Generally defined as the removal of fat from deposits beneath the skin using a cannula with the assistance of a powerful vacuum, liposuction has become one of the most sought after cosmetic surgery around the world with more than 258,558 procedures being performed in 2018 in the United States alone. The increased in the number of procedures performed has also led to the increase in the number reports on adverse outcomes - therefore, it is important that a practitioner should understand the pathophysiology of obesity and fluid management during liposuction and be aware of the complications.
Types of Anaesthesia
In general, liposuction may be performed under local, regional, or general anaesthesia. However, no single anaesthesia technique has been proven to be superior over another. The technique of anaesthesia depends on various factors such as the site and extent of liposuction as well as patient and surgeon preferences.
Anaesthetic that will be administered will also vary according to the areas being operated upon, such as; arms, thighs, abdomen, or buttocks and the volume of liposuction being performed. Small-volume liposuction cases can be performed with local anaesthesia, with or without mild sedation. Complex, large-volume liposuction and combined cases should be performed under general anaesthesia. Since these procedures are often performed as day care, it is important that there is fast recovery of psychomotor and cognitive functions ensuring early discharge of the patients. Additionally, the practice advisory on liposuction does recommend avoiding epidural and spinal anaesthesia in office-based settings because of potential hypotension and volume overload issues.
Monitored Anaesthesia Care: Monitored anaesthesia care is a useful technique for small volume liposuction. Infiltration with vasoconstrictor and local anaesthetic reduces bleeding and provides intraoperative analgesia, respectively. It therefore allows liposuction to be performed under light sedation, implying a shorter recovery time, earlier discharge, and lower cost to the patient. However, a practitioner must ensure that sedation is adequately and uniformly administered.
Lumbar Epidural Anaesthesia: This is widely used to provide analgesia in abdominal liposuction. The quality of analgesia provided is superior to that provided by local infiltration. However, an extensive epidural blockade is frequently associated with hypotension and must be limited to patients with good cardiac reserve.
Subarachnoid Block: This is a useful technique for liposuction below the umbilical area. In these conditions, this technique is safe, low cost, and with few side effects. The quality of anaesthesia and muscular relaxation is excellent and administration of opioids in the subarachnoid space provides good analgesia in the first 24 hours of the postoperative period.
Nerve Block: The nerve block technique allows for the use of minimal local anaesthetic (usually 1-3ml), which can effectively reduce the chances of toxicity in patients, yet at the same time provide a good coverage of a large area while preventing distortion of the operative site. It has also been proven to be able to better control pain than intravenous narcotics, and usually require less systemic opioids (narcotics). Patients have also reported less nausea and easier breathing.
General Anaesthesia: Usually recommended for large volume liposuction or if the patient desires it. Propofol is the induction agent of choice because of its pharmacokinetic profile and inherent antiemetic property, which ensures early recovery of the patient. Airway can be maintained with a supraglottic device laryngeal mask airway, proseal LMA (PLMA) or I-gel. Muscle relaxation may be achieved with a nondepolarizing drug – atracurium, rocuronium, or vecuronium. Analgesia is provided by short-acting opioids such as fentanyl or remifentanil and infiltration of lignocaine in the subcutaneous tissue.
Tumescent Anaesthesia: This is a technique usually involves subcutaneous infiltration of large volumes of tumescent fluid containing lidocaine, saline, and epinephrine to produce anaesthesia, swelling, and firmness of targeted areas. It is considered to be extremely safe and recommended for use in tumescent local anesthesia for office-based liposuction procedures.
At the end of the day, it is ultimately up to the practitioner to suggest the available modalities for the patient to choose from, and the performing surgeon must make aware of the most effective modality for treating the patient, with the ultimate goal always being patient safety.
Wetting Techniques: Dry, Wet, Super Wet and Tumescent
Often performed as an office procedure, there are four main types of liposuction techniques based on the volume of infiltration or wetting solution injected, dry, wet, super wet, and tumescent.
Dry Technique: At its initial introduction, liposuction was performed without any wetting solutions, and the dry technique actually employs no wetting solution and has few indications in liposuction. However, this led to blood loss of up to 45% of aspirate in some areas. Since then, liposuction has evolved over time to include the addition of wetting solutions prior to suctioning to improve hemostasis and pain control.
Wet Technique: The wet technique usually involves instillation of 200 to 300 mL of solution per area to be treated, regardless of the amount aspirated.
Super Wet Technique: This employs an infiltration of 1 mL per estimated mL of expected aspirate, and this technique is considered to be highly popular and accepted as the means of standard for most procedures.
Tumescent Technique: Popularized and coined by Klein, the term 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, (for example, the final endpoint of strong tissue turgor). This creates a plane from where suction of fat becomes easier, with lesser blood loss. The tumescent technique also involves infiltration of wetting solution that creates significant tissue turgor and results in infiltration of 3 to 4 mL of wetting solution per mL aspirated.
Tumescent Technique: Future of Liposuction
Today, the tumescent technique has become one of the most commonly adopted liposuction techniques in which large volumes of dilute local anaesthetic (wetting solution) are injected into the fat to facilitate anaesthesia and decrease blood loss. Small volume liposuction may be done under local/monitored anaesthesia care, while large-volume liposuction may require general anaesthesia.
As a large volume of wetting solution is injected into the subcutaneous tissue, the intraoperative fluid management has to be carefully titrated along with haemodynamic monitoring and temperature control. Although many different variations of solutions, have been popularised, all formulations include some variant of fluid (NS/LR), epinephrine, and lidocaine. It is important to note that Marcaine should be avoided because of its potential cardiac effects and duration of action; and it has yet to be proven clinically as a suitable anesthetic in wetting solutions.
In addition, the tumescent technqiue also makes it feasible to perform liposuction in an office setting. With an increasing number of patients who desire extensive liposuction on approximately 30% of total body surface area, this means that there may be a potential of fluid overload. Extensive liposuction involves the creation of extensive subsurface trauma, comparable in many respects to the massive injury of an internal burn. Commencing with cannula aspiration of several liters of fluid-engorged adipose tissue, during which small feeder vessels are inevitably torn.
The fluid extravasation and stasis followed suction trauma lead to hypovolemic shock, but overhydration progressing to pulmonary edema is highly common. Although infiltrated liquid is apparently suctioned out again, 60% to 70% of the solution is actually retained for absorption and contribution to plasma volume.
Blood loss using the tumescent technique is negligible and replacement is usually not required, although high-volume (more than 4–5L) liposuction may demand supplemental fluids. In extensive liposuction cases, the use of tumescent technique may be accompanied by sedation, general anesthesia, or epidural anesthesia to ensure adequate patient comfort. General anesthesia is safe and effective in accredited office-based surgery facilities, particularly suitable for complex or long operations. While epidural anesthesia associated with sedation can also be applied.
Regardless of techniques, a patient’s medical history should always be obtained to rule out cardiovascular, renal, pulmonary, and hepatic diseases in extensive liposuction. While most patients can tolerate a significant intraoperative fluid challenge when cardiac, pulmonary, hepatic, and renal status is normal, unrecognized systemic disease can significantly reduce this margin of safety. Traditional fluid replacement policy corrects the pre-existing deficits, provides maintenance fluid, and replaces additional surgical losses. Pre-operative volume deficits in healthy liposuction patients may not be sufficient to warrant replacement.
The development in liposuction has resulted in the gradual extension of body areas to be treated so as to meet the demands of patients. Therefore, it is important for a practitioner to keep abreast of trends, technologies and techniques to deliver best results and patient comfort.
Hope you have enjoyed the article! Stay tuned for our future posts about more techniques and information related to our advanced aesthetic and cosmetic training courses!
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