Liposuction is one of the most popular treatment modalities in aesthetic surgery with certain unique anaesthetic considerations. Liposuction can be of two types according to the volume of solution aspirated: High volume (>4,000 ml aspirated) or low volume (<4,000 ml aspirated). Small volume liposuction may be done under local/monitored anaesthesia care, large-volume liposuction requires general anaesthesia.
4 types of liposuction techniques
4 types of liposuction techniques have been described based on the volume of infiltration or wetting solution injected, viz dry, wet, superwet, and tumescent technique [Table 1]. The main difference between these techniques is the amount of infiltration done into the tissues and the resultant blood loss as a percentage of aspirated fluid. The tumescent technique is the most common of all liposuction techniques for small volume liposuction.
Jeffery Klein (a dermatologist in the US) who described the ‘tumescent technique’ of liposuction in the mid-1980s, which is associated with decreased blood loss, thus making it possible to perform liposuction as a day care procedure.
Klein coined the term ‘tumescent technique’. The word tumescence means ‘to swell’. In this technique, very large volumes of dilute local anaesthetic along with additives like epinephrine and sodium bicarbonate, are injected into the subcutaneous tissue to expand the tissues and make them firm, swollen, and turgid, i.e., the final endpoint of strong tissue turgor. This creates a plane from where suction of fat becomes easier, with lesser blood loss.
Lignocaine is the most commonly used local anaesthetic in tumescent solutions, the maximum dose of which along with adrenaline is considered to be 7 mg/kg. With the advent of tumescent anaesthesia, the maximum dose of lignocaine, when delivered in a tumescent solution may be significantly larger. The recommended maximum dose of lignocaine is 55 mg/kg for most patients, with a range of 35-55 mg/kg in patients undergoing liposuction. The concentration of lignocaine varies according to the vascularity of the area where liposuction is to be performed. In the more vascular or sensitive areas such as the breast and abdomen, the dose can be increased to 1,500 mg/L of normal saline. The concentration is decreased to 500 mg/L of normal saline in less sensitive areas such as the thighs. Louis Habbema has reported in a series of 3,430 liposuction procedures that a maximum lignocaine concentration of 500 mg/L of normal saline solution allows infusion of a large volume of wetting solution, without any risk of lignocaine toxicity.
A thorough history regarding use of all medications, vitamins, herbs, and anticoagulants should be documented, as they may affect blood clotting.Most of these drugs should be stopped at least 2 weeks before surgery. Any medication that interferes with metabolism of lignocaine such as statins and calcium channel blockers should be either discontinued before liposuction, or the total dosage of lignocaine should be reduced.
Monitored Anaesthesia Care
This is a useful technique for small volume liposuction. Infiltration with vasoconstrictor and local anaesthetic reduces bleeding and provides intraoperative analgesia, respectively. Thus, it allows liposuction to be performed under light sedation, implying a short recovery time, earlier discharge, and low cost to the patient. However, if infiltration is not uniform, some areas will have a lack of analgesia, thus requiring more sedation.
Sedation with midazolam (1-3 mg) and analgesia with fentanyl (25-50 mg) or remifentanil (12.5-25 mg) is commonly employed for small volume liposuction. Propofol (0.5-1 mg/kg) may be given intermittently for monitored anaesthesia care. Ketamine in low doses (0.25-0.5 mg/kg) along with midazolam decreases significantly the consumption of opioids in the intraoperative period and of analgesics in the postoperative period. Clonidine 2-5 mg/kg, is also a useful adjuvant in sedation techniques.
For small volume liposuction, standard ASA monitoring such as oxygen saturation (SpO2), noninvasive blood pressure (NIBP), end-tidal carbon dioxide (EtCO2,), electrocardiogram (ECG), and temperature monitoring suffice.
Since pre-emptive analgesia is provided by the local anaesthetic in tumescent liposuction, the requirement of analgesics in the intraoperative and postoperative period is minimal. By adding epinephrine to lignocaine, the duration of analgesia obtained from tumescent lignocaine can be extended by many hours. Non Steroidal Anti-inflammatory Drugs (NSAIDs) may also be prescribed for postoperative pain relief.
Anaesthesia for small volume liposuction is considered a very safe procedure, however it still requires a thorough understanding of the physiological changes and likely complications associated with them. Meticulous monitoring and strict adherence to guidelines for intraoperative fluid therapy ensures a good outcome.
Learn More about Liposuction & Fat Transfer under Local Anaesthesia in our faculty's Operation Room, with Hands-on Training on Live-patients :
IFAAS Mini-Fellowship (Hands-on)
Liposuction & Fat Transfer for Face & Body under Local Anaesthesia (Office Setting)
March 23-24, 2020
Seoul, South Korea
Faculty: Dr. Kasey Sung, S. Korea
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