LIPOSUCTION TEXTBOOK

The Tumescent Technique: PART I: Foundations and Issues CHAPTER 1: History of Tumescent Liposuction 
The tumescent technique for local anesthesia has revolutionized liposuction by eliminating both the risks of general anesthesia and the bleeding once associated with liposuction. The associated vasoconstriction has permitted the extensive use of microcannulas and superficial liposuction, thus dramatically improving aesthetic results. Also, patients experience less pain with tumescent liposuction than with liposuction by general anesthesia. The words tumescent, tumescence, and tumesce are derived from the Latin verb tumere, meaning “to swell, become tumid.” In clinical medicine, tumescent describes an anatomic feature that is swollen and firm; for example, an inflamed lesion may become red and tumescent. The tumescent technique permits liposuction totally by local anesthesia. The reality of clinical experience with tumescent liposuction is often the opposite of what one might predict based on “common-sense” assumptions and traditional tenets of surgery. For example, the dilution of a local anesthetic solution of lidocaine and epinephrine does not weaken its effect; rather, it enhances the degree of anesthesia and vasoconstriction. Although microcannulas remove less fat per unit of time, they actually permit the removal of greater volumes of fat than traditional liposuction cannulas. As these concepts become better accepted and understood, the tumescent technique will find increasing application in liposuction.

EARLY LIPOSUCTION

The first written description of liposuction was published by Fischer of Italy in 1977. Soon afterward the French surgeons Illouz and Fournier popularized liposuction using blunt-tipped cannulas. The common adverse sequelae of liposuction were excessive bleeding, prolonged recovery time, and disfiguring irregularities of the skin. Preoperative infiltration of a small volume of a vasoconstrictive solution of epinephrine into the targeted fat was termed the wet technique. Using no preoperative infiltration was known as the dry technique. By 1982 several American dermatologists had been to France to observe Illouz do liposuction using general anesthesia together with a subcutaneous injection of a small volume of a hypotonic solution of epinephrine and hyaluronidase. For many years, general anesthesia was a prerequisite for liposuction. The standard cannulas of the 1980s were huge, with diameters of 6 to 10 mm and cross-sectional areas 9 to 25 times greater than today’s 2-mm microcannulas. Dolsky et al¹ reviewed the development of early liposuction techniques and the associated complications. By 1983 dermatologists were doing liposuction of lipomas, the submental chin, and limited areas of the body using general anesthesia, epidural regional anesthesia, or heavy intravenous (IV) sedation supplemented by small volumes of local anesthesia. The IV sedation usually consisted of diazepam (Valium) and a narcotic analgesic and the local anesthesia 0.25% to 0.5% lidocaine (Xylocaine) with epinephrine 1:200,000.² With increasing experience, dermatologic surgeons gradually began to use larger and larger doses of lidocaine without signs of toxicity. Eventually they were routinely giving lidocaine doses two to three times the 7 mg/kg maximum dosage specified by the FDA. The common, but erroneous, explanation for this lack of toxicity was that liposuction removed the lidocaine before it could be absorbed into the patient’s blood. In late 1984, having recently achieved board certification in dermatology, I focused on starting a private practice and learning more dermatologic surgery. At that point, my years of advanced training and study of other areas of medicine seemed to have little practical relevance. In retrospect, two master degrees (mathematics as well as public health biostatistics), 2 years as a National Institutes of Health research fellow in clinical pharmacology, and board certification in internal medicine provided the concinnity of experience and knowledge that produced the concept of the tumescent technique. Ironically, I had mixed reactions on first hearing about liposuction. Larry Field, a pioneer of modern dermatologic surgery, convinced me that liposuction was destined to become an important dermatologic surgical procedure. In February 1985 I attended a liposuction course given by Gary Fenno and sponsored by the American Society for Liposuction Surgery. None of the faculty had done liposuction by local anesthesia, which was thought to be impractical, if not impossible. The plastic surgery literature stated, without discussion, that liposuction required general anesthesia. In April 1985, using local anesthesia, I performed my first liposuction procedure. By the end of that year, an elementary form of the tumescent liposuction with intramuscular (IM) diazepam sedation and meperidine (Demerol) analgesia had evolved. I first described the tumescent technique at the Second World Congress of Liposuction Surgery sponsored by the American Academy of Cosmetic Surgery held in Philadelphia in June 1986. The first article describing the tumescent technique was published in the American Journal of Cosmetic Surgery in January 1987.³ Subsequent years have seen continual improvement. With the tumescent technique, liposuction is now a procedure of exceptional finesse and gentleness that is accomplished totally by local anesthesia. Dermatologic Origins A preference for local anesthesia, an aversion to the high costs of hospital operating rooms, and skepticism about established surgical dogma explain why a dermatologist invented the tumescent technique. The tumescent technique has a natural appeal to dermatologists and is uniquely compatible with traditional dermatologic surgical training. Dermatologists prefer local anesthesia for skin surgery and abhor the complications associated with general anesthesia. They have the training, the patience, and the experience to deal with patients who are awake and alert. Without such qualifications, it is nearly impossible to do liposuction without general anesthesia, IV sedation, or narcotic analgesia. The perceived value of the tumescent technique depends on the surgeon’s education. Training that inculcates a preference for general anesthesia usually does not emphasize the benefit of having an awake patient. The distinction between necessary and convenient forms of anesthesia is often disregarded. Extensive training with general anesthesia does not afford much opportunity to acquire the experience and temperament needed to manage an alert patient during surgery. On the other hand, most dermatologic surgeons are exclusively trained to use local anesthesia. Using general anesthesia is rarely necessary or desirable.

Misconceptions About Lidocaine

The U.S. Food and Drug Administration (FDA) must approve any drug before it can be sold in the United States. As a part of this process, the FDA must also approve the exact wording of the drug information and dosage recommendations published annually in the Physicians’ Desk Reference (PDR). For lidocaine (Xylocaine) as a local anesthetic, the PDR states that “in all cases the lowest concentration and smallest dose that will produce the desired result should be given.” The tumescent technique was developed in direct response to this FDA imperative. Lidocaine is the most common local anesthetic used in cutaneous surgery, but the FDA has no data to support its officially approved recommended maximum safe dosage of 7 mg/kg body weight of lidocaine with epinephrine. The official dose limits for lidocaine were established in 1948 in a brief letter to the FDA from Astra Pharmaceutical, the drug’s manufacturer, which simply stated that “the maximum safe dose of lidocaine is probably the same as that for procainamide.” The FDA has no further data on which to support its current recommendations. The “common wisdom” about maximum safe doses of lidocaine has resulted in underestimating the maximum safe dosage of lidocaine and sometimes encouraging the unnecessary use of general anesthesia. In the early 1980s the pharmacology and absorption kinetics of local anesthesia in skin and subcutaneous tissue were considered trivial, uninteresting, and unworthy of systematic investigation. Years of well-published pharmacokinetics orthodoxy had convinced most surgeons and anesthesiologists that it was impossible to do moderate or large-volume liposuction using only local anesthesia. Several fallacious assumptions, many of which persist today, have obscured the potential benefits of local anesthesia (Box 1-1). Clinical experience and clinical studies have convinced me that these assumptions are wrong. First, no scientific publication exists to support 7 mg/kg as the maximum safe dose of lidocaine with epinephrine when infiltrated into subcutaneous tissue.¹⁰ Second, an experimental study of lidocaine published in 1948 reported that the median lethal dose (LD₅₀) of subcutaneous lidocaine in mice was inversely proportional to drug concentration; in other words, the greater the dilution, the greater the dose of subcutaneous lidocaine necessary to kill a mouse. This supported the conjecture that extremely dilute solutions of lidocaine might permit safe doses significantly greater than 7 mg/kg. Third, many surgeons, including myself, wrongly assumed that liposuction removed a significant amount of lidocaine along with fat. Because it seemed logical to remove the tumescent lidocaine as soon as possible, surgeons would do infiltration and liposuction one area at a time. In other words, after infiltration of a targeted area had been completed, liposuction would commence as soon as vasoconstriction had been achieved. This one-area-at-a-time approach would be repeated until a reasonable number of areas had been completed. As described in Chapter 19, liposuction removes only 20% of the infiltrated dose of tumescent lidocaine. Once this fact had been recognized, surgeons could reasonably complete tumescent infiltration of all areas before commencing liposuction. Finally, when blood was sampled 1 hour after a lidocaine dose of 10 to 20 mg/kg by the tumescent technique, the plasma concentrations were less than 0.3 μg/ml, well below the 5 μg/ml threshold for early lidocaine toxicity. This finding provided the naive confidence that lidocaine toxicity was a remote risk. This erroneous assumption was based on the belief, supported by virtually all previously published reports, that peak plasma lidocaine concentrations occur within 2 hours after infiltration. The perfunctory explanation for the remarkably low plasma lidocaine levels was that the liver was rapidly metabolizing the lidocaine. Only later did researchers realize that the peak lidocaine plasma levels were higher and occurred up to 12 hours after completion of tumescent liposuction. In 1987 many surgeons believed that a dose of lidocaine in excess of 7 mg/kg was considered more dangerous than the combination of general anesthesia and the high surgical blood loss that routinely required autologous blood transfusions. At a medical meeting, my report of using 15 mg/kg of lidocaine for tumescent liposuction provoked a public accusation of medical malpractice. Even today, despite the results of several well-documented studies validating the estimate of 35 mg/kg as a safe upper limit for a lidocaine dose with the tumescent technique for liposuction, many surgeons and anesthesiologists persist in using techniques that risk excessive IV fluid infusions, IV fluid overload, coagulopathy, massive bleeding, and potentially fatal complications connected with general anesthesia.

The First Case

The volunteer patient for my first liposuction surgery had a localized accumulation of fat on the lower abdomen above a transverse hysterectomy scar. Using only 50 ml of a commercially available local anesthetic formulation containing 500 mg of lidocaine [1%] and 0.5 mg of epinephrine [1:100,000], the result of the procedure was encouraging but less than satisfactory. Approximately 45 ml of fat was removed. The degree of hemostasis was profound, with the aspirated fat containing almost no blood. However, the volume of fat that could be anesthetized using only 50 ml of local anesthetic was too small. The 0.5 mg of epinephrine at a concentration of 1:100,000 caused tachycardia. The most painful part of the procedure was the burning-stinging sensation caused by the infiltration of the local anesthetic. The actual liposuction, although not painless, was more easily tolerated than the infiltration. The patient returned for a more extensive liposuction of the lower abdomen and lateral thighs 1 month later. On this occasion the anesthetic solution was more dilute, and the results were better with fewer side effects. The anesthetic solution consisted of lidocaine [2000 mg/L] with epinephrine [2 mg/L] in 1000 ml of physiologic saline, yielding a formulation of approximately 0.2% lidocaine and epinephrine 1:250,000. This concentration of epinephrine still produced tachycardia (approximately 120 beats/min), but hemostasis was excellent. The aspirate contained 450 ml of bloodless fat and 100 ml of mildly blood-tinged infranatant anesthetic solution. Pain caused by infiltration was eased with IM meperidine and diazepam. Lidocaine at a 0.2% concentration was clearly effective and well below the 0.4% [4 g/L] concentration, which at that time was the published minimal effective concentration (MEC) for cutaneous local anesthesia. Liposuction totally by local anesthesia was clearly feasible. The unanswered question was how much fat could be removed using local anesthesia. Clearly, the formulation of the anesthetic solution needed to be perfected. Two significant parameters required scientific estimation: (1) the MEC of lidocaine and epinephrine and (2) the maximum safe total dose of lidocaine.

Anesthetic Formulations

In this book, for reasons of safety and convenience, the concentrations of lidocaine and epinephrine in a tumescent solution of local anesthesia are usually specified in terms of milligrams per liter (mg/L). This convention is motivated by the fact that when specifying a concentration of lidocaine in terms of mg/L, the calculation of “total dosage (mg/kg) of lidocaine” is more easily calculated, and dosage errors are more easily avoided. Pharmaceutical manufacturers have traditionally specified the concentrations of commercially available lidocaine in terms of grams per 100 milliliters of solution (grams percent, or g%). However, a 0.1% lidocaine solution (0.1 g of lidocaine per 100 ml of solution), when intended for tumescent local anesthesia, is more appropriately specified as 1000 mg/L, that is, 1000 mg of lidocaine per liter of solvent, such as physiologic (0.9%) saline or lactated Ringer’s solution. Thus the total mg dose of lidocaine and the total mg/kg dosage of lidocaine are easily determined.

Lidocaine: Minimum Effective Concentration

In 1985 a careful review of the literature on lidocaine found no studies specifically concerned with local anesthesia of subcutaneous fat. The MECs of lidocaine and epinephrine for cutaneous and subcutaneous local anesthesia were not well defined. Any estimate of the lidocaine MEC for liposuction depends on both surgical and patient factors. Surgical factors include the completeness and the uniformity of anesthetic infiltration, the surgeon’s finesse and skill, the cannula diameter, and personality traits of the surgeon and nursing staff. Patient variables include age, gender, anxiety level, and anatomic location of the fat. Any use of anodyne drugs such as narcotic analgesics or IV sedatives also affects the limen, or threshold of pain. More clinical experience showed that a formulation consisting of 0.1% lidocaine [1 g/L] and epinephrine 1:1 million [1 mg/L] was effective. Because the burning and stinging pain persisted, however, the process of infiltration was not easily tolerated. The range of lidocaine concentrations currently recommended for tumescent liposuction totally by local anesthesia is 500 to 1500 mg/L. This range was derived with the cooperation of several patients by comparing the subjective effect of a given lidocaine concentration in one thigh with that of a slightly lower concentration in the opposite thigh. More patients can distinguish between 400 mg/L [0.04%] and 500 mg/L [0.05%] lidocaine than between 500 mg/L [0.5%] and 750 mg/L [0.75%]. Clinical experience now clearly demonstrates that 0.075% to 0.1% lidocaine [750 to 1000 mg/L] is sufficient for tumescent liposuction, totally by local anesthesia, of the hips, thighs, knees, arms, and neck/facial areas, provided the surgeon uses microcannulas and careful infiltration. Lidocaine at 0.1% to 0.125% [1000 to 1250 mg/L] provides more consistent anesthesia for the more fibrous or more sensitive areas, such as the periumbilical area, the upper abdomen, the fat of the lower abdomen deep to Scarpa’s fascia, the female infrascapular and posterior axillary areas, and the male flanks and male breasts. For liposuction of female breasts totally by local anesthesia, the lidocaine concentration is 1500 mg/L.

Epinephrine: Minimum Effective Concentration

The vasoconstriction associated with epinephrine has the following three consequences for tumescent liposuction:
1.         It prolongs the local anesthetic effect.
2.         It slows the rate of absorption of lidocaine, permitting greater doses of lidocaine.
3.         It produces such dramatic hemostasis that clinically significant surgical blood loss is eliminated. The epinephrine MEC was derived by careful clinical observation of cutaneous blanching and pulse rate.

Experience has shown that epinephrine at 0.65 to 1.0 mg/L provides consistently excellent vasoconstriction for many hours, with a very low incidence of tachycardia. By comparison, commercially available lidocaine with epinephrine typically has an epinephrine concentration of 10 mg/L, which is equivalent to 1:100,000, or 1 g/100,000 ml.

Lidocaine: Maximum Safe Dose

The search for a better estimate of the maximum safe dose of lidocaine has been controversial. Some aesthetic surgeons publicly stated that dermatologists were incapable of doing liposuction safely. Prudence and good documentation were necessary to prove that 7 mg/kg grossly underestimated the maximum safe dose for tumescent lidocaine. After 1000 mg/L [0.1%] lidocaine was established as effective, this concentration was maintained as a constant, while a total volume of solution, and thus the total dose of lidocaine, was cautiously increased. Clinical observation revealed no evidence of early lidocaine toxicity as doses were incrementally augmented during succeeding surgeries. In April 1988, after liposuction on her husband, I asked a nurse to obtain extra venous blood samples at home for determination of additional lidocaine blood levels. The sequential blood samples obtained over 7 hours produced unexpected results. The blood levels increased linearly with time over the entire 7-hour interval, indicating that the maximum concentration occurred well after 7 hours. In another patient, lidocaine blood levels taken over 24 hours showed a maximum concentration at approximately 12 hours. This finding was unprecedented. The prevailing belief was that peak lidocaine blood levels occur less than 2 hours after infiltration. No formal investigational review board (IRB) or human studies research committee gave approval before the procedures for obtaining these blood samples to determine plasma lidocaine concentration. Before being asked to participate in the pharmacologic evaluation of lidocaine levels, however, all patients had requested liposuction and had agreed to pay the usual surgical fees. Furthermore, all patients gave informed consent before participating in the sequential measurement of lidocaine blood levels. Measurements in other patients led to the determination that peak lidocaine blood levels for tumescent liposuction occur at 12 ± 3 hours. Most likely the time of this peak level varies somewhat as a function of the method of infiltration, total dosage of lidocaine, and concentrations of lidocaine and epinephrine. The pharmacologic information obtained for each patient included the peak lidocaine plasma concentration [mg/L] and total dosage of lidocaine (mg/kg) given by tumescent infiltration. By graphing the magnitude of the peak concentrations [mg/L] as a function of dosage (mg/kg), a safe dosage for tumescent lidocaine was shown to be at least 35 mg/kg. This result was published in 1990 and provided scientific justification for lidocaine doses five times greater than the 7 mg/kg limits approved by the FDA.¹¹ The first published description of the tumescent technique had already shown that it eliminates significant blood loss.⁹ Thus it was established that liposuction could be done safely with minimal risks of blood loss and minimal risks of anesthetic toxicity with the use of the tumescent technique. Together, these two findings were revolutionary and established dermatologic surgery as the authority on safe liposuction surgery. In 1993, when the Journal of Plastic and Reconstructive Surgery published its first article on tumescent liposuction, the plastic surgery community began to adopt the technique. Currently, most plastic surgeons prefer to use a modified version of the tumescent technique, or a semitumescent technique, that relies heavily on general anesthesia or IV sedation, while using tumescent infiltration for its profound vasoconstriction and surgical hemostasis.

Improved Formulation and Delivery

In 1988 I read that the addition of sodium bicarbonate (NaHCO₃) at a concentration of 10 mEq/L significantly reduced the pain associated with the infiltration of local anesthesia. Others confirmed that adding sodium bicarbonate to the anesthetic solution eliminated the burning and stinging pain associated with the acidic pH of commercially available lidocaine preparations.^5,12,13 This simple modification greatly improved patient comfort and safety. It eliminated the need for parenteral sedation with benzodiazepines, for narcotic analgesia, and for pulse oximetry and its attendant difficulties. Sodium bicarbonate was the key to large-volume liposuction totally by local anesthesia. The use of a peristaltic infiltrating pump has made it possible to use 25-gauge and 20-gauge spinal needles for the initial stages of infiltration. Previously, tumescent infiltration required much larger, 12-gauge cannulas with a 2.5-mm outside diameter. The use of spinal needles has dramatically increased the effectiveness tumescent infiltration and reduced the discomfort associated with infiltration into the most fibrous areas of fat, such as the knees, upper abdomen, the back and flanks, and male breasts. Furthermore, the pump has eliminated the “brute strength” needed to infiltrate using a syringe, allowing properly trained female registered nurses to perform the infiltration with accuracy and finesse.

Triamcinolone.
At one time, I had recommended the addition of 10 mg of triamcinolone per liter bag of tumescent solution. It is now apparent that triamcinolone is not necessary. Furthermore, as with other antiinflammatory drugs, triamcinolone may decrease the patient’s immune response and increase the risk of postoperative infection. Although the tumescent technique dramatically reduced surgical bleeding, my surgical technique was similar to that of most other surgeons. I used larger cannulas and the minimum number of incisions and closed every incision with sutures. My patients thus experienced postoperative swelling and ecchymoses. In the early days of tumescent liposuction, approximately 1 in 50 patients experienced a peculiar type of postoperative inflammation. Typically, this presented 5 to 8 days after surgery with focal areas of increased warmth, tenderness, and swelling. I referred to this clinical condition as “postliposuction panniculitis.” Every attempt to culture an affected area gave negative bacteriologic results. Furthermore, the empiric use of antibiotics produced no improvement. When 10 mg/day of the antiinflammatory corticosteroid prednisone by mouth was added to the antibiotic regimen, however, the focal inflammation subsided within 24 to 48 hours. Corticosteroids induce the synthesis of an antiphospholipase protein that inhibits the enzyme phospholipase A₂, which converts arachidonic acid to prostaglandin PGG₂. It seemed reasonable to add an injectable analog of prednisone, such as triamcinolone, to the anesthetic solution and thereby preempt the focal inflammation. Triamcinolone, with its low aqueous solubility, tends to persist locally and reduce symptomatic inflammation for up to 6 days. Triamcinolone became a standard part of the formulation of the anesthetic solution for tumescent liposuction. Subsequently I noticed that every patient had less postoperative soreness and swelling and that the incidence of postliposuction panniculitis had decreased significantly. I was mistakenly convinced that adding triamcinolone [10 mg/L] to the anesthetic solution did decrease postoperative inflammation and soreness.

Elimination of Sutures.
Eventually I learned that the relation between triamcinolone and the reduction of postoperative pain and edema was merely a spurious correlation. At the same time that I started using triamcinolone, I also ceased closing the incisions with sutures. It is now apparent that decreased postoperative inflammation is simply the result of the elimination of sutures. Omitting sutures encourages copious postoperative drainage of the inflammatory blood-tinged anesthetic solution. Any liposuction surgeon can easily test this hypothesis in the following manner. When doing liposuction of the outer thighs, place a small incision at the most distal and dependent portion of both thighs. Some amount of liposuction must be done through this incision to ensure an adequate path for drainage. Suture one distal incision, and allow the contralateral distal incision to remain nonsutured. The nonsutured incision will require an absorbent pad to contain the drainage. The relative absence of swelling, bruising, and tenderness on the side with open drainage versus the side with sutured incision will become apparent within a few days.

Careful Documentation Versus Experimentation.
Tumescent liposuction is radically different from other liposuction techniques. It is the only technique that permits liposuction totally by local anesthesia. The early development of tumescent liposuction, however, did not involve the use of lidocaine dosages above the amounts already being used by many surgeons who were doing liposuction at that time with relatively concentrated lidocaine, in combination with IV narcotics and sedation. The unprecedented aspects of the tumescent technique were the demonstration that a 10- to 20-fold dilution of commercially available 1% lidocaine with epinephrine resulted in the following:
1.         Significantly lower peak plasma lidocaine concentrations
2.         Virtual elimination of liposuction blood loss
3.         Dramatically more extensive and profound local anesthesia

Most importantly, for any given mg/kg dosage of subcutaneous lidocaine with epinephrine, dilution dramatically reduced peak plasma lidocaine concentrations. The advent of the tumescent technique provided the rationale for beginning careful clinical observations that, for the first time, provided a scientific estimate for the maximum safe dose of subcutaneous lidocaine. The development of the tumescent technique was the result of using commonly accepted doses of lidocaine and epinephrine and showing that dilution improved clinical local anesthesia. Long after tumescent liposuction was widely practiced, plasma lidocaine levels were documented in a manner analogous to the routine documentation of lidocaine plasma levels in cardiac care units. This documentation of plasma levels is regarded as sound clinical practice among cardiologists whenever significant doses of lidocaine are given. The documentation of plasma lidocaine concentrations associated with tumescent liposuction should not be regarded as clinical experimentation. Careful clinical documentation of drug levels associated with a well-established, safe clinical procedure is good clinical practice. It is not clinical experimentation.

Continuing Developments

Recent advances in the tumescent technique continue in the areas discussed earlier. Sutures are being avoided to maximize postoperative drainage and thus minimize postoperative swelling, bruising, and tenderness. Microcannulas are now employed to permit liposuction in the most fibrous areas of fat. Surgeons are realizing that microcannulas permit the removal of more fat and provide smoother results than larger cannulas. A more comprehensive pharmacokinetic study of tumescent lidocaine is in progress. It involves both formal IRB approval and submission of an Investigational New Drug (IND) application to the FDA. The IND application includes a formal request for a change in the official FDArecommended maximum dose of subcutaneous lidocaine.

Summary

The development of the tumescent technique was the result of dermatologists’ preference for local anesthesia. Dermatologic surgeons achieved this by pursuing an uncharted path to an unanticipated destination, guided only by clinical observation and cautious, incremental optimization. With time the pharmacologic principles of the tumescent technique will result in applications far beyond dermatologic surgery. The range of these applications will depend on the imagination of specialists in other clinical disciplines, the nature of the clinical problems that confront them, and the needs and satisfaction of the patients they serve.

References

1.         Dolsky RL, Newman J, Fetzek JR, Anderson RW: Liposuction: history, techniques and complications, Dermatol Clin 5:313-333, 1987. 2.         Field L: Personal communication, 1994.
3.         Klein JA: The tumescent technique for liposuction surgery, Am J Cosmetic Surg 4:263-267, 1987.
4.         de Jong RH: Local anestheics, St Louis, 1994, Mosby.
5.         Klein JA: Anesthesia for liposuction in dermatologic surgery, J Dermatol Surg Oncol 14:1124-1132, 1988.
6.         Lillis PJ: Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption, J Dermatol Surg Oncol 14:1145-1148, 1988.
7.         Gumuncio CA, Bennie JB, Fernando B, et al: Plasma lidocaine levels during augmentation mammaplasty and suction-assisted lipectomy, Plast Reconstr Surg 84:624-627, 1989.
8.         Asken S: Liposuction surgery and autologous fat transplantation, East Norwalk, Conn, 1988, Appleton & Lange.
9.         Xylocaine: maximum recommended dosages. In Physicians’ desk reference, ed 49, Montvale, NJ, 1995, Medical Economics Data.
10.       Ritchie JM, Greene NM: Local anesthetics. In Gilman AG, Rall TW, Nies AS, Taylor P, editors: Goodman and Gilman’s The pharmacologic basis of therapeutics, ed 8, New York, 1993, McGraw-Hill.
11.       Klein JA: Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction, J Dermatol Surg Oncol 16:248-263, 1990.
12.       Stewart JH, Cole GW, Klein JA: Neutralized lidocaine with epinephrine for local anesthesia, J Dermatol Surg Oncol 15: 1081-1083, 1989.
13.       Stewart JH, Chinn SE, Cole GW, Klein JA: Neutralized lidocaine with epinephrine for local anesthesia. II, J Dermatol Surg Oncol 16:842-845, 1990. BOX 1-1

Fallacious Assumptions

About Local Anesthesia:

Fallacy 1: The effect of local anesthesia rarely persists for more than 2 hours; and the higher the concentration of local anesthesia, the longer its duration.⁴

Fallacy 2: Peak plasma lidocaine levels occur within 60 to 90 minutes after subcutaneous infiltration. ^5,6

Fallacy 3: Most of the lidocaine infiltrated for tumescent liposuction is removed along with the aspirated fat.^7,8

Fallacy 4: Bupivacaine (Marcaine) is as safe as lidocaine, and the combination of lidocaine and bupivacaine for liposuction by local anesthesia is appropriate and safe.

Fallacy 5: Lidocaine dosage restrictions (7 mg/kg with epinephrine) should be the same for all forms of local anesthesia, including epidural, axillary, or intercostal nerve block and subcutaneous and intradermal infiltration.^4,9

Fallacy 6: The rate of absorption is independent of the concentration of the infiltrated lidocaine.⁴