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Liposuction -- Tumescent Liposuction (Under Local Anesthesia)
In the field of cosmetic surgery, Tumescent liposuction, awake liposuction and lunchtime liposuction are synonymous for the safest method of liposuction and body contouring. Developed and perfected by dermatologists in the 1980s, this type of lipo-sculpture or lipo-plasty as it is sometimes called, derives its name from the type of local anesthesia developed specifically for this operation-–tumescent local anesthesia.
Tumescent local anesthesia, also known as TLA or Klein’s Solution, is a carefully balanced blend of lidocaine, epinephrine and sodium bicarbonate diluted in saline and administered directly into the subcutaneous fat layers to produce total anesthesia and vasoconstriction lasting effectively up to 12 hours. After surgery, the tumescent lidocaine solution is slowly absorbed through the bloodstream and metabolized through the liver completely in about 36-48 hours.
All patients have to be evaluated prior to surgery to ensure that they have a normal functioning liver, no history of liver diseases and are not taking medications or other substances which might interfere with lidocaine metabolism in order to be considered a good candidate for this type of surgery.
Liposuction under local anesthesia is safer than liposuction under conscious sedation (IV sedation or twilight anesthesia) or liposuction under general anesthesia for several reasons:
- First, the patient maintains all of the reflexes which protect the airway – the gag reflex which prevents the accidental aspiration of vomit or corrosive stomach acids into the lungs is maintained and the patient is able to breath normally throughout the procedure.
- Second, the patient maintains control over all of the muscles which protect against the formation of deadly blood clots in the legs, lungs and elsewhere. Staying awake is the easiest and most effective method of preventing deep vein thrombosis (DVT) or venous thromboembolism.
- Third, the patient maintains the ability to communicate with the surgeon throughout the entire surgery which gives both the patient and the surgeon instant feedback and the ability to adjust the technique or the local anesthesia for maximum effect.
- Finally, awake liposuction uniquely permits the surgeon to continually evaluate the cosmetic results of the procedure by having the patient stand up to determine if the desired body contours have been achieved. Patients and surgeons alike, are quite familiar with the fact that the abdomen and other areas of the body have a completely different appearance when lying down as compared to standing up.
Most cosmetic surgeons, plastic surgeons and dermatologists who have had experience with tumescent liposuction observe that their results are better than those that they achieve with either conscious sedation or general anesthesia.
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Liposuction and Body Sculpturing
Liposuction is a surgical technique that improves the body’s contour by removing excess fat from fatty deposits located under the skin. Body sculpturing by liposuction is literally a dream come true. Localized accumulations of fat, often hereditary and frequently impossible to eliminate by exercise or dieting, can be removed permanently by liposuction surgery, never to plague you again. Liposuction requires the use of a small stainless steel tube called a cannula. The cannula is connected at one end to a specialized suction pump, and is inserted through small 2-4mm skin incisions. The removal of fat is accomplished as the suction cannula makes tiny tunnels through the fatty layers. After surgery, these tiny tunnels collapse, resulting in an improved body contour.
Body Fat & Aging
Body fat tends to increase gradually over the years. After the age of 30, fat follows a genetically predetermined distribution pattern, often very resistant to exercise and dieting. An example of fat that is resistant to dieting and exercise is the fat that appears on the abdomen and hips of some women after pregnancy. For many people who have inherited the tendency to accumulate excessive fat, liposuction is the only realistic means of significantly changing the body’s silhouette.
Areas Treated by Liposuction
For women, the most frequently treated areas are the abdomen, hips, thighs, knees, calves, ankles, and beneath the chin. For men, who make up about 25% to 30% of patients who undergo liposuction, the most commonly treated areas include the love handles, abdomen, breasts, neck and chin areas.
Liposuction Results Are Permanent
Fat cells are permanently removed by liposuction. As long as the patient does not gain an excessive amount of weight, the new, more pleasing silhouette is here to stay. A woman who tends to put weight on her thighs and knees, will find that after liposuction, these areas are less likely to accumulate fat when she gains weight. In fact, some patients having had liposuction and subsequently gained weight often maintain their new desirable silhouette, whereas areas not treated by liposuction are the sites that tend to accumulate new deposits of fat.
The Tumescent Technique
The Tumescent Technique of liposuction was developed in 1985. The Tumescent technique involves the use of large volumes of a dilute solution of lidocaine (a local anesthetic) in combination with the vasoconstrictive drug, epinephrine, which shrinks capillaries. Local anesthesia used in the Tumescent technique for liposuction is so effective that many patients no longer need intravenous sedatives, narcotic analgesics, nor general anesthesia. This technique is now considered the safest form of liposuction for removing very large amounts of fat because there is very little blood loss. Not only has the Tumescent technique proven to be much safer than the traditional technique using general anesthesia, it has also been found to be less painful, has less post operative recovery time, and produces more optimal cosmetic results. Once the area has been numbed, surgery is virtually painless. In addition, because the numbness remains in the treated area for more than 12 hours, there is very little pain immediately after surgery.
Liposuction Risks
As with any surgical procedure, liposuction is associated with certain common side effects such as bruising, swelling, and temporary numbness. Although irregularities of the skin are possible following liposuction, this side effect is minimized by the Tumescent technique. When larger cannulas are used, occasionally there are patients with an irregularity of the skin. Since smaller, micro-cannulas became available, noticeable irregularities are much less common. Because of the slow resolution of post liposuction swelling, the ultimate results usually take 12 to 16 weeks to become fully apparent. Nevertheless, patients can usually see dramatic improvements within two to four weeks after surgery. Although the results of liposuction are often quite spectacular, it is not realistic to expect perfection. Liposuction of the thighs, while improving the silhouette, does not necessarily eliminate the subtle “puckering” of the skin that is known as “cellulite.” Liposuction with the Tumescent technique reduces the degree of cellulite but it is unlikely to eliminate it. Rare problems that can potentially occur with any surgical procedure include infections, bleeding and nerve injury. The Tumescent technique, however, minimizes these risks.
How the Tumescent technique Reduces the Risk of Infection
Infections are rare, regardless of general anesthesia or local anesthesia. Although there have been reports in the medical literature of patients who have had serious infections following liposuction surgery, to the best of our knowledge, there have never been any patients who have had life-threatening infections following Tumescent liposuction performed using only local anesthesia. Lidocaine, the local anesthetic that is used for the tumescent technique, kills bacteria.
Returning to Normal Activities
Because of the significant decrease in swelling and decrease in inflammation and pain after surgery, patients are able to return to normal physical activities very soon after the procedure. There is no limitation of physical activity other than what common sense would dictate. Some patients are able to return to jogging, golf, or light aerobic exercise within a day or two after surgery. Some patients do find the soreness after surgery to be more significant than others, but on the average, most patients are surprised at how quickly they are able to return to normal activity.
Better, Smoother Results from the Tumescent Technique
Because small cannulas are used with the Tumescent technique, it permits a more delicate, gentle approach to liposuction as the surgeon can control the direction and position of the cannula with more accuracy. This results in reduced risk of inadvertently approaching the undersurface of the skin too closely and unintentionally causing skin irregularities. Further, the use of small cannulas enables the surgeon to make such small incisions that no stitches are used. The wounds heal by themselves and virtually disappear over time. By not using stitches to close skin incisions, the rate of healing is faster. Another benefit of not closing the incisions is that, after the procedure, the open incisions allow easy drainage of the anesthetic solution. This has a dramatic effect in minimizing bruising. Many patients notice that bruising is almost absent after surgery.
Types of Liposuction
There are four main liposuction techniques. All the liposuction techniques offer advantages and disadvantage. The specific liposuction device used alone or in combination with other liposuction equipment, must be individualized based upon the patient needs, desires, technical feasibility and realistic expectations.
In general, the use of ultra-sound assisted liposuction, including the Vaser® Liposelection require larger skin incisions and the need to suture them at the end of the surgery. They can be associated with complications such as burning and/or tingling, swelling, skin burns, and fluid collecting under the skin (seromas).
- Suction-assisted Liposuction (SAL)
The traditional approach to liposuction. Using general anesthesia, regional anesthesia, heavy sedation or totally under local tumescent anesthesia, the cosmetic surgeon removes fat by inserting a small, hollow tube (cannula) connected to a vacuum aspirator device, directing the cannula into the areas to be suctioned through tiny incisions.
- Power-Assisted Liposuction (PAL)
A cannula with a back and forth, or rotational, motion of the tip passes through the tissue to suction out fat and fibrous or scar tissue. The benefits are (1) less trauma to the tissues and (2) reduced effort for the surgeon.
- Ultrasound-assisted Liposuction (UAL) Vaser Liposuction
Intermittent or continuous bursts of ultrasonic energy (sound waves) are transmitted to the tip of the cannula to break up and melt fat cells which are then removed by suction. External ultrasound-assisted liposuction (E-UAL) uses external ultrasound waves to alter the fat cells in an effort to melt the fat before it is removed by suction. Thousands of VASER Lipo procedures have been performed on men and women on just about any part of the body you can imagine. The benefits of VASER® Lipo include smooth results, precise contouring, minimal pain and fast recovery time. Physicians around the world are recommending VASER Lipo. When the goal is to remove the superficial and deep fat that covers target muscles, conventional liposuction cannulas, specialized cannulas, power cannulas, internal ultrasound or laser lipolysis techniques can be used.
- Laser-assisted Liposuction (LAL)
At the present time there are two laser-assisted liposuction technologies available in the USA:
- Low-level Assisted Liposuction (4L Erchonia)
The device is a portable low-level laser unit (dual-diode laser) that creates a thin beam of red light. Its external application on the skin helps to create fat liquefaction, making the suction of the fat easier and quicker. Moreover, the use of the laser after liposuction eases pain, reduces bruising, improves healing, and provides a more rapid recovery. This is a non-invasive laser that does not create pain during its use and it is nearly imperceptible to the patient.
- SlimLipo Laser. Laserlipolysis (pulsed, Nd YAG laser)
This laser has recently received FDA approval. A small cannula containing a laser fiber is inserted into the skin, the cannula is moved back and forth delivering the laser's energy to the fat cells causing them to rupture and easily drain away. The laser energy also interacts with the dermis resulting in collagen shrinkage responsible for a good contraction of the skin. Slimlipo is minimally invasive procedure that can be done easily with local tumescent anesthesia. The Slimlipo is a great adjunct to standard liposuction (suction-assisted, power-assisted, laser-assisted liposuction), though it can not replace conventional liposuction. They have found the Slimlipo ideal for treating small areas of the face, neck, arms, breasts, high definition liposculpturing such as abdominal etching ("6-pack etching"), and areas of loose and flabby skin (floppy skin.)
Excessive Liposuction (Megaliposuction, Staged Liposuction)
There is no universally agreed upon definition for excessive liposuction (Megaliposuction). Nonetheless, there is a limit to the amount of liposuction from which a healthy person can be expected to heal without significant risks. The patient's size and weight and the amount of fat aspirated are the main factors. As a general rule, ISCG cosmetic surgeons consider the aspiration of 4 liters of fat from a large patient the safe limit of conservative office liposuction, and a total aspirate volume of 6 liters should rarely be exceeded for one sitting liposuction session.
For patients who require megaliposuction exceeding the safe limit for one sitting liposuction procedure, ISCG cosmetic surgeons offer the alternative option of serial or staged liposuction. The megaliposuction is performed over the course of two or more sessions spread several days or weeks apart. Staged liposuction allows ISCG cosmetic surgeons to remove safely very large amounts of fat over a protracted period of time with no untoward complications.
Staged liposuction is a less invasive and safer alternative to bariatric surgery (gastrointestinal bypass procedures) for a significant number of obese patients in relatively good health. Liposuction will not treat the cause of the obesity, but it will result in a significant improvement of body contouring, and will remove large quantities of fat cells, while creating an adequate retraction of the excess skin.
Staged megaliposuction has shown that large quantities of fat can be extracted with minimal risk and that the large localized obesities can be definitely improved or eliminated while avoiding the significant morbidity associated with bariatric surgery. The operation is also beneficial to treat residual adiposities following bypass procedures.
High Definition Liposuction (6-pack etching)
High definition liposuction is the three dimensional sculpting of the abdominal muscles, the chest muscles, the lower back and gluteus to enhance their appearance. The procedure is designed as an advanced scultping technique rather than standard liposuction and requires an experienced surgeon. The procedure is indicated for males and females who have good muscle tone, exercise regularly, have good quality skin, and have been unable to achieve their desired muscle definition. The procedure is performed under local tumescent anesthesia;
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