The Tumescent Technique By Jeffrey A. Klein MD
Educational and Clinical Qualifications
What type of training and experience are necessary for doing safe and artistically refined liposuction surgery? What are the minimal qualifications? What are the optimal qualifications? These questions have been contemplated by surgical specialty societies, state medical boards, malpractice insurance carriers, and hospital credentialing committees. The only certainties about liposuction qualifications are that no consensus exists and professional politics dominates.
From a patient’s perspective, issues that concern medical politics and economic “turf battles” between specialties are unprofessional and puerile. Patients simply want to know what qualifications are most likely to predict the safest surgical technique and the most satisfying cosmetic results.
Cosmetic surgery’s safety standards and priorities are different from those of therapeutic and restorative surgery. Safety standards for cosmetic surgery are higher than for therapeutic surgery. In cosmetic surgery, significant risks must always be avoided; in therapeutic surgery, significant risks are often unavoidable. In cosmetic surgery, only healthy patients are acceptable candidates for surgery; in therapeutic surgery, unhealthy patients are the rule. Cosmetic surgery is prudent, and serial procedures are preferred to avoid the risks of excessive trauma; therapeutic surgery often necessitates one major, potentially life-threatening procedure. Thus the philosophy and training for cosmetic surgery are qualitatively different.
Surgical training in liposuction must teach a philosophy that places patient safety above all other priorities. Safety must have primacy over convenience and efficiency. Without an absolute commitment to optimizing safety, surgical training in liposuction will beget misconception and tragedy. The first priority of liposuction training is teaching safety and prevention; the second is teaching operating room (OR) skills.
Surgical training that places the highest priority on operative techniques and surgical dexterity is destined to produce an unnecessarily high incidence of complications. Any aspiring liposuction surgeon must have training and experience in basic aseptic surgical technique and the artistic use of liposuction cannulas. Instruction in such skills is not as important, however, as instruction that covers judicious patient selection and the pathophysiology and prevention of liposuction complications. Thorough instruction of the relevant clinical pharmacology, clinical psychology, and pathophysiology is prerequisite to minimizing complications. Such instruction should precede the OR experience and hands-on liposuction training.
Board certification in any surgical specialty is desirable but not sufficient to guarantee optimal patient safety. The absolute number of years of formal surgical training is not correlated with increased liposuction safety. If longer surgical training tends to engender an overconfident attitude, it may ultimately be responsible for excessively aggressive and dangerous liposuction. In fact, the incidence of liposuction-associated malpractice litigation increases with increasing years of surgical training in systemic anesthesia.1
Every liposuction surgeon should have an expert’s knowledge of the following:
- Pharmacology, drug interactions, and fluid kinetics of the tumescent technique
- Prevention of perioperative infections
- Diagnosis and initial management of infectious, cardiopulmonary, and surgical emergencies
- Appropriate consultation when needed
Residency training in internal medicine may be more appropriate and more effective than general surgery training in the prevention and management of common liposuction-related emergencies. All available data suggest that the danger of liposuction is the result of complications associated with anesthesia, inappropriate patient selection, or overaggressive surgery. Knowing how to select appropriate surgical candidates and how to make an early diagnosis of the most dangerous liposuction complications (cardiopulmonary insufficiency, thromboembolism, infection, drug toxicity) is more important than extensive experience in treating surgical complications. The surgeon who has avoided intravascular fluid imbalances by not doing excessive liposuction is better qualified to do cosmetic surgery than the surgeon who regularly does too much surgery and must treat iatrogenic hypovolemia or hypervolemia.
Considering the relative rarity and wide range of possible liposuction complications, no surgeon can be expected to manage every serious complication. Knowing when to seek a consultation from an appropriate specialist is the mark of good clinical judgment. A surgeon who pretends to have expertise in the management of all possible liposuction complications lacks good judgment.
Residency training in general surgery or board certification in anesthesia does not protect liposuction patients from complications that follow a decision to do too much surgery. On the other hand, outmoded residency training and antiquated board certification are dangerous if surgeons are unaware of limitations and inadequacies.
Surgeons with more than 5 years of surgical training and experience in treating massive trauma must guard against overconfidence. A cavalier attitude about the consequences of extensive surgical trauma in elective cosmetic surgery is probably the greatest risk for death in liposuction surgery. Extra years of surgical training do not automatically guarantee a superior safety record in liposuction surgery.
Every liposuction surgeon should have training that is equivalent to the American Heart Association’s certification in Advanced Cardiac Life Support (ACLS). In addition to the surgeon, at least one other member of the OR staff should have ACLS certification.
When tumescent liposuction is done in an office setting, the following equipment should be immediately available: supplemental oxygen supply, Ambu bag for assisted respiration, cardiac monitor, defibrillator, pulse oximeter, and automatic blood pressure machine with various sizes of cuffs. Three sizes of blood pressure cuffs are recommended: regular-size arm cuff, thigh cuff for an obese patient’s arm, and pediatric cuff for a patient’s wrist during arm liposuction. The surgeon and staff must be well trained in the use of this equipment.
All patients assume that surgeons are well trained and capable of managing the most common acute cardiopulmonary emergencies. If the surgeon and staff do not have up-to-date training that is equivalent to ACLS certification, preoperative informed consent should indicate that the surgeon and staff are not capable of managing a cardiac arrest.
As mentioned, the first priority when teaching a surgeon to do liposuction is to inculcate a philosophy of “safety first.” Hands-on OR training is of secondary importance. The specialty that regards learning surgical technique as sufficient for doing liposuction will have the highest malpractice and mortality rates.
The novice liposuction surgeon should take one or more courses accredited by an organization qualified to grant continuing medical education (CME) credits. The surgeon should attend comprehensive didactic lectures, live OR demonstrations, and scientific conferences. All liposuction surgeons, but especially the novice, should attend scientific meetings that focus on recent advances in liposuction safety and technique. Interdisciplinary meetings are invaluable for their free and open exchange of ideas and unabashed discussions about complications and safety. Discussions about the ethics of cosmetic surgery are also an essential part of liposuction training (see Chapter 3).
Instructional material should provide in-depth coverage of patient selection and education, liposuction complications and pathophysiology, relevant clinical pharmacology, surgical anatomy of subcutaneous fat, tumescent infiltration technique, microcannular surgical technique, and postoperative care. A knowledge of the risks of excessive liposuction and excessive intravenous fluids is an essential factor in truly safe liposuction.
With this fundamental knowledge and experience observing live OR surgeries and postoperative care, a fledgling liposuction surgeon can begin hands-on experience with tumescent liposuction. Initial attempts at liposuction should be limited to a small procedure treating a limited area. After acquiring some experience with limited procedures, such as on the female hip, the novice surgeon can then gradually increase the scope and duration of procedures.
With liposuction totally by local anesthesia, the patient can safely return for sequential procedures, spaced sufficiently apart, without the risks of multiple exposures to systemic anesthesia. This gradual, step-by-step approach is safer than merely assuming that several years of training in general surgery automatically guarantees the surgical skills, common sense, and good judgment necessary for safe liposuction.
The definition of “adequate training” for a multidisciplinary procedure such as tumescent liposuction should not be based on the narrow criteria of one specialty. Again, traditional training in general surgery does not guarantee safe liposuction. More than 90% of all liposuction-related malpractice lawsuits have involved surgeons with several years of training in treating major trauma but virtually no training in tumescent local anesthesia.1
All liposuction surgeons should have training in doing liposuction totally by local anesthesia. Whereas virtually all liposuction surgical deaths have been associated with systemic anesthesia, no death has been associated with the true tumescent liposuction totally by local anesthesia. Liposuction surgeons who lack training in this technique automatically relegate their patients to systemic anesthesia.
Surgeons who do tumescent liposuction should have clinical expertise in the pharmacology of all anesthetic and perioperative drugs that are being used for their patients. The number of drugs used and the individual dosages should be minimized. In particular, the surgeon should know (1) appropriate doses; (2) rates of systemic absorption, metabolism, and elimination; (3) principal cytochrome P450 isoenzymes responsible for metabolism; (4) common and potentially serious drug interactions; (5) contraindications; and (6) nature and clinical presentations of adverse effects.
The surgeon should be prepared to manage all potential adverse drug effects.
The office-based liposuction surgeon should have a surgical OR that is dedicated to sterile surgical procedures. If any drugs are used at dosages that could impair a patient’s protective airway reflexes, the surgery must be performed in a facility with competent licensed personnel in attendance and adequate monitoring and resuscitation equipment available.
Regular peer review is an essential component of continuing quality assurance. All liposuction surgeons should participate in ongoing peer review and quality assurance programs. At present, no organized peer review programs exist for office-based liposuction. Because of the restrictive criteria often used for granting hospital surgical privileges for liposuction, hospital-based peer review for liposuction does not guarantee the highest standard of care. A disproportionate majority of liposuction-associated malpractice cases have involved surgeons who have hospital surgical privileges and who are subject to hospital peer review.1
All surgeons, including dermatologic, obstetric-gynecologic, and cosmetic surgeons who do safe tumescent liposuction surgery totally by local anesthesia, should be encouraged and welcomed to participate in hospital credentialing, peer review, and ongoing quality assurance programs. Peer review is meant to enhance patient safety. Peer review for liposuction should involve all the major specialties that perform liposuction. In particular, hospitals should encourage the peer review participation by specialties with the best liposuction safety record. This is the most efficient means of eliminating dangerous “substandard standards of care.”
State or local medical associations or specialty societies should cooperate with cosmetic surgeons in establishing voluntary peer review programs for monitoring out-of-hospital cosmetic surgery. Such a program might require a participating surgeon to keep complete lists of all liposuction procedures and complications. Surgical records would be subject to review, serious complications would be reportable, and disciplinary action would result from any action or inaction that suggests a deliberate effort to conceal the facts about a complication.
Commitment to Share Knowledge
Liposuction is a multidisciplinary procedure, not the exclusive domain of any one specialty. For optimal patient care, liposuction surgeons should seek interdisciplinary educational experiences, and specialty organizations should participate in interdisciplinary meetings. At present, a North American liposuction society excludes all other specialists from its meetings. Such intellectual isolation tends to exclude fresh ideas, institutionalize outmoded procedures, and promote antiquated and unsafe techniques.
Regulatory agencies must avoid being influenced by any group of specialists who claim hegemony in liposuction. State regulatory agencies should seek to identify surgical specialties with the most liposuction-related deaths and malpractice cases, then help those specialties improve their training.
The intellectual isolation of a surgical specialty limits awareness of current advances and the current scope of training in other specialties. Unaware of newer and safer techniques, a group of isolated surgical specialists may be truly convinced of the superiority of their own training. They may not appreciate the skill and advanced training of other specialists.
Hospital Surgical Privileges
Any surgeon who claims proficiency in tumescent liposuction should seek to participate in peer review for liposuction procedures. Unfortunately, the opportunity to participate in peer review typically requires hospital privileges for liposuction. In many enlightened medical communities, dermatologists, obstetricians-gynecologists, and other specialists have obtained hospital surgical privileges for liposuction. In other communities, well-qualified liposuction surgeons are routinely denied hospital privileges for liposuction under the pretext that these specialists have inadequate surgical training. In the world of hospital politics the definition of “inadequate surgical training” is based more on economic self-interest than on objective data.
An application for hospital surgical privileges for liposuction is evaluated by a hospital credentialing committee whose policies are influenced by surgeons who only do liposuction by systemic anesthesia. These surgeons may or may not have a realistic perspective on the important safety factors of liposuction. For example, pooled data from 1996 to 1998 from physician-owned malpractice insurance companies showed that 70% of all liposuction-related malpractice cases were performed in hospital.1 Surgeons who currently have hospital surgical privileges for liposuction might learn more about liposuction safety from specialists who are routinely denied such privileges.
The bizarre logic that is cited when qualified surgeons are denied hospital privileges for liposuction surgery totally by local anesthesia is an example of political sophism. A sophism, or sophistic logic, is an argument that is deceptively plausible but knowingly fallacious. A political sophism is used to deliberately deceive or mislead. The classic example of political sophistry in the realm of hospital privileges is the following “reasoning”:
- “Liposuction surgery under general anesthesia is so dangerous that only surgeons who have had extensive training using general anesthesia should have hospital surgical privileges for liposuction.”
- “Dermatologic surgeons have not had extensive training in the use of general anesthesia.” (Instead, they do liposuction totally by local anesthesia.)
- “Therefore dermatologic surgeons should not have hospital surgical privileges for liposuction.”
This self-serving sophistry ignores that liposuction surgery totally by local anesthesia is much safer than liposuction surgery by systemic or general anesthesia (inhalational or intravenous anesthesia). It ignores that two distinct surgical procedures have been labeled as “liposuction” and that one is safe and one is less safe (see Chapter 2).
A more realistic syllogism (deductive reasoning in which a conclusion is derived from two premises) is the following:
- To improve the safety of liposuction for patients, surgeons should participate in quality assurance programs such as hospital peer review, which usually requires hospital surgical privileges.
- True tumescent liposuction totally by local anesthesia is so safe that it does not require years of training in general surgery.
- Therefore, in the best interest of patients, general surgery training should not be required for hospital privileges and participation in peer review.
A cynical observer might suspect the true reason that surgeons who do liposuction by systemic anesthesia oppose liposuction hospital privileges for surgeons who do liposuction totally by local anesthesia is to discourage competition and to avoid being criticized for using a more dangerous technique.
Summary: Liposuction Privileges
Many well-qualified and prudent liposuction surgeons find it difficult to obtain hospital surgical privileges. Surgeons are usually required to meet the following criteria:
- Board certification in a surgical specialty
- Board certification in a specialty that recognizes liposuction as a surgical technique germane to that specialty
Many gynecologists and otolaryngologists are also well-qualified liposuction surgeons. Hospital credentialing committees may be reluctant to grant them liposuction privileges, however, until these surgeons’ specialty boards explicitly state that liposuction is within their purview.
The nature of dermatologic training and clinical dermatology as practiced in the United States has changed from a medical specialty to an increasingly surgical specialty. Surgical procedures account for approximately 70% of the fees earned by the average U.S. dermatologist. Many dermatologists have attained an outstanding degree of surgical training and expertise. Tumescent liposuction is a dermatologic surgical procedure that was invented and popularized by dermatologists and is recognized by the American Board of Dermatology (ABD). All physicians who take the examination for ABD certification must answer questions pertaining to tumescent liposuction.
I believe that hospital surgical credentialing committees are increasingly likely to grant surgical privileges for liposuction to dermatologists and other specialists with appropriate documentation of training and experience.
- Coleman, WP III, Hanke CW, Lillis P, et al: Does the location of the surgery or the specialty of the physician affect malpractice claims in liposuction? Dermatol Surg 25:343-347, 1999.