How it works

The tumescent liposculpture uses several liters of a very dilute solution of local anesthesia that is gently injected into subcutaneous fat. Tumescent liposuction is the only technique that permits liposuction to be accomplished totally by local anesthesia. It is also the only technique that virtually eliminates both the need for general anesthesia and surgical blood loss as a routine problem of liposuction. Some surgeons use a modified version of tumescent liposuction consisting of general anesthesia or heavy IV sedation and tumescent infiltration for eliminating blood loss.

 

Traditional Assumptions

Traditional assumptions were not correct. In many ways the effect of the tumescent technique for local anesthesia is just the opposite of what one might predict using "common-sense" assumptions and traditional surgical teachings.
One might suspect that by diluting a solution of local anesthetic (containing lidocaine and epinephrine) the anesthesia would be less effective; instead the dilution permits a larger volume of local anesthesia that can spread more widely and produce larger areas of anesthesia.

Although microcannulas remove less fat per minute compared to larger traditional cannulas, microcannulas permit the removal of greater total volume of fat and produce much smoother more precise results.

During liposculpture by local anesthesia patients are awake but experience less post operative pain than patients who have liposuction under general anesthesia. After awakening from general anesthesia patients require narcotic analgesia, whereas local anesthesia persists for many hours after surgery so that patients may only require acetaminophen (Tylenol.)

General Anesthesia Might Be Used Unnecessarily

General anesthesia might be used unnecessarily when anesthesiologists are unaware that the FDA limits on lidocaine were designed exclusively for epidural anesthesia (7 mg/kg) and that the limits for tumescent local anesthesia are much higher (45 mg/kg). In effect, the underestimation of the maximum safe dosage of dilute lidocaine and epinephrine when injected under the skin has encouraged the use of general anesthesia in some situations where it is not necessary.

Liposuction Before Tumescent Technique

For many years general anesthesia was an absolute requirement for liposuction. The standard cannulas of the 1980's were huge, having diameters of 6 to 10 mm and cross sectional areas 9 to 25 times greater than today's 2 mm microcannulas. The first written description of liposuction was published by Fischer of Italy in 1977. Soon afterwards the French surgeons Illouz and Fournier popularized liposuction using blunt-tipped cannulas. Preoperative infiltration of a small volume of a vasoconstrictive solution of epinephrine into the targeted fat was termed the wet technique. Using no preoperative infiltration was known as the dry technique. In 1982 several American dermatologists, plastic and cosmetic surgeons visited France to observe Illouz do liposuction. By 1983 Americans were doing liposuction using general anesthesia, epidural regional anesthesia, or heavy IV sedation supplemented by small volumes of local anesthesia. In the 1980's and early 1990's, among surgeons who did not use the tumescent technique, liposuction was frequently associated with excessive bleeding, prolonged recovery time, and disfiguring irregularities of the skin.

Invention of the Tumescent Technique

In 1985 Liposuction by local anesthesia was thought to be impossible. However it seemed obvious that one could at least do a small volume of liposuction by local anesthesia. The real question was "how much liposuction could be done using local anesthesia?" It was decided to determine how much fat could be removed with the use of a maximum of 500 mg of lidocaine, and 0.5 mg of epinephrine. It was observed that each increase in the dilution of the lidocaine and epinephrine permitted local anesthesia of a greater volume of the subcutaneous fat. It only remained to determine the ideal dilution, and to estimate a safe maximum total dosage of lidocaine.

The First Tumescent Liposuction Patient

On April 5, 1985, the first liposuction procedure was performed. The patient had a localized accumulation of fat on the lower abdomen above a transverse hysterectomy scar. The liposuction was accomplished using undiluted commercially available concentrations of local anesthesia (500 mg of lidocaine and 1 mg of epinephrine in 50 milliliters), and only a small volume of fat (less than 100 ml) was removed. This first patient experienced absolutely no pain during the liposuction, and also no surgical bleeding because of the epinephrine caused capillary vasoconstriction. However, the injection did cause a stinging pain and there was a rapid heart rate (tachycardia) after completing the injection as a result of the high concentration of epinephrine (also known as adrenalin).

Maximum Safe Dose of Tumescent Lidocaine

Having established the feasibility and safety of liposuction using large volume of tumescent local anesthesia containing lidocaine the final step was to find an estimate of the maximum safe dose of lidocaine. A dose of lidocaine is considered to be excessive and potentially toxic if the concentration of lidocaine in the blood exceeds 6 milligrams per liter. By repeatedly measuring lidocaine concentration in the blood after tumescent infiltration it was discovered that the peak lidocaine concentration in the blood occurs at approximately 12 hours initiating the tumescent infiltration. This finding was unprecedented. The prevailing belief was that peak lidocaine blood levels occur less than 2 hours after infiltration. By graphing the magnitude of the peak concentrations as a function of the lidocaine dosage (mg/kg), a safe dosage for tumescent lidocaine was shown to be 35 mg/kg to 50 mg/kg. (Klein JA, Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. Journal of Dermatologic Surgery and Oncology 16:248-263,1990).