Liposuction Defined

Liposuction is defined as the removal of fat from deposits beneath the skin using a hollow stainless steel tube (called a cannula) with the assistance of a powerful vacuum. Liposuction can be accomplished either with the use of general anaesthesia, or with heavy IV sedation, or totally by local anaesthesia.

Tumescent Liposuction

Tumescent liposuction refers to a technique that uses large volumes of very dilute local anaesthesia that is injected into the fat causing the targeted areas to be cometumescent, or swollen and firm. Local anaesthesia is widely regarded as the safest form of anaesthesia. Because local anaesthesia persists for many hours there is no need for narcotic pain medications after surgery.

Modified Tumescent Liposuction

Modified tumescent liposuction refers to a combination of tumescent local anaesthesia plus some form of systemic anaesthesia (general anaesthesia or heavy IV sedation). Because general anaesthesia or heavy IV sedation can be dangerous, they must be administered by an anaesthesiologist.

The Different Liposuction Techniques

There are many ways to do liposuction, for example liposuction can be accomplished painlessly either totally by local anaesthesia or with general anaesthesia. In the realm of liposuction, maximum speed and maximum volume of aspirate are not criteria for excellence. Ultimately, excellence is measured in terms of patient happiness which is a function of safety, patient comfort, finesse, and quality of results.

The "Art of Liposuction"

Liposuction is a medium of artistic expression that displays itself in (1) a practical application of scientific knowledge, (2) the production of what is beautiful, (3) a perfection of workmanship, (4) a perpetual quest for improvement in technique, and (5) a skill attained through clinical experience, and above all (6) making people feel happy about what they see in the mirror.

Risks of Liposuction

Risks of Liposuction must be well understood by all prospective liposuction patients. This web site emphasizes the need to constantly be aware of safety issues. In order to minimize the risk of liposuction, the patient must be aware of the following facts:

• Too much liposuction is an excessive volume of aspirated fat, or an excessive number of areas treated. Excessive surgical trauma (excessive liposuction) is dangerous and is an important cause for serious liposuction complications.
• Unrelated surgical procedures on the same day as liposuction are unnecessary. Prolonged exposure to anaesthesia is dangerous and is an important cause for serious liposuction complications.
• Disfiguring skin irregularities and depressions are frequently the result of the surgeon's inattention to detail. For example, if a liposuction surgeon attempts to do too much on a single day, and becomes fatigued, the result may be an inattention to detail, and undesirable cosmetic results. A liposuction cannula is a stainless steel tube inserted through an incision in the skin that is employed to suction the fat. The size of the liposuction cannula can influence the smoothness of the skin after liposuction. The use of large cannulas tends to create irregularities more commonly than microcannulas (outside diameter less than 3 millimeters). Surgeons who do total-body liposuction tend to use larger cannulas.

Tumescent Technique is Safest

The tumescent technique for liposuction is unquestionably the safest form ofliposuction. When tumescent liposuction is done correctly (not excessively), it is a very safe procedure. For example, there have been no reported deaths associated with tumescent liposuction totally by local anaesthesia. Even when general anaesthesia is combined with the tumescent technique, liposuction is quite safe provided the volume of fat removed and the number of areas treated during a single surgery is not excessive. The dilute epinephrine contained in the tumescent anaesthetic solution profoundly shrinks capillaries and thus virtually eliminates surgical blood loss.

Smoother Cosmetic Results

The tumescent technique permits the use of microcannulas which in turn yields smoother cosmetic results. Traditional liposuction cannulas (stainless steel tubes) have a relatively large diameter and remove fat rather quickly. However, with the use of large cannulas (diameter greater than 3 millimetres) there is an increased risk of irregularities and depressions in the skin. Microcannulas with a diameter less than 3 millimetres, allow fat to be removed in a smoother and more uniform fashion. Some surgeons prefer larger cannulas because it allows liposuction to be done more quickly.

Rapid Healing

After tumescent liposuction, there is a certain amount of blood-tinged local anaesthetic solution that remains under the skin. This excess fluid is either slowly absorbed over several weeks into the blood stream, or it can be rapidly removed by drainage through skin incisions and absorbed by special absorptive pads

Rapid Drainage

Rapid drainage of blood-tinged anaesthetic solution out of incision sites, accelerates the rate of healing, and reduces post-operative pain swelling, and bruising. Post- liposuction drainage of blood-tinged anaesthetic solution can be maximized by 1) leaving incision sites open and not closed with sutures, 2) placing several adits (1.5 mm tiny round holes) in the skin to encourage drainage, 3) placing pads on the skin to absorb the drainage, and 4) wearing spandex compression garments to encourage drainage.

Standards of Safety

The tumescent technique for liposuction has evolved into two distinct but similar procedures, with two distinct standards of safety. The basic difference between these two standards is "the amount of liposuction that is considered to be safe". The term "amount of liposuction" refers to both the volume of fat removed and the number of areas treated by liposuction on a single day or week. When compared to liposuction by general anaesthesia, liposuction totally by local anaesthesia is usually done more gently, with fewer areas treated and smaller total volumes removed, and fewer unrelated surgical procedures attempted on the same day. When liposuction is done under general anaesthesia there is a temptation to maximize the total volume of fat remove, to treat too many areas, and to do other unrelated cosmetic surgical procedures on the same day.

The Dangerous Aspect of General Anaesthesia

This is not the anaesthesia but the use of general anaesthesia to permit 1) excessive volumes of liposuction, 2) multiple unrelated cosmetic procedures on the same day resulting in excessive surgical trauma and prolonged exposure to general anaesthesia.

There are safety limits on the total amount of local anaesthesia that one can use on a single day, which in turn limits the amount of liposuction on a single day. There are no clear limits on the amount of general anaesthesia that can be used. The use of general anaesthesia makes it easier to attempt excessive amounts of cosmetic surgery on a single day. Surgeons and anaesthesiologists are both responsible for insisting on optimal patient safety and avoiding excessive cosmetic surgery on a single day. A patient who consents to doing "everything on a single day" might be exposing herself or himself to unnecessary risks and dangers. The real danger of general anaesthesia is that it permits both patients and surgeons to foolishly attempt too much surgery on the same day.

Convenience versus Safety

When considering liposuction of a large volume of fat, one must weigh the safety against the convenience and economy of doing all the liposuction during a single day. Considering the expense associated with each use of general anaesthesia, financial concerns may induce a patient to have multiple cosmetic surgeries done on a single day. Doing one mega-session of cosmetic surgery only requires one recovery period, but dividing multiple cosmetic surgeries into separate days may allow shorter recovery periods and less total time away from work. Many patients and surgeons believe it is safer to 1) limit the amount of liposuction done in one day, and 2) avoid doing liposuction with unrelated cosmetic surgeries on the same day. It is up to the patient to make the choice.

Excessive Liposuction is Dangerous

It is impossible to know the exact point at which too much of a safe procedure becomes dangerous. There is no distinct boundary line that defines the limits of safe surgery. When liposuction crosses into the domain of excessive surgical trauma, it changes from a benign cosmetic procedure into a potentially lethal process. Satisfying a desire to "do it all in one surgery" may be dangerous. There is no antidote for a toxic dose of surgical trauma. The only safe approach is prevention, which requires common sense, and prudent limits to the amount of surgery.

Excessive Surgical Trauma is Dangerous

The body can only survive a limited amount of surgical trauma before the risks of serious surgical complications increase dramatically. Too much surgical trauma in the form of total body liposuction on the same day can be fatal. It is also dangerous to attempt too many unrelated cosmetic surgical procedures on the same day. For example, a facelift, breast augmentation, facial laser resurfacing and large volume liposuction on the same day can be fatal. Cosmetic surgery is not emergency surgery. It far safer to subdivide a long list of desired cosmetic procedures in two or more separate days.

Conclusion

Liposuction by either local or general anaesthesia is regularly accomplished without serious morbidity. However, when attempting a very large volume of liposuction, there is a tendency for a surgeon to unwittingly exceed the limits of safety. In this sense, there are far greater risks with liposuction using general anaesthesia. To the best of our knowledge, there have been no deaths associated with tumescent liposuction totally by local anaesthesia when the surgeon used well recognized safe dose limits of local anaesthesia.

Tumescent Liposuction

The word "tumescent" means swollen and firm. By injecting a large volume of very dilute lidocaine (local anaesthetic) and epinephrine (capillary constrictor) into subcutaneous fat, the targeted tissue becomes swollen and firm, or tumescent. The tumescent liposuction technique is a method that provides local anaesthesia to large volumes of subcutaneous fat and thus permits liposuction totally by local anaesthesia. The tumescent liposuction technique eliminates both the need for general anaesthesia and need for IV narcotics and sedatives. The tumescent technique for liposuction 1) provides local anaesthesia, 2) constricts capillaries and prevents surgical blood loss 3) provides fluid to the body by subcutaneous injection so that no IV fluids are needed.

Dilution & Vasoconstriction Produce Safety

Tumescent liposuction totally by local anaesthesia has proven to be extremely safe despite the use of unprecedented large doses of lidocaine and epinephrine. The explanation for this remarkable safety is the extreme dilution of the tumescent local anaesthetic solution. Large volumes of dilute epinephrine produce intense constriction of capillaries in the targeted fat, which in turn greatly delays the rate of absorption of lidocaine and epinephrine. Undiluted lidocaine and epinephrine is absorbed into the bloodstream in less than an hour. Tumescent dilution causes widespread capillary constriction which causes the absorption process to be spread over 24 to 36 hours. This reduces peak concentration of lidocaine in the blood, which in turn reduces the potential toxicity of a given dose of lidocaine. Dentists typically use concentrated epinephrine which may cause a rapid heart rate if the epinephrine is rapidly absorbed. When very dilute tumescent epinephrine is used, the wide spread vasoconstriction slows the rate of epinephrine absorption, which in turn prevents an increase in heart rate.

Vasoconstriction Prevents Blood Loss

Profound vasoconstriction (shrinkage of capillary blood vessels) results from the tumescent infiltration of a large volume of dilute epinephrine into subcutaneous fat. Tumescent vasoconstriction is so complete that liposuction can be done with virtually no blood loss. In contrast, the older forms of liposuction used before the invention of the tumescent technique were associated with so much surgical blood loss that autologous blood transfusions were often routine.

Vasoconstriction Prolongs Local Anaesthesia

Because the vasoconstriction delays lidocaine absorption, the local anaesthetic remains in place in the fat for many hours. This prolonged anaesthesia permits surgery for up to 10 hours after infiltration, and provides 24 to 36 hours of significant postoperative analgesia.

Other Advantages of Tumescent Anaesthesia

Because tumescent local anaesthesia lasts so long, tumescent liposuction is less painful and more pleasant than liposuction under general anaesthesia or IV sedation. With tumescent local anaesthesia, patients are able to avoid the post-operative nausea and vomiting associated with general anaesthesia. Tumescent anaesthesia is so efficient at providing fluid to the body that it is unnecessary to use IV fluids. There is a risk of dangerous fluid overload if excessive IV fluids are given to a tumescent liposuction patient.