Two Standards of Care for Liposuction
Because of its superior safety, the tumescent technique is now regarded as the worldwide standard of care for liposuction. The tumescent technique for liposuction has evolved into two distinct but similar procedures, with two distinct standards of care: tumescent liposuction totally by local anesthesia and tumescent liposuction with systemic anesthesia.
A systemic anesthetic is any parenteral drug that can be expected to impair the patient’s respiration, protective airway reflexes, and ability to communicate verbally when given in a sufficiently large dose. Systemic anesthetics include inhalational agents such as halothane or isoflurane, intravenous (IV) drugs such as propofol (Diprivan), benzodiazepines such as midazolam (Versed), narcotic analgesics such as meperidine (Demerol) or fentanyl (Sublimaze), and similar drugs used for conscious sedation, including ketamine (Ketalar). For the purposes of this book, general anesthesia, conscious sedation, monitored anesthesia care (MAC), and heavy IV sedation are considered synonymous with systemic anesthesia.
Most surgeons who do liposuction with systemic anesthesia have not had the experience of doing liposuction totally by local anesthesia. Without specific training, a surgeon would be incapable of doing routine tumescent liposuction totally by local anesthesia without systemic anesthesia.
When one considers the safety record and the risks of serious complications, tumescent liposuction by local anesthesia and tumescent liposuction with systemic anesthesia are clearly two distinct procedures with two distinct levels of safety.
Liposuction-related malpractice litigation has shown that more problems occur when liposuction is done with systemic anesthesia versus liposuction totally by local anesthesia. The pooled data from an organization of malpractice insurance companies from 1996 through 1998 found that 257 lawsuits were attributed to surgeons who used systemic anesthesia, with total losses of more than $9 million. Only two lawsuits involved surgeons who performed tumescent liposuction totally by local anesthesia.1
The competition between the two standards of care for tumescent liposuction is a natural and a desirable part of the “darwinian” evolution of competing surgical techniques. In the context of therapeutic surgical techniques, a competition between two standards of care is decided by means of clinical trials, and the winner is the technique that offers the greatest degree of patient safety. In the context of cosmetic surgical techniques, however, safety issues can be subordinated by the economics of “turf battles” between competing specialties. This is a reality of liposuction surgery and cannot be ignored.
State legislatures are correctly concerned about safety issues that involve liposuction and cosmetic surgery. Two strategies exist for a legislative remedy that would minimize the risks of liposuction. Legislatures can pass laws that either (1) restrict liposuction to surgeons who are trained in only the use of systemic anesthesia or (2) encourage surgeons to perform liposuction more safely by using local anesthesia. Current legislative strategies seem to be more concerned about turf battles between competing specialties than about optimizing patient safety (Box 2-1).
The superior safety record of liposuction by local anesthesia should not be obscured by the political lobbying of those whose financial well-being depends on the use of systemic anesthesia.
Whereas local anesthesia is safer, systemic anesthesia is more convenient. Safety is the preeminent value for the standard of care that favors local anesthesia. Convenience is more valued by those who favor the standard of care that permits the use of systemic anesthesia.
When a surgeon is planning to remove a large volume of fat, it is safer to do serial liposuction procedures on separate days, but it is more convenient to do all the liposuction during a single procedure. With local anesthesia it is safer to limit the surgery done in one day to only liposuction and to do other cosmetic surgeries on a separate day. In contrast, with systemic anesthesia, it is more convenient and cost-effective to do all anticipated cosmetic surgical procedures together with liposuction on the same day. Because of the expense and danger of multiple exposures to general anesthesia, many surgeons who prefer systemic anesthesia consider it safer to do one megasession of cosmetic procedures.
Surgeons who do liposuction using systemic anesthesia presume that patient safety risks associated with systemic anesthesia are only slightly greater compared with local anesthesia. They believe that the risks of liposuction using systemic anesthesia are outweighed by the convenience. Many believe it is safe to remove more than 4 to 5 L of supranatant fat during a single surgery and to perform marathon surgeries that include liposuction, facial surgery, and breast surgery.
Systemic anesthesia has a permissive effect that allows (1) multiple concomitant cosmetic procedures on the same day, (2) excessively prolonged and extensive cosmetic procedures exposing patients to many hours of general anesthesia, and (3) more voluminous liposuction. Regardless of surgical specialty, a more aggressive approach to cosmetic surgery is often more dangerous. In this sense, systemic anesthesia has been responsible for virtually all liposuction deaths.
Systemic anesthesia removes the self-limiting safety net imposed by local anesthesia. With systemic anesthesia, no well-defined boundary line exists between “conservatively safe” and “excessively dangerous.” Restrictions on the total dose of lidocaine limit the amount of fat removed and the number of areas treated by liposuction on a single day. Most surgeons who do liposuction by systemic anesthesia are reasonable and conservative. Nevertheless, systemic anesthesia facilitates a trend toward excessive, and unsafe, cosmetic surgical practices.
Every death reported in association with liposuction has been associated with systemic anesthesia or heavy IV sedation or with bupivacaine. To my knowledge, no deaths have been associated with tumescent liposuction totally by local anesthesia.
Special Knowledge and Skills
Effective tumescent infiltration without systemic anesthesia requires special technical training and empathetic interpersonal skills. Special knowledge of lidocaine pharmacology and pharmacokinetics is required to perform tumescent liposuction totally by local anesthesia. Sophisticated “people skills” are required when doing liposuction in a fully conscious and conversant patient.
Liposuction by local anesthesia requires lidocaine. The liposuction by systemic anesthesia uses subcutaneous infiltrate only to achieve surgical hemostasis by the vasoconstriction induced by dilute epinephrine; lidocaine is often eliminated from the subcutaneous infiltrate.
Excessive Versus Limited Liposuction
It is impossible to know the exact point at which too much of a safe procedure becomes dangerous. The ability to survive a toxic dose of a traumatic surgical procedure is a probabilistic phenomenon without a distinct border that delineates the zone of danger.
When liposuction crosses beyond the boundary of common sense and into the domain of excessive surgical trauma, it metamorphoses from a benign cosmetic procedure into a potentially malignant process. An imperious surgical attitude, a naive sense of security, and a foolish desire to satisfy a patient’s request to “do it all in one surgery” are dangerous ingredients; add systemic anesthesia to the recipe and the result is a prescription for disaster. No antidote exists for this toxic combination.
The only safe approach is prevention, which requires common sense, a knowledge of modern pharmacology and physiology, a careful surgical technique, and prudent limits to the amount of surgery.
With tumescent liposuction totally by local anesthesia, surgeons typically remove no more than 2 to 3 L of supranatant fat in one session. In obese patients, even the removal of up to 4 L of supranatant fat by liposuction totally by local anesthesia has never been associated with serious complications. For liposuction of more than 4 L of fat, it is progressively safer to divide the liposuction into smaller procedures, doing serial surgeries separated by weeks or months.
When using systemic anesthesia, some surgeons remove more than 5 to 8 L of supranatant fat during a prolonged liposuction procedure.
Before the tumescent technique, the safe maximum volume of liposuction was limited by surgical blood loss. With the advent of tumescent hemostasis, surgical blood loss is almost invisible, and the safety limits for liposuction are much less obvious. Tumescent hemostasis seduces surgeons into a false sense of security. With liposuction totally by local anesthesia, a conscious patient can communicate and warn the surgeon about symptoms of excessive surgery, such as hypervolemia, hypovolemia, hypotension, hypothermia, and pulmonary congestion.
Excessive liposuction is most frequently associated with systemic anesthesia because excessive volumes of fat can be liposuctioned without complaint from the patient. Consequently, the risk of an iatrogenic death is significantly greater with liposuction by systemic anesthesia than with liposuction totally by local anesthesia. Based on data published in the dental surgery literature, I would estimate that the risk of death associated with liposuction is at least 100 to 1000 times greater with general anesthesia compared with pure tumescent local anesthesia.2
Liposuction by either local or systemic anesthesia is regularly accomplished without serious morbidity. With liposuction by systemic anesthesia, however, a surgeon unwittingly tends to exceed the limits of safety. In this sense, much greater risks are associated with liposuction using systemic anesthesia.
Differences in surgical training are not an important predictor of liposuction safety. The most significant factor in determining the safety of liposuction is the type of anesthesia used. The tumescent technique for liposuction totally by local anesthesia is safer than the liposuction by systemic anesthesia.
1. 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.
2. Coplans MP, Curson I: Deaths associated with dentistry, Br Dent J 153:357-362, 1982.
|BOX 2-1 Analogy: Two Legislative Standards|
|Suppose one group of dental surgeons has no training in doing dentistry totally by local anesthesia and instead performs all dentistry using systemic anesthesia. Another group of dentists does all dental procedures totally by local anesthesia. Which of the following two legislative strategies would be preferred in resolving the conflict between these two groups?|
|1. Pass laws that restrict dentistry exclusively to dentists who have years of training using systemic anesthesia.|
|2. Pass laws that encourage safety by requiring all dentists to learn the use of local anesthesia.|
|Prohibiting dentists from doing dentistry merely because they do not have years of training using systemic anesthesia is irrational and is not in patients’ best interest. Legislators should not be misled by a small group of dentists who, under the guise of having more training using systemic anesthesia, want to eliminate competition from dentists who use local anesthesia.|