The tumescent technique: the effect of high tissue pressure and dilute epinephrine on absorption of lidocaine

Injection of lidocaine into the subcutaneous tissues by the tumescent technique results in a delayed absorption of the local anesthetic and has allowed clinicians to exceed the maximum recommended dose of lidocaine without reported complications. However, little knowledge exists about the mechanisms that permit such high doses of lidocaine to be used safely with this technique. The presence of low concentration epinephrine and the increased tissue pressure resulting from the tumescent injection have both been implicated as important factors, but neither has been studied in patients whose results were not altered by the variability of the suction procedure. The purpose of this work was to determine the effect of tissue pressure during tumescent injection and presence of low concentration epinephrine on the absorption of lidocaine from subcutaneous tissues in human volunteers. Twenty healthy female human volunteers were randomized into four study groups. After body fat measurements, all subjects received an injection of 7 mg/kg of lidocaine into the subcutaneous tissues of both lateral thighs. The injected solution consisted of 0.1% lidocaine and 12.5 meq/liter sodium bicarbonate in normal saline with or without 1:1,000,000 epinephrine. Tissue pressure was recorded during injection using a specially designed double-barreled needle. The time required for injection was also recorded. Subjects in group 1 received lidocaine with epinephrine injected by a high-pressure technique. Group 2 subjects received lidocaine with epinephrine injected by a low-pressure technique. Group 3 subjects received lidocaine without epinephrine injected under high pressure. Group 4 subjects received lidocaine without epinephrine injected under low pressure. Following injection, sequential blood samples were drawn over a 14-hour period, and plasma lidocaine concentrations were determined by gas chromatography. No suction lipectomy was performed. Maximum tissue pressure during injection was 339 +/- 63 mmHg and 27 +/- 9 mmHg using high- and low-pressure techniques, respectively. Addition of 1:1,000,000 epinephrine, regardless of the pressure of injected fluid, significantly delayed the time to peak plasma concentration by over 7 hours. There was no significant difference in the peak plasma concentration of lidocaine among the four groups. Peak plasma concentrations greater than 1 mcg/ml were seen in 11 subjects. Epinephrine (1:1,000,000) significantly delays the absorption of lidocaine administered by the tumescent technique. High pressure generated in the subcutaneous tissues during injection of the solution does not affect lidocaine absorption. The delay in absorption may allow time for some lidocaine to be removed from the tissues by suction lipectomy. In addition, the slow rise to peak lidocaine concentration in the epinephrine groups may allow the development of systemic tolerance to high lidocaine plasma levels.     

Plasma lidocaine levels during augmentation mammaplasty and suction-assisted lipectomy

Many plastic surgical procedures are dependent on or aided by the use of local anesthetics. Drug toxicity, although uncommon, is the most feared complication of this technique. There are multiple factors that lead to varying drug levels. These include drug concentration, speed of injection, rate of degradation, total dosage, site of injection or application, rate of administration, and the adjunctive use of vasoconstrictors. This study evaluates the use of subcutaneously injected lidocaine in patients undergoing suction-assisted lipectomy and augmentation mammaplasty. Lidocaine in the concentration of 0.5% containing either 1:100,000 or 1:200,000 epinephrine was used in doses up to 500 mg. Serial lidocaine levels were then obtained up to 1 1/2 hours after injection utilizing two different assay techniques. Our findings demonstrate consistently nondectable serum lidocaine levels despite the use of doses in excess of recommended "safe" amounts. This suggests that under specific circumstances and with certain operative procedures, lidocaine dosing can be liberalized.     

Large-volume suction lipectomy: an analysis of 108 patients.

Suction lipectomy was initially advocated for the treatment of localized collections of fat and for the removal of less than 1500 ml of material. However, many patients wished to have multiple areas treated or had diffuse collections of fat. In such instances, the removal of over 1500 ml of material and circumferential lipectomy are necessary to provide optimal aesthetic results. However, when over 1500 ml of material is removed, anesthetic requirements, fluid replacement, and treatment of blood loss become important if the operation is to be performed safely. We have treated 108 patients who had over 1500 ml of material removed. Eight-eight percent of the patients were female; 12 percent were male. Using the body-mass index, 3 percent of patients were underweight, 70 percent were normal weight, and 27 percent were overweight. Fifty-five patients (51 percent) had 1500 to 2499 ml of material removed, 26 patients (24 percent) had 2500 to 3499 ml removed, 16 patients (15 percent) had 3500 to 4499 ml removed, and 11 patients (10 percent) had over 4500 ml removed. All patients were treated in the hospital; 44 percent were admitted after surgery. A total of 227 units of autologous and 2 units of homologous blood were transfused. As measured by a computerized monitor, the average amount of blood in the material removed from thighs was 30 percent; from abdomens, the blood loss was 45 percent. The aesthetic results were generally excellent. No complications were encountered. A few patients developed undesired sequelae, the most common of which was seroma formation, which occurred in 19 percent of those who had suction of abdominal-wall fat. We believe that large-volume suction lipectomy is safe and efficacious, provided attention is directed to such important aspects of patient care as anesthesia, fluid replacement, and blood loss.     

Quantitative analysis of blood and fat in suction lipectomy aspirates

This study of suction lipectomy aspirates from 15 consecutive patients was undertaken to biochemically quantitate the blood-to-fat ratios of the aspirates. A wide variation in the blood-to-fat ratios (8 to 54 percent) was noted, but the authors failed to demonstrate any relationship between the blood-to-fat ratios and the suction lipectomy operative site. Prophylactic measures to allow treatment of patients in a consistently safe manner include carefully screening of patients to exclude those with bleeding disorders or significant illnesses, perioperative oral iron therapy, infiltrating the operation site with a dilute epinephrine solution, hydrating the patients adequately perioperatively, using smaller-diameter cannulas for the aspiration, minimizing aspiration once the aspirate turns grossly bloody, and limiting the aspirate to a volume of less than 1750 ml for any operative procedure.     

Computerized suction lipectomy aspirator monitor for improved results in suction lipectomy

A new computerized suction aspirator monitor is described. This device offers the benefits of instantaneous and concurrent scientifically accurate readout of aspirate contents in five separate bodily areas. Thus knowledge of amounts of blood versus fat can be immediately known without resorting to guess, estimate, or cumbersome lipocrit determination by centrifuging. Advantages of such a device include better accuracy in determination of fat removal from each area, with improvement of symmetrical fat removal. More exact determination of blood loss with improved hemodynamic replacement is also more easily and safely accomplished. In an area of mystique, experience, artistry, and aesthetic appreciation which has cloaked the initial enthusiasm for suction lipectomy, a new generation of scientific accuracy is now possible. Thus accurate determination of aspirate content vis-a-vis fat and blood can now transform this procedure into a more sophisticated and scientifically accurate operation which traditionally is desired by most practitioners of suction lipectomy.     

Suction lipectomy: complications and results by survey

In October of 1983, we sent a questionnaire on suction lipectomy to 2524 U.S. and Canadian members of the American Society of Plastic and Reconstructive Surgeons. Six-hundred and twelve plastic surgeons returned questionnaires (24.2 percent response rate). One-hundred and seven responding surgeons reported 1573 operations in which suction lipectomy with or without skin excision was used for 2685 procedures on various parts of the body. In the subset of 1249 operations in which suction lipectomy only was used to treat 2261 anatomic areas, surgeons reported greater than 80 percent good or excellent aesthetic results. The overall complication rate was 9.3 percent. The most frequent complications were persistent hypesthesia (2.6 percent), seroma (1.6 percent), and persistent edema (1.4 percent). Skin pigmentation, pain, hematoma, infection, and slough each occurred with an incidence of 1.0 percent or less. Based on the results of this survey, suction lipectomy is a valuable new modality for surgical improvement of body contour.     

Fat redistribution following suction lipectomy: defense of body fat and patterns of restoration

No randomized studies in humans have examined whether fat returns after removal or where it returns. We undertook a prospective, randomized-controlled trial of suction lipectomy in nonobese women to determine if adipose tissue (AT) is defended and if so, the anatomic pattern of redistribution. Healthy women with disproportionate AT depots (lower abdomen, hips, or thighs) were enrolled. Baseline body composition measurements included dual-energy X-ray absorptiometry (DXA) (a priori primary outcome), abdominal/limb circumferences, subcutaneous skinfold thickness, and magnetic resonance imaging (MRI) (torso/thighs). Participants (n = 32; 36 ± 1 year) were randomized to small-volume liposuction (n = 14, mean BMI: 24 ± 2 kg/m(2)) or control (n=18, mean BMI: 25 ± 2) following baseline. Surgery group participants underwent liposuction within 2-4 weeks. Identical measurements were repeated at 6 weeks, 6 months, and 1 year later. Participants agreed not to make lifestyle changes while enrolled. Between-group differences were adjusted for baseline level of the outcome variable. After 6 weeks, percent body fat (%BF) by DXA was decreased by 2.1% in the lipectomy group and by 0.28% in the control group (adjusted difference (AD): -1.82%; 95% confidence interval (CI): -2.79% to -0.85%; P = 0.0002). This difference was smaller at 6 months, and by 1 year was no longer significant (0.59% (control) vs. -0.41% (lipectomy); AD: -1.00%; CI: -2.65 to 0.64; P = 0.23). AT reaccumulated differently across various sites. After 1 year the thigh region remained reduced (0.77% (control) vs. -1.83% (lipectomy); AD: -2.59%; CI: -3.91 to -1.28; P = 0.0001), but AT reaccumulated in the abdominal region (0.64% (control) vs. 0.42% (lipectomy); AD: -0.22; CI: -2.35 to 1.91; P = 0.84). Following suction lipectomy, BF was restored and redistributed from the thigh to the abdomen.     

Gynecomastia: analysis of 159 patients and current recommendations for treatment

Gynecomastia has been treated surgically in 159 patients during the past 22 1/2 years. Prior to 1980, all patients had traditional excision, which was followed by a high incidence of complications and undesired sequelae, not the least of which was that the results of this aesthetic operation were often unaesthetic. Since 1980, when suction lipectomy became the cornerstone of treatment, the results have been much better. As a result, current recommendations for treatment are as follows: If the gynecomastia is entirely due to fat, suction lipectomy alone is sufficient treatment. However, since suction will not remove breast parenchyma, those patients whose gynecomastia is due to parenchymal hypertrophy also require local excision of the parenchyma. Skin excision is rarely, if ever, necessary.     

Gynecomastia: suction lipectomy as a contemporary solution

Suction lipectomy is adapted for the correction of gynecomastia. Previous attempts using suction lipectomy for gynecomastia still required the use of sharp dissection for removal of the glandular breast tissue as well as excision of redundant skin. With this new technique, gynecomastia is corrected solely with the use of suction lipectomy. The technique is successful if the gynecomastia is due to excess fat or parenchymal hypertrophy. A 7-mm cannula is inserted first, to remove the adipose tissue. Then a 2.4-mm cannula is used to remove the glandular and ductal tissue. The 7-mm cannula is then reinserted to remove subareolar parenchyma and to make final contour adjustments. The surrounding subcutaneous tissue is easily undermined to avoid a saucer deformity and to allow for skin contraction. Patients return to full activities in 48 hours. A compressive garment is worn for 4 to 6 weeks. The results of 10 patients are discussed.     

Suction lipectomy of the neck

Suction lipectomy of the neck has been advocated in other reports. However, because of skin laxity, a simultaneous face/neck lift has been performed usually. In this series of 49 patients, ages 18 to 73, removal of submandibular fat was performed by suction lipectomy. A simultaneous face/neck lift was not done. In addition, no skin was excised. On the contrary, the apparent excess skin was found to be required for contouring. Approximately one-third of the patients had a simultaneous chin implant. Others had different aesthetic surgical procedures performed during the same operation. The removal of neck fat by suction has proven to be more efficacious than excisional methods of lipectomy. The risks of operation have been found comparable to suction lipectomy performed in other anatomic locations.     

Epinephrine-induced changes in the distribution of lymphocyte subsets in peripheral blood of humans

We have previously demonstrated that mitogen responsiveness of mononuclear cells (MNC) from peripheral blood is reduced after a single injection of epinephrine to human subjects. The purpose of the present study was to characterize the relative distributions of MNC subsets after epinephrine administration using monoclonal antibodies and conventional cell markers. The absolute number of circulating MNC increased 64% within 30 min after injection of epinephrine, and returned to baseline by 2 hr. Analysis of MNC subsets revealed that there were no changes in the relative percentages of total T lymphocytes [T3+ cells, or neuraminidase-treated sheep red blood cell rosettes (EN-rosettes)], B lymphocytes (B1+, or cells with surface-bound immunoglobulin), or monocytes (by morphologic criteria) after epinephrine administration. The percentage of inducer T cells (T4+) declined at 30 and 60 min postinjection. Overall, the percentage of suppressor/cytotoxic T cells (T8+) did not change after injection of epinephrine; however, analysis of individual subjects revealed opposing responses of this subset. The T4:T8 ratio was 2.19 before injection, declined to 1.56 at 60 min, then increased to 3.10 2 hr postinjection. The percentage of natural killer/killer cells (HNK-1+) increased from a baseline of 15.5% before epinephrine injection to 29.6% at 30 min postinjection, then declined to 11.4% at 2 hr. Therefore, the administration of physiologic doses of epinephrine results in changes in the relative proportions of lymphocyte subsets in peripheral blood, in addition to reduced mitogen responsiveness as reported previously.     

Lipodissection in body sculpturing: the dry procedure

We have used the honeycombed suction lipectomy (wet and/or dry) in over 700 patients. It represents a major advancement in the treatment of the localized adiposities of the body. Its advantages are eliminating the need for long, unsightly scars and reducing operating time and morbidity. Selection of appropriate patients is of paramount importance for reliable results because this technique is truly sculpting of the soft tissues. Results improve also with the proper training and experience of the surgeon. The indications and complications have been discussed. This technique (honeycombed suction lipectomy) appears more reliable than suction curettage that employs sharp dissection.     

Suction mammaplasty: the use of suction lipectomy to reduce large breasts

The use of suction lipectomy to reduce breast volume is described. The technique applies only to a very limited group of patients whose nipple-areola complexes are normally located and whose enlargement is primarily fibrofatty in nature. Suction mammaplasty can be used as a sole technique in congenital asymmetry or in post-reduction enlargement or asymmetry.     

The influence of permanent magnetic field therapy on wound healing in suction lipectomy patients: a double-blind study

The authors present their experience with the healing influence of permanent magnets on postoperative wounds. The responses of 20 patients who underwent suction lipectomy and postoperative negative magnetic field therapy were studied in a double-blind fashion. Magnets in the form of patches (10 patients) or sham magnet patches (10 patients) were placed over the operative region in each of the patients. Pain, edema, and discoloration (ecchymosis) were evaluated at 1, 2, 3, 4, 7, and 14 days postoperatively. Our results show that the treatment group had significant reductions in pain on postoperative days 1 through 7, in edema on days 1 through 4, and in discoloration on days 1 through 3 when compared with the control group. These results demonstrated that commercially available magnets have a positive influence on the postoperative healing process in suction lipectomy patients.     

Does tumescent infiltration have a deleterious effect on undermined skin flaps?

In summary, we think that the intradermal injection of the tumescent solution with epinephrine, which produced a peau d'orange appearance of the overlying skin, resulted in superficial flap loss secondary to the vasoconstrictive property of epinephrine combined with the hydrostatic pressure of the injection in this patient within a superficial plane and flap elevation. This delayed the clearance of epinephrine from the flaps. In this case, removal of the sutures did not result in any improvement in the flap, and this maneuver was performed too late. If a peau d'orange appearance is observed after injection, we recommend waiting until the fluid has time to recirculate (15 to 30 minutes, at a minimum) and avoid immediate incising or undermining of the flap.     

Toxic shock syndrome after suction lipectomy

We present a case of toxic shock syndrome with necrotizing fasciitis after suction lipectomy. The patient underwent aesthetic suction lipectomy of the abdomen, buttocks, and thighs during an office procedure by a cosmetic surgeon. On postoperative day 2, the patient was referred to the emergency department of our hospital because of pain. On admission, the patient was in toxic shock. She required intensive medical treatment for about 1 month, along with psychiatric help to adapt after the illness. Although toxic shock syndrome is a rare postoperative complication, every plastic surgeon should be acquainted with it. A combination of early recognition, diagnosis, and aggressive supportive therapy is the only successful treatment.     

A national survey of complications associated with suction lipectomy: a comparative study

In March of 1988, a survey form was sent to all 2695 U.S. and Canadian members of the American Society of Plastic and Reconstructive Surgeons. Nine-hundred and thirty-five members responded, for a response rate of 34.7 percent. The purpose of the survey was to ascertain the total number of major liposuction, dermatolipectomy, and abdominoplasty procedures performed from January of 1984 to January of 1988 and to compare nine specific complications that are associated with these three procedures. The 935 surgeons reported a total of 112,756 procedures performed: major liposuction (75,591), dermatolipectomy (10,603), and abdominoplasty (26,562). Nine major complications were surveyed: mortality, myocardial infarction, cerebrovascular accident or transient ischemic attack, pulmonary thromboembolism, fat embolism, major skin loss, anesthesia complication, transfusion complications, and deep venous thrombosis. The findings in this survey showed, when comparing these three procedures and the nine types of complications, that the complication rate for major suction lipectomy was 0.1 percent, for dermatolipectomy 0.9 percent, and for abdominoplasty 2.0 percent. Fat emboli did not prove to be a significant factor associated with any of the three procedures. However, of the 15 reported deaths (major liposuction 2, dermatolipectomy 2, and abdominoplasty 11), pulmonary thromboembolism was the causative factor in 9 deaths (60 percent). Based on these analyzed data, we feel that major suction lipectomy has a low complication rate and is a reasonably safe procedure.     

Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques

In recent years, adipocytes obtained by suction-assisted lipectomy have been used for implantation by injection methods. This study is designed to assess the appearance of suctioned and excised adipose tissue and its survival after being injected or implanted into different tissues (0.5 cc into the rectus muscle and 0.5 cc into the dorsal ear skin) of New Zealand White rabbits. The results showed that significant numbers of adipocytes were ruptured after suction procedures. The intact cells represented approximately 10 percent of the fat cell population. Fat cells in aspirated and excised samples remained intact and did not differ histologically. After being injected into tissue, adipocytes appeared to survive better for a short term in a more vascularized bed (rectus muscle) than in a low vascular area (ear dermis). Long-term studies at 6- to 9-month intervals revealed transplanted adipose tissue, taken by suction or excision, being replaced with fibrosis, although cystic spaces and only a small number of surviving adipocytes were still present. Insulin did not show any protective effects on survival of the adipocytes during their transplantation.     

A comparison of two methods of infiltration in breast reduction surgery

The superwet technique has been shown in previous studies to dramatically reduce blood loss in breast reduction surgery, compared with standard infiltration. A retrospective chart review of 303 consecutive patients undergoing bilateral breast reduction surgery was undertaken to demonstrate additional differences in complication rate, operative time, or sponge use in the operating room. In this series, 132 consecutive patients received standard infiltration along incision lines (25 cc per breast of 1:100,000 epinephrine), and 171 patients received superwet infiltration with 240 cc per breast of 1:1,000,000 epinephrine. The average operative time was significantly reduced in the superwet group, from 78.5 minutes to 70.7 minutes (p < 0.01 level). The average number of sponges used intraoperatively was also decreased significantly (p < 0.01), from 26 to 20 sponges. Complication rates were equally low in both groups, demonstrating the safety of the superwet technique. In addition to limiting blood loss, the superwet infiltration effectively reduces operative time and sponge use without increasing complications in breast reduction surgery.     

Regional fat aspiration for body contouring

Our experience with the original suction lipectomy is presented. The fat removal, done with a specially designed suction tube, is performed layerwise, creating a continuous, regular cavity that is transformed into a virtual space by compressive dressings. The main indication being excessive peritrochanteric fat pads, the operation is done under either epidural or general anesthesia. No antibiotics or anticoagulants are administered, and the patients are mobilized as soon as fully awake. Practicing suction-assisted lipectomy for more than seven years, we have never observed an infection, thrombosis, or fat embolism. In experienced hands, good results can be expected in about 80 percent of patients. Complications are almost always of an aesthetic nature as a result of bad indications. The method is not a surgical treatment for severe obesity.