& Microcannular Liposuction
|7 mg/kg of lidocaine continues to be the maximum safe dosage of commercial out-of-the-bottle lidocaine with epinephrine. 35 mg/kg of tumescent lidocaine (very dilute: less than 1.5 g/L = 0.15%) with epinephrine is the maximum safe dosage for local anesthesia without liposuction. 50 mg/kg of tumescent lidocaine (very dilute: less than 1.5 g/L = 0.15%) with epinephrine is the maximum safe dosage for liposuction.
& Microcannular Liposuction
JEFFREY A. KLEIN, MD
Associate Clinical Professor
Department of Dermatology
University of California, Irvine
College of Medicine
Rudolph de Jong, MD
Columbia, South Carolina
Cover Illustration by
Earl D. Klein
With 575 illustrations,
Including 130 line drawings by Elizabeth Massari
Acquisitions Editor: Liz Fathman
Project Manager: Carol Sullivan Weis
Designer: Mark A. Oberkrom
Copyright © 2000 by Mosby, Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher.
Pharmacology is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the treating physician, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the publisher nor the editor assumes any liability for any injury and/or damage to persons or property arising from this publication.
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To Earl and Maria
All too rarely, a medical text arrives that truly does justice to the term seminal, in the sense of being original and creative and laying the foundation for the development of new therapeutic approaches. Dr. Klein’s Tumescent Technique is all that and more, since it challenges traditional long-cherished pharmacologic tenets to open up new cross-specialty practice horizons. As a single-authored text, it offers the uniformity of style, the coherence of thought, the consistency of description, the breadth of detail, and the depth of experience so often lacking in multiauthored volumes.
In 40 chapters, grouped into physiology, pharmacology, techniques, complications, and applications, the essentials of tumescent liposuction are presented with clarity, common sense, and case vignettes. Dr. Klein is uniquely qualified to author this comprehensive yet readable text, having pioneered the technique of high-volume, dilute-medication field block. He coined the term tumescent anesthesia, which has made Klein and his technique synonymous around the world. The author comes with a rich and diverse scientific base, drawing on mathematics, statistics, and clinical pharmacology. Dual-boarded in internal medicine and dermatology, he has maintained academic standing despite a thriving private practice and has published substantially, culminating in this landmark text.
Tumescent Technique is a tribute to a pioneering, internationally renowned medical vision, since tumescent anesthesia, involving subcutaneous infiltration of highly dilute lidocaine with epinephrine, has been controversial. I was one of the doubters. To the author’s credit, his clinical research left little alternative other than to accept that conventional pharmacology was inadequate to the task. New concepts apply to the pharmacokinetics of highly dilute drugs. The science of pharmacokinetics had to be expanded and revitalized to meet the challenges of unexplained observations by Dr. Klein.
The author presents his facts and findings and allows physicians to decide when, where, and why to apply the information to their practice. As stressed throughout, tumescent anesthesia is not foolproof; the massive doses of lidocaine used in the tumescent technique are safe only if and when the author’s unique technique of infiltrating highly dilute local anesthetic (with added epinephrine) is followed precisely. A dichotomy in empirical pharmacology is exposed here, since lidocaine is a two-headed local anesthetic dragon: docile and compliant when diluted extensively, but fiery and vicious when injected at full strength, directly out of the bottle.
Here, at last, is the long-awaited definitive text of tumescent liposuction from the technique’s originator. Thorough, complete, level headed, pace setting, and objective, Tumescent Technique is a must-have practice guideline for physicians worldwide.
Rudolph H. de Jong, MD
Professor of Surgery/Anesthesia
University of South Carolina School of Medicine
Tumescent liposuction totally by local anesthesia is about safety, finesse, gentleness, and optimal cosmetic results. Liposuction is a medium of artistic expression that displays itself in (1) the practical application of scientific knowledge, (2) the production of what is beautiful, (3) the perfection of workmanship, (4) the continuing improvement in technique, and (5) the skill attained through intellectual inquiry and clinical experience.
The art in liposuction requires an open mind. Many ways are available to do liposuction, and there is always a better way. Maximum speed and maximum volume of aspirate are not criteria for excellence. An attitude that regards liposuction as a crude and brutal procedure is self-fulfilling. Ultimately, excellence is measured in terms of patient satisfaction, which is a function of safety, patient comfort, and quality of results.
Artistry and ethical behavior are not independent. The artist competes in the market by providing better results and using the safest technique. For example, even if a patient wants to have a large volume of liposuction accomplished in one session, the artist convinces the patient that serial liposuction, with several weeks between sequential procedures, is safer and ultimately yields better results. Taking risks and pushing the technique to the limits of safety are not artistic.
Invented and developed in 1985, first presented at a scientific meeting in 1986, and first published in 1987, tumescent liposuction totally by local anesthesia significantly improves the safety of large-volume liposuction by eliminating significant surgical blood loss and the risks of systemic anesthesia, including general anesthesia, intravenous (IV) sedation, and narcotic analgesia. In contrast, traditional forms of liposuction relied on systemic anesthesia and were associated with so much surgical blood loss that autologous blood transfusions were often routine.
Liposuction was developed by multiple specialties. Fundamental prerequisites for competent liposuction include surgical training in an accredited residency training program (e.g., dermatology, general surgery, gynecology, ophthalmology, otolaryngology, plastic surgery) and expertise in aseptic surgical technique and emergency management of surgical and medical complications. Didactic instruction in liposuction and clinical experience with hands-on liposuction training through an accredited continuing medical education (CME) course are essential. Advanced cardiac life support training and certification should also be part of every liposuction surgeon’s qualification.
The tumescent technique is a method for drug delivery of local anesthesia that maximizes safety by using pharmacokinetic principles to achieve extensive regional anesthesia of skin and subcutaneous tissue. The subcutaneous infiltration of a large volume of very dilute lidocaine and epinephrine causes the targeted tissue to become swollen and firm, or tumescent, and permits large-volume liposuction totally by local anesthesia.
Microcannular tumescent liposuction incorporates the tumescent technique for local anesthesia with the use of liposuction microcannulas and multiple adits (1-mm, 1.5-mm, and 2-mm punch biopsy excisions) for microcannula access that are not closed with sutures. Adits promote copious postoperative drainage, which in turn reduces bruising, tenderness, swelling, and systemic lidocaine absorption.
Maximum recommended dosage of tumescent lidocaine is much greater than the standard dosage limitations recommended for out-of-the-bottle commercial preparations of lidocaine with epinephrine. The tumescent technique permits safe lidocaine dosage of 35 to 50 mg/kg and typically provides effective surgical anesthesia for more than 8 to 10 hours. With thorough infiltration technique, tumescent anesthesia provides 24 to 36 hours of significant postoperative analgesia. This book explores the pharmacokinetics of subcutaneous local anesthesia, as well as the inaccurate and unsubstantiated but widely accepted “FDA-approved” dosage limitation of 7 mg/kg for lidocaine with epinephrine when injected into subcutaneous tissue.
The concepts that justify the tumescent technique are often contrary to surgeons’ intuition and understanding of traditional pharmacologic and surgical dogma. For example, a 10:1 or 20:1 dilution of commercial lidocaine with epinephrine provides more profound and more extensive local anesthesia than out-of-the-bottle preparations. Also, microcannulas facilitate more complete fat removal than larger cannulas, and incisions heal better when not closed with sutures. Finally, tumescent liposuction totally by local anesthesia is less painful with more rapid healing than liposuction using systemic anesthesia.
Many thought that the infiltration of a large volume of tumescent fluid would distort subcutaneous fat and make accurate liposuction more difficult. Such misconceptions, based on intuition rather than experience, were widely prevalent. Many surgeons preferred to treat surgical hemorrhage by using autologous blood transfusions rather than prevent hemorrhage by using the tumescent technique to produce intense vasoconstriction.
The absorption of tumescent anesthesia from a subcutaneous deposit is analogous to the absorption of a slow-release tablet taken by mouth. Although the drug is inside the body, most of the drug is isolated from the circulation. Only the drug on the outer surface of the subcutaneous tumescent reservoir is available for systemic absorption. The capillary bed within the central portion of the tumescent adipose tissue is so completely vasoconstricted that no significant absorption can occur from these tissues. Thus the tumescent technique results in extremely slow and safe lidocaine absorption.
The greatest danger of liposuction is the use of systemic anesthesia and the associated tendency for surgeons to do too much liposuction and infuse unnecessary IV fluids. Liposuction under general anesthesia can be accomplished safely and with excellent results, but tumescent liposuction plus systemic anesthesia has proved to be an unnecessarily dangerous combination.
Tumescent liposuction has long been the standard of care for liposuction among dermatologic surgeons. The concept of tumescent liposuction, however, has diffused slowly across the boundaries between surgical specialties. As of early 2000, I am unaware of any mention in the anesthesiology literature that the tumescent technique is available for regional anesthesia by direct infiltration or that tumescent delivery permits safe lidocaine dosage of 35 to 50 mg/kg. Through this book I hope to promote the interchange of knowledge among all surgical specialists and anesthesiologists.
Clinical isolation has prevented surgeons from becoming aware of the degree of safety provided by the tumescent technique. The vast majority of surgeons who do liposuction by general anesthesia have never witnessed liposuction totally by local anesthesia. Even the “teachers” in some specialties have not witnessed liposuction of two or more areas in a patient who is awake, fully conversant, and comfortable. Also through this book, I hope to enlighten all specialties about the full capabilities of the tumescent technique, which has numerous advantages.
Even when general anesthesia is combined with the tumescent treatment, liposuction is quite safe provided the volume of fat removed and the number of areas treated during a single surgery are not excessive and unrelated surgical procedures are avoided. The profound hemostasis provided by tumescent infiltration is now widely recognized as indispensable for safe liposuction with or without general anesthesia.
Some surgeons are unaware of tumescent liposuction’s other benefits. The ability to perform superficial liposuction, syringe liposuction, and even ultrasonic liposuction is the direct result of the tumescent technique. Open drainage and bimodal compression, when used with the tumescent liposuction, decrease the systemic absorption of lidocaine and accelerate postoperative healing, with reduced pain, swelling, and bruising.
New applications of the tumescent technique permit surgical procedures of the skin that can be accomplished totally by local anesthesia, including breast reduction by microcannular liposuction, dermabrasion, CO2 laser resurfacing, chemical peels, ambulatory phlebectomy, facelift, hair transplantation, abdominoplasty, burn resuscitation, anesthesia for zoster dermatitis, endoscopic breast biopsy, skin grafts, and virtually any dermatologic surgical procedure. In addition to surgical analgesia, tumescent anesthesia provides postoperative analgesia and assists in accelerated wound healing.
Future applications of the tumescent technique for drug delivery might include prophylaxis against surgical wound infections; targeted delivery of therapeutic, chemotherapeutic, and diagnostic agents to lymphatic vessels; therapy for snakebite envenomation; and delayed systemic absorption of parenteral medications. New therapeutic applications will depend on the imagination of specialists in other clinical disciplines and the nature of the clinical problems they must solve. For example, the tumescent delivery of chemotherapeutic agents to lymphatic vessels might be applicable to the treatment of lymphatic metastases associated with breast cancer.
Every aspect of the tumescent technique can be expected to evolve and be improved. Liposuction surgeons can assist in this development by publishing descriptions of liposuction complications. Further information will be available at www.liposuction.com. The reader may send comments and suggestions regarding this book or information about unusual or severe liposuction-related complications to me by e-mail at email@example.com.
Jeffrey A. Klein
|Disclosure of Financial Interests Related to Liposuction Devices
|My financial interests to this book consist of ownership of HK Surgical, Inc., a corporation that markets devices designed specifically for tumescent liposuction and items for patient care after tumescent liposuction. The scope of this book, including descriptions of techniques and instrumentation, has been limited to those areas in which I have some expertise. I have made no attempt to provide a comprehensive survey of all available techniques and instrumentation. Although my enthusiasm for tumescent liposuction extends to the instruments and equipment that were developed to make the technique a reality, I have made a concerted effort to be objective, to be unbiased, and to avoid commercial exploitation.
My wife, Kathleen Hutton-Klein, MD, without whose love, help, and encouragement, this book would never have been written.
My children, Elan, Luke, Dora, and Paytra, were exceedingly tolerant and good natured about the constant presence of “Dad with his laptop” at home and on our family vacations.
My nurses and my staff. Consistently effective and comfortable tumescent liposuction is impossible without the assistance of nurses who are experienced and empathetic in dealing with fully awake and alert patients. Success at doing tumescent liposuction depends greatly on the assistance of my nurses. My office staff cultivate an elegant atmosphere in our office, facilitate communication with patients, provide patient education, and allay patient apprehensions and anxieties. Special thanks to Linda Flomerfelt for organizing the manuscript and illustrations.
My colleagues. Their support and their teachings are largely responsible for the popularity of tumescent liposuction totally by local anesthesia. All surgeons who do tumescent liposuction are especially indebted to William P. Coleman III, Patrick J. Lillis, Rhoda S. Narins, Richard G. Glogau, Edward Lack, Gerald Bernstein, William C. Hanke, William R. Cook, Jr., Lawrence M. Field, Pierre Fournier, Giorgio Fischer, Gérard Boutboul, and Gerhard Sattler. Likewise, many of the surgeons who have attended tumescent liposuction courses taught at the Capistrano Surgicenter have asked the questions that have given a focus to this book. My colleague Norma Kassardjian, MD, and my brother Andrew J. Klein, MD, have been especially helpful.
My teachers. Rudolph de Jong taught me much of what I know about local anesthesia. Warren Winkelstein, University of California, Berkeley, School of Public Health, taught me to be skeptical about the scientific design of published clinical research. Leslie Benet and Howard Maibach, University of California, San Francisco, provided the opportunity to learn clinical pharmacology. Gerald Weinstein, Ronald Barr, and Gary Cole taught me dermatologic surgery and dermatology at the University of California, Irvine.
My editors. Susie Baxter, Liz Fathman, Roger McWilliams, and Carol Sullivan Weis were vital in making this book a reality.
My artist. Elizabeth Massari provided the excellent medical illustrations.
ABOUT THE AUTHOR
Jeffrey Alan Klein, MD, studied mathematics and physics as an undergraduate at the University of California (UC) Riverside (BA in mathematics). As a graduate student, he studied mathematics at the Université de Paris and UC San Diego (MA in mathematics, 1971). He graduated from the School of Medicine, UC San Francisco in 1976 and spent 8 additional years in advanced postgraduate training, with a master’s degree in public health (biostatistics and epidemiology) from UC Berkeley; 3 years at UC Los Angeles as a resident in internal medicine (certification by the American Board of Internal Medicine, 1980); 2 years as a National Institute of Health research fellow in clinical pharmacology; and 3 years at UC Irvine as a resident in Dermatology (certification by the American Board of Dermatology, 1984). Dr. Klein is currently Associate Clinical Professor of Dermatology at UC Irvine College of Medicine and in private practice in San Juan Capistrano, California. He lives in Newport Beach, California, with his wife, Kathleen, and children, Elan, Luke, Dora, and Paytra.
PART IFOUNDATIONS AND ISSUES
1 History of Tumescent Liposuction, 3
2 Two Standards of Care for Liposuction, 9
3 Ethical Considerations, 12
4 Educational and Clinical Qualifications, 16
5 Problems in Reporting Liposuction Deaths, 20
PART II PATHOPHYSIOLOGY AND COMPLICATIONS
6 Clinical Biostatistics of Safety, 27
7 Risks of Systemic Anesthesia, 32
8 Miscellaneous Complications, 43
9 Superwet Liposuction and Pulmonary Edema, 61
10 Thrombosis and Embolism, 67
11 Postliposuction Edema, 79
12 Infections, 88
13 Hypothermia and Cryoanesthesia, 102
14 Perioperative Bleeding Disorders, 106
15 Maximum Safe Dose of Liposuction, 114
PART III CLINICAL PHARMACOLOGY
16 Pharmacology of Tumescent Technique, 121
17 Pharmacology of Lidocaine, 124
18 Cytochrome P450 3A4 and Lidocaine Metabolism, 131
19 Pharmacokinetics of Tumescent Lidocaine, 141
20 Lidocaine Toxicity and Drug Interactions, 162
21 Maximum Recommended Dosage of Tumescent Lidocaine, 170
22 Bupivacaine, Prilocaine, and Ropivacaine, 179
23 Tumescent Formulations, 187
24 Ancillary Pharmacology, 196
PART IV FUNDAMENTAL ASPECTS OF TUMESCENT LIPOSUCTION
25 Subcutaneous Fat: Anatomy and Histology, 213
26 Tumescent Infiltration Technique, 222
27 Microcannulas, 235
28 Surgical Technique: Microcannular Tumescent Liposuction, 248
29 Critique of Ultrasonic Liposuction, 271
30 Postliposuction Care: Open Drainage and Bimodal Compression, 281
PART V TUMESCENT LIPOSUCTION BY AREA
31 Abdomen, 297
32 Lateral Thighs, 325
33 Female Hips and Back and Male Flanks, 342
34 Medial Thighs, Knees, and Anterior Thighs, 357
35 Chin, Cheeks, and Jowls, 372
36 Buttocks, 392
37 Male Breasts, 404
38 Female Breasts, 413
39 Arms, 427
40 Female Legs and Ankles, 440
APPENDIX PATIENT FORMS
& Microcannular Liposuction