The tumescent technique, which permits liposuction totally by local anesthesia, is the brainchild of Dr. Jeffrey Klein. In developing this technique, Dr. Klein placed safety as his top priority followed by excellent cosmetic results and rapid post-operative return to normal activities. Since its invention in 1985, Dr. Klein has taught numerous classes on the tumescent technique to cosmetic surgeons all over and it has become the worldwide standard of care for maximizing the safety of liposuction.

Dr. Klein instructing a class on the tumescent technique to cosmetic surgeons at his center in Orange County, California.

Liposuction Information

Liposuction Defined
Liposuction is defined as the removal of fat from deposits beneath the skin using a hollow stainless steel tube (called a cannula) with the assistance of a powerful vacuum. Liposuction can be accomplished either with the use of general anesthesia, or with heavy IV sedation, or totally by local anesthesia. This web site considers both the benefits and the potential dangers of local anesthesia and of systemic anesthesia.

Tumescent Liposuction
Tumescent liposuction refers to a technique that uses large volumes of very dilute local anesthesia that is injected into the fat causing the targeted areas to be come tumescent, or swollen and firm. Local anesthesia is widely regarded as the safest form of anesthesia. Because local anesthesia persists for many hours there is no need for narcotic pain medications after surgery.

Modified Tumescent Liposuction
Modified tumescent liposuction refers to a combination of tumescent local anesthesia plus some form of systemic anesthesia (general anesthesia or heavy IV sedation). Because general anesthesia or heavy IV sedation can be dangerous, they must be administered by an anesthesiologist.

The Different Liposuction Techniques
There are many ways to do liposuction, for example liposuction can be accomplished painlessly either totally by local anesthesia or with general anesthesia. In the realm of liposuction, maximum speed and maximum volume of aspirate are not criteria for excellence. Ultimately, excellence is measured in terms of patient happiness which is a function of safety, patient comfort, finesse, and quality of results. The important distinction between liposuction surgeons who are board certified is the liposuction technique that they use. The surgeon's specialty is not as important as the surgeon's technique, experience and attitude toward safety.

Liposuction Complications
Liposuction complications are often the direct result of lack of caution, poor judgment, over confidence, ignorance about pharmacology, or adherence to faulty dogma. This web site discusses these traits, and explains how to reduce the risk of liposuction surgical complications.

The "Art of Liposuction"
Liposuction is a medium of artistic expression that displays itself in (1) a practical application of scientific knowledge, (2) the production of what is beautiful, (3) a perfection of workmanship, (4) a perpetual quest for improvement in technique, and (5) a skill attained through clinical experience, and above all (6) making people feel happy about what they see in the mirror.

Artistry and Safety are Related
This web site asserts that artistry and safety depend on each other. The word "art" implies skill and mastery of a technique. In order to master an artistic liposuction technique, the surgeon must have the skill and intelligence to avoid exposing patients to unnecessary dangers. The true artist provides better results, and uses the safest technique and never forgets the duty to "first, do no harm." 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 procedures are safer and ultimately yield better results. It is not artistry to take unnecessary risks or push liposuction to the limits of safety.

Risks of Liposuction
Risks of Liposuction must be well understood by all prospective liposuction patients. This web site emphasizes the need to constantly be aware of safety issues. In order to minimize the risk of liposuction, the patient must be aware of the following facts:

Too much liposuction is an excessive volume of aspirated fat, or an excessive number of areas treated. Excessive surgical trauma (excessive liposuction) is dangerous and is an important cause for serious liposuction complications.
Unrelated surgical procedures on the same day as liposuction are unnecessary. Prolonged exposure to anesthesia is dangerous and is an important cause for serious liposuction complications.
Disfiguring skin irregularities and depressions are frequently the result of the surgeon's inattention to detail. For example, if a liposuction surgeon attempts to do too much on a single day, and becomes fatigued, the result may be an inattention to detail, and undesirable cosmetic results. A liposuction cannula is a stainless steel tube inserted through an incision in the skin that is employed to suction the fat. The size of the liposuction cannula can influence the smoothness of the skin after liposuction. The use of large cannulas tend to create irregularities more commonly than microcannulas (outside diameter less than 3 millimeters). Surgeons who do total-body liposuction tend to use larger cannulas.

Tumescent Technique is Safest
The tumescent technique for liposuction is unquestionably the safest form of liposuction. When tumescent liposuction is done correctly (not excessively), it is a very safe procedure. For example, there have been no reported deaths associated with tumescent liposuction totally by local anesthesia. Even when general anesthesia is combined with the tumescent technique, liposuction is quite safe provided the volume of fat removed and the number of areas treated during a single surgery is not excessive. The dilute epinephrine contained in the tumescent anesthetic solution profoundly shrinks capillaries and thus virtually eliminates surgical blood loss.

Smoother Cosmetic Results
The tumescent technique permits the use of microcannulas which in turn yields smoother cosmetic results. Traditional liposuction cannulas (stainless steel tubes) have a relatively large diameter and remove fat rather quickly. However, with the use of large cannulas (diameter greater than 3 millimeters) there is an increased risk of irregularities and depressions in the skin. Microcannulas with a diameter less than 3 millimeters, allow fat to be removed in a smoother and more uniform fashion. Some surgeons prefer larger cannulas because it allows liposuction to be done more quickly.

Rapid Healing
After tumescent liposuction, there is a certain amount of blood-tinged local anesthetic solution that remains under the skin. This excess fluid is either slowly absorbed over several weeks into the blood stream, or it can be rapidly removed by drainage through skin incisions and absorbed by special absorptive pads (HK Pads).

Rapid Drainage
Rapid drainage of blood-tinged anesthetic solution out of incision sites, accelerates the rate of healing, and reduces post-operative pain swelling, and bruising. Post-liposuction drainage of blood-tinged anesthetic solution can be maximized by 1) leaving incision sites open and not closed with sutures, 2) placing several adits (1.5 mm tiny round holes) in the skin to encourage drainage, 3) placing HK Pads on the skin to absorb the drainage, and 4) wearing spandex compression garments to encourage drainage.

Liposuction Techniques

There are various techniques for doing liposuction. Some techniques are now longer considered safe (Dry Technique), and some are recognized as world-wide standards of care (Tumescent Technique). The links above will take you to written discussions of the most popular and important of the liposuction techniques.

Liposuction Procedures

The links will take you to pages of text that discuss the various aspects and unique considerations of liposuction for that selected area of the body.
Abdomen | Anterior Thighs | Arms | Back, Female | Breasts, Female | Breasts, Male | Buttocks | Face & Neck | Flanks, Male | Inner Thighs | Legs & Ankles | Outer Thighs

Safety and Complications

A surgical complication is defined as any undesirable result of surgery. The most common complication of liposuction is a result that produces an unhappy patient. The most common cause of an unhappy patient is a patient's unrealistic expectations before surgery. Avoiding unrealistic expectations requires careful and accurate communication between patient and surgeon. This entire web site is dedicated to providing patients with information so that they can make a well-informed decision about having liposuction. Detailed information about specific complications is presented in the following pages entitled:

An Overview of Liposuction Complications
Excessive Liposuction
Common & Minor Complications
Rare & Severe Complications
Drugs That Increase Bleeding
Risks of Local Anesthesia
Risks of General Anesthesia
Risks of Ultrasonic Liposuction
Excessive Liposuction
The greatest risks of liposuction are associated with the tendency of some surgeons to do too much surgery on the same day. The three types of excessive surgery include 1) removal of an excessive volume of fat by liposuction on a single day, 2) liposuction of an excessive number of body areas on the same day, 3) combinations of liposuction and other unrelated surgical procedures which involves excessive surgical trauma and prolonged exposure to general anesthesia. (See Excessive Liposuction).

Common & Minor Complications
Common & minor complications are conditions that do not threaten a patient's life, normal body functions or the ability to work. These include superficial irregularities of the skin, seromas, hematomas, focal skin necrosis, allergic reactions to drugs, visible or disfiguring scars, discoloration of the skin, fainting during or after surgery, temporary bruising, numbness or nerve injury, and temporary adverse drug reactions. Most of these complications can be considered minor, however some may become quite serious. Post-liposuction syncope (fainting) the next morning at home, especially after urinating is not rare. This can be serious if the patient falls and experiences a head or neck injury. (See Common & Minor Complications).

Rare & Severe Complications
Rare & severe complications associated with liposuction include problems with anesthesia, blood clots in the leg or lung, injury to the abdominal organs, excessive intravenous fluids, excessive blood loss, excessive loss of body heat (hypothermia), infections, allergic drug reactions, aspiration pneumonia (most likely under general anesthesia), cardiac arrest and potentially fatal cardiac arrhythmias, permanent nerve damage, brain damage due to lack of oxygen under general anesthesia, and seizures. See Rare & Severe Complications.

Drugs That Increase Bleeding Drugs that increase bleeding, if taken by a patient soon before having liposuction, can cause liposuction complications such a hematoma (a large collection of blood trapped beneath the skin), or excessive bleeding that might require hospitalization. Among the more common drugs that can interfere with normal clotting of blood are aspirin, ibuprofen (Motrin, Advil), and warfarin (Coumadin). Even vitamin E, red wine, and some herbal remedies can cause prolonged bleeding. You are provided with a long list of prescription drugs and non-prescription drugs that interfere with bleeding (see Drugs that Increase Bleeding).

Risks of Local Anesthesia
Lidocaine is the safest of local anesthetics available for liposuction. At lidocaine concentrations in the blood exceeding 6 milligrams/liter, patients might experience some toxicity. Blood concentrations of lidocaine in excess of 12 milligrams/liter can produce serious cardiac toxicity. The maximum recommended dosage of lidocaine for tumescent liposuction is 50 mg/kg (50 milligrams/kilogram of patient weight). The most extraordinary aspect of the tumescent technique is its unprecedented safety record when used as directed. Most liposuction surgeons know that it can be dangerous to give a patient a dosage of tumescent lidocaine that exceeds 50 mg/kg. All liposuction-related deaths have been associated with either the use of general anesthesia, or IV sedation, or lidocaine doses in far in excess of 75 mg/kg. The tumescent technique is dangerous in the hands of surgeons or anesthesiologists who have not had specific training in the technique. There has never been a reported death associated with tumescent liposuction totally by local anesthesia.

Risks of General Anesthesia
General anesthesia for liposuction can be considered safe when 1) the general anesthesia is administered by a board certified anesthesiologist, 2) liposuction is not performed with other unrelated surgical procedures, and 3) there is no excessive liposuction. The most dangerous aspects of general anesthesia are respiratory depression and impairment of protective airway reflexes. The risks of general anesthesia include human error, unsuspected inherited hypersensitivity to anesthetic drugs, accidental overdose of anesthesia, any undetected airway disconnection or airway blockage. General anesthesia, which increases the risk of vomiting and impairs protective airway reflexes, can cause aspiration of stomach contents. Because general anesthesia impairs the ability to breathe, when a complication does occur it can lead to disaster.

Dangers of Ultrasonic Liposuction
Ultrasonic Assisted Liposuction (UAL) requires the use of tumescent fluid and uses either a metal probe or metal paddle to deliver ultrasonic energy and heat into subcutaneous fat. Internal UAL has largely been abandoned because of the risk of full-thickness skin burns and severe scaring. The initial reports of internal UAL were unrealistically enthusiastic. Some authors did not report their complications, and others have learned of major UAL complications after publishing their articles. Because of insufficient proof of safety, UAL devices have not been approved by the FDA for use in doing liposuction.

Safety is a Relative Term
It is impossible to prove that a surgical procedure is absolutely safe. On the other hand it is realistic and appropriate to compare two procedures and conclude that one is relatively safer than the other. Prospective liposuction patients should strive to understand the options that are available and choose the safest procedure.

Preventing Complications
Preventing complications should be the most important concern of both patients and liposuction surgeons. Surgeons can reduce the risk of complications by proper selection of patients. Surgeons should avoid patients who have 1) unrealistic medical expectations, 2) a history of significant medical problems. Patients can reduce the risk of complications by 1) resisting the temptation to save time by attempting to do multiple unrelated surgical procedures along with liposuction, and 2) resisting the temptation to maximize the volume of fat removed on a single day. It is much safer to divide one very large liposuction procedure into two or more separate procedures done on separate days. Liposuction by general anesthesia can be considered safe, however, liposuction totally by local anesthesia is safer.

Post-Operative Care

The Tumescent Technique
The tumescent technique for liposuction uses a large volume of a dilute solution of lidocaine and epinephrine. The tumescent technique for liposuction has become the worldwide standard of care for liposuction because it has eliminated the common problem of surgical bleeding associated with older techniques. The dilute tumescent fluid contains both lidocaine for local anesthesia and dilute epinephrine that shrinks capillaries. After liposuction, a large volume of blood-tinged tumescent anesthetic solution remaining trapped under the skin may slow postoperative recovery.

Open Drainage and Bimodal Compression
This is a new method for post-liposuction care. It provides improved patient comfort, shortens the healing time, and decreases the number of postoperative visits to the surgeon. Open-drainage with bimodal compression is a modern technique that greatly reduces the degree of pain, swelling, bruising and convalescence time. Nevertheless, many surgeons and nurses continue to use antiquated post-liposuction care techniques that were used before the invention of the tumescent liposuction. This chapter will introduce you, and perhaps your surgeon to the newer technique for accelerating post-liposuction recovery known as Open-Drainage and Bimodal Compression.

Traditional After-Liposuction Care Methods
Traditional After-Liposuction Care Methods rely on 1) the closure of incisions with sutures and 2) the prolonged use of high compression elastic garments for two weeks or more. Most liposuction surgeons would agree that these traditional methods of caring for patients after liposuction leave much room for improvement. The common undesirable characteristics of the healing phase after liposuction include protracted swelling, bruising, tenderness, as well as time-consuming post-operative follow-up visits with the surgeon.

Minimizing Swelling, Bruising, & Tenderness
Swelling, bruising, tenderness are the result of 1) persistent blood-tinged tumescent anesthetic solution trapped under the skin after liposuction, and 2) injury to subcutaneous lymphatic capillaries caused by the liposuction procedure. Lymphatic capillaries are small vessels that drain fluid away from injured body tissues. Temporary injury to lymphatic capillaries as a result of liposuction cannot be avoided. However the persistence of blood-tinged tumescent solution trapped under the skin can be prevented. Older techniques for post-liposuction care do not facilitate rapid drainage of this blood-tinged anesthetic solution. The newer technique known as "open drainage" diminishes the swelling and speeds recovery after tumescent liposuction.

Prolonged High-Compression In the Old Days
Prolonged High-Compression in the old days was necessary. Before the tumescent technique for liposuction, bleeding was the major problem associated with liposuction. After a liposuction had been completed, patients had to wear a high compression garment for many weeks in order to minimize the problems caused by so much bleeding. Immediately after surgery the high compression garments were required to compress the bleeding vessels and stem the loss of blood. Patients continued to wear high compression garments for up to six weeks in order to decrease the swelling caused by the blood trapped beneath the skin.

Prolonged Compression Now Makes Matters Worse
Now that tumescent technique has become the standard of care, the traditional post-liposuction techniques, established before the invention of the tumescent technique, may now contribute to delayed healing and prolonged swelling. With tumescent liposuction there is no need for prolonged high compression because there is no significant bleeding during surgery, and virtually no blood remains trapped beneath the skin. After tumescent liposuction, closing incisions with sutures will prevent drainage of residual blood-tinged anesthetic solution, and encourage swelling. In addition, the prolonged use of excessive compression after tumescent liposuction will compress the subcutaneous lymphatic capillaries and impair the lymphatic drainage system that is responsible for removing fluid from injured tissues. After tumescent liposuction, the goal is to maximize the rate of drainage of residual blood-tinged tumescent anesthetic solution.

Preventing Swelling
Preventing swelling, bruising and inflammation before they occur by removing the subcutaneous blood-tinged fluids and encouraging lymphatic drainage is the ideal method for post-liposuction care. The method known as Open-Drainage achieves these results by 1) encouraging open drainage by not closing incisions with sutures, 2) the use of special pads that both absorb the messy blood-tinged drainage and reduces bruising by uniformly distributing the compression of elastic garments, and 3) using special elastic compression garments designed for optimal drainage as well as patient convenience and comfort.

Open-Drainage
Open-Drainage after tumescent liposuction refers to the technique for maximizing the drainage of blood-tinged tumescent solution by 1) using small adits which are tiny round holes (1 mm, 1.5 mm or 2 mm in diameter) made by skin-biopsy punch to facilitate postoperative drainage, 2) placing adits in strategic locations in order to maximize gravity-assisted drainage, 3) allowing the adits to remain open instead of being closed with sutures.

Fewer Postoperative Visits
Fewer postoperative visits to the surgeon's office can save time and hassle for the patient and the patient's family. Because there are no sutures to be removed, the patient can eliminate the need to return to the surgeon to have the sutures removed. Because there is less swelling, and pain with Open-Drainage, there is less need for the patient to return to see the surgeon in the early postoperative period for time-consuming follow-up examinations. Patients should feel free to return to see the surgeon if there is any concern about the healing process. On the other hand, if everything is healing well and the patient has no significant concerns then the first follow-up visit is often not until six weeks after surgery.

Super-Absorbent Pads
These prevent staining clothes and furniture, and to avoid the "sight of blood" that would otherwise accompany the drainage of blood-tinged tumescent fluid. For example, the HK Pads that measure 12 x 20 inches weigh just 6 ounces and have the capacity to absorb more than a liter (two pounds= 32 ounces) of water, or more than 5.5 times their own weight. In practice, the absorbent pads have two distinct functions. First, they absorb the large volume of tumescent drainage to improve patient comfort and hygiene, and secondly the pads distribute the elastic garment's compressive force more uniformly. This uniform compression narrows the gaps between interstitial collagen bundles in the dermis and prevents red blood cells from moving toward the skin surface where it appears as a bruise. HK Pads (US Patent 6,162,960) are the only commercially available pads of this type.

Adhesive Foam Pads
Adhesive foam pads such as Reston foam can decrease bruising, but not swelling, when applied to the skin over an area treated by liposuction. Reston foam has been associated with an increased risk of infection, skin ulceration and skin necrosis. Some surgeons continue to use Reston foam after liposuction. The manufacturer of Reston foam, the 3M Corporation, has advised surgeons that Reston foam is not intended to be used for liposuction.

Bimodal Compression Bimodal Compression refers to the sequential use of two different stages of post-liposuction compression. During the first stage of bimodal compression, a high degree of compression is maintained for as long as drainage persists, plus an additional 24 hours past the time when all drainage has ceased. The second stage of bimodal compression begins 24 hours after all drainage has ceased, and employs either moderate compression or no compression. Some patients prefer to continue wearing a minimally compressive garment for comfort. Optimal compression garments should maximize the rate of open drainage, while minimizing the risk of complications due to excessive compression such as blood clots in the legs and lungs. An ideal garment must also be able to accommodate bulky absorbent pads, and be easy for the patient to apply and remove without assistance.

The Ideal Elastic Compression Garment
The ideal elastic compression garment must be easily put-on and taken-off by the patient without assistance, and it must easily accommodate the use of bulky super-absorbent pads that are necessary when open-drainage is used to accelerate healing.

Traditional Elastic Compression Garments
Most of the available elastic compression garments have a traditional design. Traditional garments usually have a zipper on the side and are made of an elastic cloth that is relatively resistant to stretching. Traditional garments are relatively difficult to put-on or take-off without assistance. This difficulty is especially troublesome for someone who has just had liposuction and is sore, swollen and unable to easily bend-over and wiggle into a tight garment.

Why don't more surgeons use open drainage?
Some surgeons simply do not appreciate the advantages of open-drainage after tumescent liposuction. Other surgeons persist in the opinion that the prolonged high compression provided by traditional compression garments is necessary and they do not feel confident using any other type of garment. Traditional compression garments are difficult to put-on when bulky, super-absorbent pads, have been placed on the patient. It is easier to simply close all of the incisions with sutures, and thus the problem of messy drainage. The use of open-drainage without the use of super-absorbent pads, would produce a very messy situation. The blood-tinged fluid would drain out of incisions and onto the patient's clothing, bedding, carpets and furniture. Another solution to this problem is to use garments that provide both high compression and that can accommodate the use of super-absorbent pads.

Garments Designed for Open-Drainage
HK garments produced by HK Surgical, Inc., are examples of elastic compression garments that provide high compression, that are designed to accommodate bulky super-absorbent pads, and that are easy to put-on and take-off without assistance. HK Torso Garments are elastic garments worn over the torso with additional elastic binders to provide adjustable compression after liposuction of the abdomen, hips, waist, or breasts HK Over-all Garments, are usually worn two at a time, one on top of the other, and are used after liposuction of the thighs or hips, or abdomen. Each garment when worn alone provides a moderate degree compression, but when two garments are worn at the same time, their compression is additive, and together they provide a high degree of compression. It is much easier for a patient to put on two moderate-compression garments which can be done without assistance, than it is to apply a single high-compressive garment that often requires the assistance of a spouse or friend.

Pharmacology

This page is concerned with clinical pharmacology of the tumescent technique for local anesthesia using large volumes of very dilute lidocaine (local anesthetic) and epinephrine (vasoconstrictor that shrinks capillaries). The word tumescent means swollen and firm. With the tumescent technique such a large volume of dilute lidocaine is injected into the targeted fatty tissues that those areas become tumescent (swollen and firm). The tumescent technique produces profound local anesthesia of the skin and subcutaneous fat that lasts for many hours.

Safety of the Tumescent Technique
Safety of the tumescent technique is remarkable. No deaths have ever been reported in association with the tumescent technique for liposuction totally by local anesthesia. Most serious liposuction complications seem to be associated with excessive liposuction or multiple simultaneous unrelated surgeries, and the use of general anesthesia or narcotic analgesics. The amazing safety record of liposuction totally by local anesthesia was surprising because the technique uses dosages of lidocaine (local anesthetic) that were considered potentially toxic. The mystery of this unexpected safety was solved by studying the pharmacokinetics of tumescent lidocaine.

Pharmacokinetics
This is the science that studies the concentration, pathway and fate of drugs as they travel through the body. For example, the pharmacokinetics of tumescent lidocaine is concerned with measuring the concentration of lidocaine in the blood, and how this concentration changes over time. The toxicity of a local anesthetic is a function of its peak plasma concentration which in turn depends on several factors including the total milligram per kilogram dose, and the rates of systemic absorption and elimination.

Safe Dose
A safe dose of tumescent lidocaine is estimated to be 45 mg/kg for thin patients, and 50 mg/kg for average to overweight patients. (Tumescent Technique, by J. Klein, Mosby Publishers, 2000).

Lidocaine Can Be Toxic
Lidocaine can be toxic if its concentration in the blood exceeds a threshold of 6 milligrams/liter. The most extraordinary aspect of the tumescent technique is its unprecedented safety record when used as directed. Most liposuction surgeons know that it can be dangerous to give a patient a dosage of tumescent lidocaine that exceeds 50 mg/kg. All liposuction-related deaths have been associated with either the use of general anesthesia, or IV sedation, or grossly excessive lidocaine doses in excess of 75 mg/kg. The tumescent technique is dangerous in the hands of surgeons or anesthesiologists who have not had specific training in the technique. There has never been a reported death associated with tumescent liposuction totally by local anesthesia.

Total Dosage of Lidocaine Affects Safety
The total amount of lidocaine, measured in terms of milligrams of lidocaine per kilogram of body weight (mg/kg), that is given to a patient directly determines the risk of lidocaine toxicity. Following an injection of lidocaine, the concentration of lidocaine in the blood gradually increases, eventually reaching a peak, and then declines. The risk of toxicity depends on the peak concentration of lidocaine. Lower peak plasma lidocaine concentrations reduce the risk of lidocaine toxicity. The fundamental reason for the great safety of tumescent local anesthesia is its exceptionally slow rate of lidocaine absorption.

Drug Interactions Affect Safety
Certain drugs such as the SSRI antidepressant Zoloft), the antibiotic erythromycin, the antifungal drugs ketoconazole (Nizoral) and Fluconazole (Diflucan) can impair the enzyme in the liver (cytochrome P450 3A4) that is required to metabolize lidocaine. Such drugs slow the rate of metabolism, and thus increase the amount of lidocaine in the body and the peak lidocaine concentration in the blood, which in turn increases the risk of lidocaine toxicity. It is important that patients and liposuction surgeons be aware this type of drug interaction, and either discontinue all such drugs at least 10 days before surgery or reduce the dosage of lidocaine to less than 35 mg/kg. (See Drugs that Inhibit CYP3A4)

Lidocaine Absorption Rate Affects Safety
For any given milligram per kilogram (mg/kg) dose of lidocaine, anything that slows the rate of lidocaine absorption, will reduce the peak lidocaine plasma level, and thus reduce the risk of lidocaine toxicity. There are three factors that cause tumescent lidocaine to be absorbed from fat at an exceptionally slow rate: 1) subcutaneous fat has a relatively low volume of blood flow, 2) dilute epinephrine produces a prolonged and profound degree of vasoconstriction, and 3) lidocaine is lipophilic and is readily sequestered in fat cells. When lidocaine is injected into muscle, through a vein directly into the blood, or in the gums (for dental anesthesia) the rate of absorption into the blood is much more rapid than when lidocaine is injected into fat. Different rates of lidocaine absorption require different lidocaine dosage limits.

Tumescent Anesthesia is Local Anesthesia
When the tumescent technique is performed properly, the effects of tumescent lidocaine are local and not systemic. However, there are surgeons who do very large volume liposuction surgeries; these surgeons may use large amounts of tumescent anesthesia and expose their patients to potentially excessive amounts of injected fluids or excessive amounts of lidocaine.

Definition of Dosage and Dose
There is a distinction between the words dosage and dose.

The word dosage describes the amount of drug given to a patient expressed in units of mg/kg where mg = the weight of the drug expressed in milligrams, and kg = the patients weight expressed in kilograms. The word dose describes the amount of drug expressed in mg units where mg = total milligrams of drug given to a patient. The word dose does not take into account the patients total body weight. By using the mg/kg dosage to determine the amount of drug given to a patient, a physician can more accurately predict equivalent effects among patients whose weights are considerably different.

Reduced Discomfort Upon Injection
Commercially available solutions of lidocaine are made acidic in order to increase the solubility of lidocaine. If the lidocaine solution also contains epinephrine, then an acidic solution is necessary to increase the shelf-life of epinephrine. Unfortunately, acidic solutions produce a slightly painful stinging sensation upon injection into the skin or into subcutaneous fat. The stinging discomfort of an injection of lidocaine can be reduced by the addition of sodium bicarbonate into the solution to neutralize the pH of commercially available solutions.

Effect on Nerve Fibers Types
Local anesthetics tend to block small nerve fibers sooner than larger fibers. Clinically this is manifested by the observation that small fibers that mediate pain and temperature, are blocked more easily than the larger sensory nerve fibers that mediate pressure, and vibrations, or motor nerves that mediate muscle function. Tumescent local anesthesia in adipose tissue produces a rapid blockade of pain and temperature sensation, while local anesthesia has less effect on pressure and vibratory sensation. Thus, with adequate infiltration of tumescent local anesthesia, patients should not feel pain during tumescent liposuction, however they will often be aware of vibrations, and a peculiar rasping sensation.

Antibacterial Effects of Lidocaine
Tumescent liposuction is associated with a remarkably low risk of postoperative infections. This enviable clinical record provides strong evidence that in-vivo tumescent local anesthesia is bacteriostatic (prevents the growth of bacteria) and bacteriocidal (kills bacteria). There are few, if any, extensive surgical procedures with a lower incidence of infection than that of tumescent liposuction.

Lidocaine Reduces the Risk of Infections
Two recent reports have found that dilute lidocaine in a concentration of 500 mg per liter of solution (0.05%) does have in-vitro antibacterial activity. Another study found this lidocaine dilution to be bacteriostatic for Staphylococcus aureus. Another in-vitro study, using suspensions of bacteria containing approximately 105 bacteria per ml found that all gram-positive organisms tested, including S. aureus, had significantly lower colony counts in 0.05% or higher concentrations of lidocaine diluted by the IV anesthetic propofol. There is in-vitro evidence that lidocaine is not just bacteriostatic but actually bacteriocidal for organisms isolated from skin lesions. Recently it has been shown that when sodium bicarbonate is added to lidocaine, this in-vitro bacteriocidal activity is increased.

Doing Too Much Liposuction is Dangerous
Common sense is still necessary. The enviable record of tumescent liposuction is attributable to 1) moderation in terms of the amount surgical trauma inflicted during a single surgical procedure, and 2) a wise selection of healthy patients. If surgeons disregard common sense and moderation in liposuction, and attempt to do too much liposuction on a single day, then the record of postoperative complications is no longer enviable.

Liposuction History