Weill Cornell Contribution Update on Liposuction: Clinical Pearls Misbah H. Khan, MD Tumescent liposuction (TL) is one of the most promoted syringe-assisted liposuction in 1987. Prior commonly performed cosmetic surgeries in to the advent of tumescent anesthesia, dry liposuc- the United States. Although liposuction is not a tion, which utilizes general anesthesia with little or therapy for obesity, it can be used to create a no local anesthesia, was the predominant method of more aesthetic silhouette for a given body shape. liposuction practiced in the United States. This tech- Tumescent liposuction allows for the removal nique resulted in substantial blood loss and lengthy of large volumes of fat with minimal blood loss, recovery times. low postoperative morbidity and mortality, The introduction of tumescent anesthesia rev- and excellent cosmesis. This article reviews olutionized liposuction among dermatologic and preoperative and postoperative considerations as cosmetic surgeons. A 2011 survey of dermatologic well as techniques to optimize treatment outcomes procedures performed among American Society for in various body areas. Dermatologic Surgery members revealed that of more Cutis. 2012;90:259-265. than 151,000 body sculpting procedures, noninva- sive treatment of fat and cellulite was most common (73,900), followed by cryolipolysis (55,500) and iposuction is the surgicalCUTIS aspiration of sub- tumescent liposuction (16,800). 5 A remarkable safety cutaneous fat using cannulas introduced into profile, minimal blood loss, faster recovery time, and Lthe skin through small incisions. Tumescent elimination of general anesthesia have made TL a liposuction (TL) is a technique by which the subcu- favorable, affordable, and commonly performed pro- taneous compartment is infiltrated with dilute con- cedure. This article will review preoperative consid- centrations of lidocaine and epinephrine, as described erations as well as techniques to optimize treatment by Klein.1 By definition, TL excludes the use of other outcomes in various body areas. Postoperative care anestheticsDo that have risks for suppressingNot the respira- also is discussed.Copy tory system, as this procedure is performed under local anesthesia. Tumescent liposuction is an outpatient Preoperative Considerations procedure that allows for the removal of large vol- Consultation—When a patient first calls to schedule umes of fat with minimal blood loss, low postopera- an appointment for a liposuction procedure, it is tive morbidity and mortality, and excellent cosmesis. important for the staff member to be knowledgeable It has been successfully used to contour several body about the procedure to answer any questions the areas and also can be used to correct other related patient might ask in determining if liposuction is suit- noncosmetic adipose collections such as lipomas, able for his/her needs. A thorough consultation in the gynecomastia, and hyperhidrosis. office should take 30 to 60 minutes. Before Klein1 introduced TL in 1987, liposuc- The patient’s medical history is an important tion had been performed with en bloc resection part of the consultation. Tumescent liposuction is of human fat and skin or by scraping off excess fat intended for healthy adults who are within a rea- through skin incisions.2 Italian cosmetic surgeons sonable range of their ideal body weight and have Fischer and Fischer3 introduced the suction tech- realistic expectations for results. It is important to nique for fat removal in 1976, and Fournier,4 who have a low threshold for medical clearance, as some is considered a pioneer in the field of liposuction, patients are unaware of their medical history and/or tend to downplay the severity of their medical condi- From Weill Cornell Medical College, Cornell University, New tions. Medical clearance is recommended for patients York, New York. The author reports no conflict of interest. older than 60 years and for those with a history Correspondence: Misbah H. Khan, MD, Weill Cornell Medical College, of cardiovascular disease, diabetes mellitus, and/or New York, NY 10075 ([email protected]). hypertension. Because lidocaine is metabolized by the WWW.CUTIS.COM VOLUME 90, NOVEMBER 2012 259 Copyright Cutis 2012. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Weill Cornell Contribution liver, a history of hepatitis B and C virus infection, surgery group. This finding confirms that patients antiretroviral therapy, alcoholic liver disease, and/or seeking aesthetic surgeries are not necessarily driven chemotherapy must be considered, as they can impair by low self-esteem or other psychological issues, and liver function and cause lidocaine toxicity.6,7 their motives should be assessed individually during Preoperative screening studies should be per- preprocedure consultation. Patients who combine formed on all patients, including a complete blood body contouring procedures with appropriate diet cell count, chemistry profile with liver function tests, and exercise regimens experience the highest satisfac- and coagulation profile. Additionally, screening for tion rates.9 human immunodeficiency virus and hepatitis B and Overall, it is important for patients to have a clear C viruses also should be conducted. On the day of the understanding of which areas will and will not show procedure, a urine pregnancy test is recommended for improvement following liposuction procedures to all premenopausal women. ensure realistic expectations. Recording the patient’s surgical history is an essen- tial part of the preprocedure consultation. History of Tumescent Anesthesia abdominal surgeries, keloids, hypertrophic scars, her- Since the introduction of TL in 1987, several groups nias, prior scars, and liposuction, as well as presence have studied the safety profile of tumescent anes- of postliposuction defects, should be documented; thesia. In 1990, Klein10 established a conservative scars and defects also should be photographed with guideline for the maximum dose of lidocaine used great precision. in tumescent anesthesia (35 mg/kg). He also dem- The patient’s medication history must be com- onstrated that peak plasma levels of lidocaine in the plete. High-dose estrogen can put a woman at a high blood were reached at 12 to 14 hours postinfusion.10 risk for thromboembolism within the first year fol- Nordström and Stånge11 evaluated lidocaine lowing treatment, especially if she smokes.8 Because plasma levels as well as objective and subjective lidocaine is metabolized by liver enzyme cyto- symptoms of lidocaine toxicity for 20 hours following chrome P450 (CYP450), drugs that are competi- administration of tumescent anesthesia for abdominal tive inhibitors or inducers of this enzyme can liposuction, which included 35 mg/kg of lidocaine. affect lidocaine metabolism andCUTIS levels in the blood. The researchers subcutaneously infiltrated 3 liters Allergies to all medications should be listed. The of buffered lidocaine 0.08% with epinephrine in 2 most important drugs used in TL are lidocaine the abdomen of 8 female patients. The patients did and epinephrine. Allergy to lidocaine is extremely not receive any intravenous fluids. Plasma lidocaine rare; if reported, this allergy should always be taken levels as well as subjective symptoms (eg, digital/ into serious consideration. These patients should circumoral paresthesia, facial fasciculation, numbness be referred to an allergist for provocative testing. in untreated areas, lightheadedness, tinnitus) and MoreDo commonly, patients demonstrateNot allergies to objective Copy symptoms (eg, nystagmus, hypertension, methylparaben, a preservative in lidocaine. Patients hypotension, arrhythmia, unnatural drowsiness) were with allergies to ester amides of anesthetics also are recorded every 3 hours for a total of 20 hours. Peak allergic to methylparaben, as the p-aminobenzoic plasma levels were 2.3 mg/mL and were reached acid cross-reacts with it. These patients should be 5 to 17 hours postinfusion. There was no correlation treated with caution and should only be adminis- between peak plasma levels of lidocaine and dose per tered preservative-free lidocaine. kilogram of body weight or total amount of lidocaine. Patient Expectations—It is essential to thoroughly Patients did not experience objective symptoms of discuss the patient’s goals and expectations prior to fluid overload or lidocaine toxicity.11 the liposuction procedure to ensure his/her goals are Peak plasma levels for lidocaine are achieved congruent with what the procedure can accomplish. sooner when tumescent anesthesia is used in the head In 1998, Ozgür et al9 surveyed 3 patient populations: and neck areas12; therefore, TL treatment of the head those seeking aesthetic surgery (n100), those seek- and neck should not be combined with treatment of ing reconstructive surgery (n100), and a control the extremities or trunk on the same day because of group of non–surgery-seeking patients (n100). Each the rapid absorption of lidocaine from the head and group was asked to complete the socio-demographic neck areas. The approximate amount of tumescent questionnaire, life-satisfaction index, self-esteem anesthesia that can be infiltrated in a certain body inventory, and body-image inventory. The life- site is briefly outlined in the Table. satisfaction index and body-image inventory were not significantly different in these 3 groups; however, Optimizing Treatment Outcomes the self-esteem