Introduction
The word "tumescent" means
swollen and firm. By injecting a large volume of very dilute
lidocaine (local anesthetic) and epinephrine (capillary
constrictor) into subcutaneous fat, the targeted tissue
becomes swollen and firm, or tumescent. The tumescent
technique is a method that provides local anesthesia to large
volumes of subcutaneous fat and thus permits liposuction
totally by local anesthesia. The tumescent technique
eliminates both the need for general anesthesia and need for
IV narcotics and sedatives. The tumescent technique for
liposuction 1) provides local anesthesia, 2) constricts
capillaries and prevents surgical blood loss 3) provides fluid
to the body by subcutaneous injection so that no IV fluids are
needed.
Tumescent Dilution
Depending upon
the clinical requirements, a tumescent anesthetic solution may
contain a 5 to 40 fold dilution of lidocaine found in
commercially available formulations of local anesthesia.
Commercial solutions of lidocaine used by dentists and
anesthesiologists typically contain 1 gram of lidocaine and 1
milligram of epinephrine per 50 milliliters of saline. In
contrast, tumescent solutions of local anesthesia contain
approximately 1 gram of lidocaine and 1 milligram of
epinephrine in 1,000 milliliters of saline. This is a 20 fold
dilution of the commercial version of lidocaine and
epinephrine.
Dilution & Vasoconstriction Produce Safety
Tumescent
liposuction totally by local anesthesia has proven to be
extremely safe despite the use of unprecedented large doses of
lidocaine and epinephrine. The explanation for this remarkable
safety is the extreme dilution of the tumescent local
anesthetic solution. Large volumes of dilute epinephrine
produce intense constriction of capillaries in the targeted
fat, which in turn greatly delays the rate of absorption of
lidocaine and epinephrine. Undiluted lidocaine and epinephrine
is absorbed into the bloodstream in less than an hour.
Tumescent dilution causes widespread capillary constriction
which causes the absorption process to be spread over 24 to 36
hours. This reduces peak concentration of lidocaine in the
blood, which in turn reduces the potential toxicity of given
dose of lidocaine. Dentists typically use concentrated
epinephrine which may cause a rapid heart rate if the
epinephrine is rapidly absorbed. When very dilute tumescent
epinephrine is used, the wide spread vasoconstriction slows
the rate of epinephrine absorption, which in turn prevents an
increase in heart rate.
Vasoconstriction Prevents Blood Loss
Profound
vasoconstriction (shrinkage of capillary blood vessels)
results from the tumescent infiltration of a large volume of
dilute epinephrine into subcutaneous fat. Tumescent
vasoconstriction is so complete that liposuction can be done
with virtually no blood loss. In contrast, the older forms of
liposuction used before the invention of the tumescent
technique were associated with so much surgical blood loss
that autologous blood transfusions were often routine.
Vasoconstriction Prolongs Local Anesthesia
Because the
vasoconstriction delays lidocaine absorption, the local
anesthetic remains in place in the fat for many hours. This
prolonged anesthesia permits surgery for up to 10 hours after
infiltration, and provides 24 to 36 hours of significant
postoperative analgesia.
Recommended Lidocaine Dosage
Maximum
recommended lidocaine dosage is 40 mg/kg to 50 mg/kg for
tumescent liposuction when lidocaine is greatly diluted. This
is a relatively large dosage compared to the 7 mg/kg which is
widely accepted as the "safe maximum dose for lidocaine with
epinephrine" that anesthesiologist use non-diluted lidocaine
for nerve blocks such as epidural blocks.
Microcannulas
A liposuction
cannula is a stainless steel tube which is inserted into
subcutaneous fat through a small opening or incision in the
skin. A microcannula has an outside diameter of less than 3
millimeters (mm). The diameter of microcannulas range from 1
mm to 3 mm. With special designs, microcannulas can remove fat
very efficiently. The use of larger cannulas, for example
those having an outside diameter ranging from 3 mm to 6 mm
require larger incisions which usually leave visible scars.
Adits
Adits are small
holes in the skin made with round, skin-biopsy punches. Adits
are used as access sites, which the liposuction cannula is
passed in and out during the liposuction process. Adits also
facilitate the drainage of blood-tinged anesthetic solution
after liposuction. Because of the skin's ability to stretch,
microcannulas can usually fit through a 1.0 mm, 1.5 mm, or 2
mm round hole made in the skin with a skin biopsy punch. Such
tiny holes usually disappear without scars after liposuction.
Adits are so small that it is not necessary to close them with
sutures. Because adits are not closed with sutures, they
promote copious postoperative drainage of blood-tinged
tumescent anesthesia, which in turn reduces post-operative
bruising, tenderness, swelling.
Larger cannulas require larger incisions. When larger
incisions are closed with sutures, there is delayed drainage,
and prolonged swelling, bruising and pain after liposuction.
Smoother Liposuction Results
Smoother
liposuction results can be achieved by using microcannulas
which allow a more gradual and controlled removal of fat. This
improves the ability of the surgeon to achieve smoother
results. Larger cannulas are associated with an increased risk
of liposuction producing skin depressions and irregularities.
Larger cannulas may remove fat so quickly that there is a risk
of removing too much fat. It is also more difficult to
precisely control the direction of a large cannula. With any
attempt to make a small incremental change in the direction of
a large cannula there is tendency to re-enter a pre-existing
tunnel within the fat. This lack of precise control
contributes to the risk of skin irregularities associated with
liposuction when using large cannulas..
Other
Advantages of Tumescent Anesthesia
Because
tumescent local anesthesia lasts so long, tumescent
liposuction is less painful and more pleasant than liposuction
under general anesthesia or IV sedation. With tumescent local
anesthesia patients are able to avoid the post-operative
nausea and vomiting associated with general anesthesia.
Tumescent anesthesia is so efficient at providing fluid to the
body that it is unnecessary to IV fluids. There is a risk of
dangerous fluid overload if excessive IV fluids are given to a
tumescent liposuction patient.
Brief history
of Tumescent Liposuction
Tumescent
liposuction was invented and developed in 1985. It was first
presented at a scientific meeting in 1986, and first published
in 1987 (JA Klein. The tumescent technique for liposuction
surgery. Journal of the American Academy of Cosmetic Surgery,
volume 4, pages 263-267,1987). See also History of Tumescent
Liposuction.
The definitive book about tumescent
liposuction is entitled The Tumescent Technique: , by Jeffrey
Klein, M.D., published , in 2000 by Mosby, St Louis, MO. Dr.
Klein is the inventor of the tumescent technique. This book
contains approximately 500 pages of detailed information that
includes tumescent anesthesia, microcannular liposuction,
local anesthesia, pathophysiology, complications,
pharmacology, pharmacokinetics, surgical technique,
postoperative care, and explanations of the special
considerations for liposuction of each area of the body. This
book can be purchased on line from hksurgical.com.
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