of such clinical studies might convince additional clinical anesthesiologists and surgeons to do more surgeries totally by local anesthesia and thus expose fewer patients to the unnecessary use of general anesthesia. However, The Accreditation Association for Ambulatory Health Care Institute for Quality Improvement found in a study of 688 cases that TL is a safe procedure with a low rate of complications and high patient satisfaction [33].

383 liposuction with general anesthesia. Furthermore, they believe that liposuction represents significant risk to the patient and, consequently, should only be performed by a board-certified plastic surgeon in a hospital setting. On the other hand, many dermatologists have already embraced the tumescent technique as a very safe office-based procedure, and believe that all liposuction surgeons should use the technique. As one might imagine, the controversy hinges on the two definitions of TL. To be more specific, the divergent perspectives are a direct consequence of the respective group’s preferences for one or the other type of anesthesia.

8. Liposuction with general anesthesia
The most dangerous aspects of liposuction may be associated with excess surgical trauma perhaps facilitated by general anesthesia. Owing to the risk associated with cumulative surgical trauma, it is prudent to limit the duration of surgery. Because there is a maximum dose of local anesthesia that can be administered, the tumescent technique has an intrinsic limitation on the amount of surgical trauma that can be sustained. In contrast, the use of general anesthesia recognizes no well-defined maximum dose or duration, thereby allowing the possibility of excessive surgical trauma if too many procedures are undertaken in one session. There is a threshold of cumulative surgical trauma and exposure to systemic anesthesia beyond which the risks of complications outweigh the economic benefits of combined procedures. Certainly, most surgeons consider patient safety more important than financial gain and thus would never consider subjecting a patient to multiple unrelated surgeries on the same day. However, the practice of aspirating extremely large volumes (N4 L) of tissue should be done with extreme caution. Both of these practices compound the patient’s risk. Consequently, when a death does occur in this setting, usually due to pulmonary thromboembolism, it is commonly reported as a death associated with TL. In addition, the reader should be aware of other forms of anesthesia used in liposuction, such as monitored anesthesia care, which provides a middle ground between general anesthesia and TL [34].

9. Preoperative assessment 7. Liposuction safety controversies
To state that TL is safe is controversial in both the medical literature and the public media. The tumescent technique was devised to eliminate the greatest risks of liposuction associated with copious blood loss and general anesthesia. Owing to lack of training or convincing evidence in the medical literature concerning the safety of the tumescent technique, many surgeons still prefer to do As a result of the cosmetic and purely elective nature of TL, preoperative assessment needs to focus particular attention on disease states that may coexist with obesity. Hypertension, diabetes mellitus, coronary artery disease, and obstructive sleep apnea are only a few of the coexisting diseases that are associated with obesity. In addition, the drug interactions that may affect the metabolism of lidocaine must be evaluated during the preoperative assessment.

384 The clinical anesthesiologist must review all medications carefully, as use of herbals, such as ephedra, has risen steadily in the United States, and has been linked to cardiomyopathies, anxiety, heart palpitations, hypersensitivity myocarditis, nausea, heart failure, and death [35,36]. The ASA suggests that all herbals be discontinued at least two weeks before surgery [37]. This is done because of limited knowledge regarding the potential interactions of herbal medicines and lidocaine. In general, patients who are good candidates for TL are classified as ASA physical status I or II, which indicates that they are generally healthy with no major illnesses. The health and medication history of each patient must be investigated before initiating TL, as with any other cosmetic procedure.

I.J. Kucera et al. based procedures such as TL. In addition, most surgeons do not have experience managing the changing insulin requirements in fasted patients.

9.3. Immunocompromised patients
Patients with known immunodeficiencies are at a higher risk for perioperative infection and drug interactions, and may not be candidates for certain invasive cosmetic procedures. For example, HIV patients taking protease inhibitors are excluded from TL because of slower lidocaine metabolism through the inhibition of cytochrome P450 3A4. Moreover, HIV patients are typically classified as ASA III or greater, which further reduces their candidacy for such procedures. Although no conclusive evidence exists indicating that liposuction does not represent a significant risk for perioperative infections, high-risk cases should be approached with caution until such risks are known [39].

9.1. Obesity
Tumescent liposuction is not indicated for generalized obesity; instead, it is intended for removal of localized depositions of fat. However, TL may be done on obese patients for localized removal of fat. Results of liposuction done on previously obese patients who have lost adipose mass are often disappointing to both the patient and surgeon, and may be technically more difficult to perform. Realistic expectations should be fostered by extensive preprocedure counseling by the surgeon. Furthermore, obesity alone increases surgical and anesthetic risks, and may preclude office-based procedures in more obese patients if larger volumes of fat removal are planned. Many of these patients will be classified as ASA III or IV due to sequelae of their obesity, and the ethics of performing liposuction on these patients is questionable. Morbid obesity is a contraindication to liposuction because of increased complications, particularly related to the cardiopulmonary system. These patients have markedly deranged physiology and should be treated in a fully equipped acute care facility tailored to their health needs. They also have abnormal wound healing capabilities and are at risk for infection after any surgical procedure, particularly in poorly vascularized areas. The rate of full-thickness skin necrosis after liposuction is dramatically increased in morbidly obese patients as a result of excessively large skin flaps, inadequate postoperative compression, and poor skin hygiene.

9.4. Age
Advanced age is not a contraindication for TL as long as other conditions are met, such as lack of major comorbidities. In fact, older patients sometimes experience simpler procedures because their fat is less fibrous and easier to aspirate. Conversely, younger patients such as teenagers may not be mature enough to make an informed decision and may also have relatively undeveloped body proportions at the time of request. It is the ethical obligation of the physician to counsel these patients and their parents fully about the risks and benefits of cosmetic surgery at that time [17].

9.5. Hypertension
As with other major systemic illnesses, hypertension is often associated with various comorbidities, which classify the patient as ASA III or IV. Hypertension is common in the obese, particularly in the morbidly obese, and is frequently undertreated. Patients who are hypertensive at the time of the preoperative visit or on the day of planned surgery should be referred to their primary care physician for adequate treatment before the procedure. If adequate blood pressure control cannot be achieved, the procedure should not be performed.

9.2. Diabetes mellitus
Diabetes mellitus alone causes many physiological abnormalities that are frequently associated with several comorbidities that compound patient risk for anesthesia and surgical procedures. In general, chronic complications include pathology of the eyes, nerves, kidneys, and [38]. In particular, diabetes mellitus may be present in obese patients, which increases their risk of delayed wound healing, and makes recovery from any invasive procedure more problematic. These patients will not meet the ASA I or II guidelines listed above, and are not candidates for office-

9.6. Hepatic disease
The risk of administering large volumes of dilute lidocaine to patients with hepatic disease is not known and probably varies according to the disease state and liver function. Many patients who are chronically infected with hepatitis C have clinically silent disease and hepatic function remains intact throughout life, but the course of the disease is unpredictable and difficult to ascertain at any particular time. In addition, the risk to operating room staff of hepatitis C is not clear, and many surgeons refuse to expose themselves and their staff to possible exposure

Liposuction: contemporary issues for the anesthesiologist merely for a cosmetic procedure. In general, it is probably safest to avoid TL in patients who have any outward signs of hepatic disease, and it should be considered an absolute contraindication in the overtly symptomatic patient.

385 consultants for evaluation before the physician agrees to perform a procedure. If they are being treated with antidepressants, clinically important drug interactions may occur and should be anticipated by a thorough evaluation before the procedure. These drugs may need discontinuation or dosage reduction before surgery (guided by the prescribing physician) or may need reduced dosages of lidocaine. In some cases, these measures may be inappropriate for an individual patient, in which case TL is contraindicated.

9.7. Smoking
Smoking affects wound healing and pulmonary function, and is also regarded as a significant risk for deep venous thrombosis and pulmonary embolism, which in turn is the leading cause of liposuction-related deaths among patients who have the procedure during anesthesia. Smoking cessation immediately before a procedure may be associated with increased complications. Therefore, patients should be advised to quit several weeks before the anticipated surgery. In general, because few patients who are advised to quit smoking will do so, it is not regarded as a contraindication to the procedure. However, the surgeon should try to resect less tissue and caution the patient during the first three postoperative days to avoid smoking [40].

9.12. Other considerations
All female patients should have a urine pregnancy test on the day of surgery before liposuction. In addition, if there is any history of fainting or vasovagal reactions, patients should be given 0.3 mg atropine IV before tumescent infiltration. Furthermore, the patient and family members should be warned about the significant likelihood of morning after post-micturition syncope.

9.13. Expectations
As with any other cosmetic procedure, expectations of the patient must be explored at preprocedure consultations. A major source of postoperative dissatisfaction stems from unrealistic expectations, which sometimes can be traced to inappropriate counseling of the patient by the surgeon. Under certain circumstances, the physician may need to dissent from surgery if they feel that a mutual satisfactory goal is unachievable, so as to avoid gratuitous malpractice litigation.

9.8. Cardiovascular disease
Patients with demonstrable cardiovascular disease are classified as ASA III or IV, and represent an absolute contraindication for this procedure. Patients with a history of coronary artery disease that has been treated but who continue to have signs of poor cardiac function such as impaired exercise tolerance, congestive heart failure, or angina, would fall into this category. A patient who has occult cardiac disease and receives epinephrine in the TL solution may decompensate quickly, leading to significant morbidity and even death.

9.9. Thyroid disease
Controlled thyroid disease, either hypothyroidism or hyperthyroidism, provides little risk of perioperative complications. However, uncontrolled disease is associated with major risks and is a contraindication for TL. The physician should verify in the preoperative evaluation, that thyroid hormone levels are within normal limits.

10. Monitoring and techniques
Because TL is intended as an office-based procedure in ASA I or II patients, standard monitors are all that is required. If it is felt that patients require more intensive monitoring, TL may not be appropriate for that patient. During the procedure, patients should be monitored for the early signs of lidocaine toxicity such as perioral numbness, tinnitus, and CNS excitation/depression. Because patients should be minimally sedated for this procedure, evaluation of CNS status should not be difficult. Another key to
Table 2 Recommendations

9.10. Coagulopathies
A personal or family history of thromboembolic events or excessive clinical bleeding should be investigated thoroughly before any procedures and is a contraindication if confirmed. Although deaths attributed to TL are extremely rare, pulmonary emboli are occasionally found at autopsy [41]. Because many potential risks of TL are associated with large-volume liposuction, the surgeon needs to identify these high-risk patients to avoid potential lifethreatening complications [42].

9.11. Psychiatric disease
Patients with clinical psychiatric disorders are generally poor candidates for TL and should be referred to appropriate

1. Baseline vital signs, including blood pressure and heart rate, are to be recorded preoperatively and postoperatively. 2. If there is more than 100 mL of aspirate, there is the capability of continuous blood pressure monitoring, cardiac monitoring with pulse oximetry, and the availability of supplemental oxygen. 3. Patients who have received significant amounts of sedation should be monitored after the procedure until they have fully recovered. 4. A plan for management of medical emergencies is in place.
Adapted from J Am Acad Dermatol. 2001;45:438-47.

Table 3 1. 2. 3. 4. 5. Factors associated with increased morbidity

I.J. Kucera et al. to recognize the early symptoms of lidocaine toxicity. As previously mentioned, there is significant debate regarding the safety of more involved liposuction procedures. Many of the fatalities that have been reported in the larger-scale procedures tend to share similar characteristics (Table 3).

Large volume liposuction (over 5000 mL). Multiple procedures (in addition to liposuction). Cumulative surgical trauma. Increased levels of intravenous saline. General anesthesia without appreciation of early signs of lidocaine toxicity.

Adapted from J Am Acad Dermatol. 2001;45:631-645.

13. Conclusions
Liposuction is a common procedure that has developed over the last three decades for removal of subcutaneous fat for cosmetic purposes. Tumescent liposuction involves using large volumes of dilute lidocaine and epinephrine to facilitate anesthesia and decrease blood loss. Significant debate remains regarding the maximum dose of lidocaine that can safely be administered. However, there is a significant amount of practical experience using large doses of lidocaine with a low likelihood of toxicity. The increased dose of lidocaine used during TL makes a thorough understanding of lidocaine metabolism and drug interactions a prerequisite to performing this procedure.

minimizing morbidity is limiting IV fluid administration. The goal should be to replace preoperative deficit and then give standard maintenance fluids. Multiple boluses of fluid should be avoided because insensible losses from the procedure are minimized because of vasoconstriction from epinephrine. In fact, the large volume of subcutaneously infiltrated isotonic saline acts like an interstitial infusion [43]. Systemic absorption of tumescent fluid crystalloid (NS or Ringer’s) routinely produces a 5% to 10% hemodilution with or without liposuction. Thus, any gratuitous IV fluid administration can easily produce systemic fluid overload, particularly in patients with mitral valve regurgitation. Therefore, there is no need to replace intraoperative fluid loss by IV infusion, and it is a contraindication in outpatient TL [44].

[1] Flynn T, Narins R. Preoperative evaluation of the liposuction patient. Dermatol Clin 1999;17:729 - 34. [2] Rigel DS, Wheeland RG. Deaths related to liposuction. N Engl J Med 1999;341:1001 - 2. [3] Hanke CW, Coleman WP. Morbidity and mortality related to liposuction. Dermatol Clin 1999;17:899 - 902. [4] Fischer A, Fischer G. First surgical treatment for molding body’s cellulite with three 5mm incisions. Bull Int Acad Cosmet Surg 1976;3:75 - 9. [5] Fischer G. Liposculpture: the correct history of liposuction: part I. J Dermatol Surg Oncol 1990;16:1087 - 90. [6] Coleman W. The history of liposuction and fat transplantation in America. Dermatol Clin 1999;17:723 - 7. [7] Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg 1987;4:263 - 7. [8] Courtiss EH, Choucair RJ, Donelan MB. Large volume suction lipectomy: an analysis of 108 patients. Plast Reconstr Surg 1992;89:1068. [9] Klein JA. Tumescent technique for local anesthesia improves safety of large-volume liposuction. Plast Reconstr Surg 1993;92:1085 - 98. [10] Klein JA. Clinical biostatistics of safety. In: Klein JA, editor. Tumescent Liposuction: Tumescent Anesthesia and Microcannular Liposuction, vol. 1 (1). St. Louis7 Mosby; 2000. p. 27 - 31. [11] Katz BE, Bruck MC, Felsenfeld L, Frew KE. Power liposuction: a report on complications. Dermatol Surg 2003;29:925 - 7. [12] Klein JA. Critique of ultrasonic liposuction. In: Klein JA, editor. Tumescent Liposuction: Tumescent Anesthesia and Microcannular Liposuction, vol. 1 (1). St. Louis7 Mosby; 2000. p. 271 - 80. [13] Rubin JP, Bierman C, Rosow CE, et al. The tumescent technique: the effect of high tissue pressure and dilute epinephrine on absorption of lidocaine. Plast Reconstr Surg 1999;103:990 - 6. [14] Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35mg/kg for liposuction. J Dermatol Surg Oncol 1990;16:248 - 63. [15] Butterwick KJ, Goldman MP, Sriprachya-Anunt S. Lidocaine levels during the first two hours of infiltration of dilute anesthetic solution for tumescent liposuction: rapid versus slow delivery. Dermatol Surg 1999;25:681 - 5.

11. Postoperative care
Owing to the nature of TL, patients should have excellent pain control in the immediate postoperative period. By adding epinephrine to lidocaine, the duration of analgesia obtained from the tumescent lidocaine can be extended many hours. Proper caution must be emphasized to the patient about the potential hazards of contact with hot objects and other injurious substances in the anesthetized area [45]. In addition, this extended duration of analgesia yields the potential for delayed manifestations of lidocaine toxicity. Care should be taken in the immediate perioperative period to educate the patient of the signs of early lidocaine toxicity and to report it immediately. The American Academy of Dermatology has produced a group of recommendations regarding the safe administration and monitoring for TL (Table 2).

12. Non-TL
Clearly, the clinical anesthesiologist may encounter a variety of types of liposuction different from the true tumescent technique described here, including more involved procedures that may require general anesthesia. Preoperative evaluation of patients undergoing larger procedures is similar to that for TL, except the operative risks are even more extensive. Patients are at increased risk secondary to fluid shifts and general anesthesia. In addition, for patients given general anesthesia, it will be more difficult

Liposuction: contemporary issues for the anesthesiologist
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