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Tumescent Anesthesia

Tumescent anesthesia using only local anesthesia with lidocaine is the safest liposuction in the world today. 55mg per Kg of bodyweight is extremely safe. Only about half of this dosage is required to perform liposuction of one body area. The solution contains 400-500mg of lidocaine in one liter of normal saline with 1mg of epinephrine and 10 milliequivelents of sodium bicarbonate.

Tumescence of the liposuction area is a part of the surgical procedure and causes less tissue trauma by reduced shearing and avulsion forces as well as open drainage.

The state of tumescence is the preparation of the surgical field by hidrodissecting the tissue planes with tumescent solution and homogenization of the fat. It is also defined as persisting skin tissue condition of skin tightness by hydrostatic pressure due to infiltration of the tumescent local anesthesia over a period of 30 minutes.

Lidocaine is the local anesthetic and epinephrine is a normally found hormone in the body which causes the blood vessels to close down. (Vasoconstriction.) Sodium bicarbonate helps to minimize the pain of the normally acidic lidocaine solution.  Usually most areas can be adequately anesthetized with 400mg per liter of lidocaine except the midline areas where 500mg per liter is required.

Using the safety guidelines a maximum of 8.25 liters of solution can be used for a 60KG patient. For a 70 Kg patient 9.6 liters and for a 80 Kg patient 11 liters of solution can be used safely.

These are the goals of tumescent anesthesia.

  1.  Adequate anesthesia with long duration in the target tissue
  2. Vasocronstriction. (closing of all the blood vessels of the area)
  3. Enlargement of the fat collection necessary for very even fat removal
  4. Protection of deep neurovascular bundle
  5. Local Antibacterial effect
  6. Washout effect
  7. Protection of the skin due to the tumescent anesthesia provides reduction of the complication rates and a better cosmetic result
  8. PProtection of the fibroseptal network ( fibrous tissue bands which attach the skin to the deeper muscles)  thereby increasing the skin tightness following the liposuction.
  9. No pain in the post operative period. (Patients can essentially drive home or go to work after the surgery)  This prevents complications due to immobility such as deep vein thrombosis, pulmonary embolism etc.

This is Dr Jeff Klein who discovered tumescent anesthesia speaking at the 2nd Annual World Academy of Cosmetic Surgery in Vienna Austria.

Here is Dr Nimal Gamage with Jeff Klein at the same conference.

Tumescent local anesthesia has recently being used for non cosmetic surgeries including skin grafting of burns, Mastectomy (removal of breasts usually in breast cancer patients) and treatment of subclavian steal syndrome.

Lidocaine toxicity is directly related to serum lidocaine concentration. 5micrograms per ml is the therapeutic threshold for arrythmia and 6 micrograms per ml is the threshold for systemic toxicity. Recently tumescent anesthesia has been found to reduce platelet aggregation which occurs in post operative period. This may be another reason in for lack of DVT and thrmoboembolism following surgery performed with tumescent anesthesia. As mentioned above with tumescent anesthesia patients are allowed to ambulate even during the surgery (2-3 breaks given during the surgery) to prevent complications. 

A recent trial by Dr Klein determined that up to 45 mg/kg of lidocaine dosage is safe for liposuction under tumescent anesthesia.   Slightly higher dosages can be used in Thighs and Hips compared to Abdomen liposuction due to slower  absorption of lidocaine from thighs and hips.

Dr Nimal Gamage has performed over 11000 procedures with only tumescent liposuction without any complications as of September 2011.

So what happened after the introduction of tumescent local anesthesia.

  1. Increased number of liposuction performed by Cosmetic Surgeons
  2. Dramatic increase of the total number of liposuctions around the world
  3. Dramatic decrease of complications medically and cosmetically
  4. Increase in the quality of liposuction results, indications and patients expectations
  5. Starting of competition between plastic surgeons who continued to practice the traditional liposuction with general anesthesia with the risk of mortality (patient death) and the cosmetic surgeons practicing liposuction under tumescent local anesthesia without the riks of death as well as all of the aboive benefits to the patient.