A comprehensive overview of techniques and applications for tumescent liposuction were presented by Lisa M. Donofrio, M.D., at Academy '99.

Tumescent Anesthesia

Dermatologists and nondermatologists can use the term "tumescent anesthesia" loosely, said Dr. Donofrio, assistant clinical professor of dermatology, Yale University School of Medicine. "The main point is that you're administering purely local anesthesia," she said. "If you start putting patients to sleep and using tumescent fluid, by definition that's no longer tumescent anesthesia. To say you use tumescent anesthesia you must give reference to the point that you are just using local anesthesia. There are guidelines for the amount and the dilutions.

The purely local anesthesia is lidocaine-based and -diluted (500mg to 1000mg/L). Facts to keep in mind include:

• Epinephrine at 0.5mg/L peaks plasma lidocaine sooner than 1mg/L.

• Lidocaine is lipophilic.

• Serum lidocaine peaks are delayed 4 to 15 hours.

• Very little lidocaine is in aspirate.

• Infusion pumps do not significantly alter lidocaine serum levels.

While not fact, it is surmised that patients with higher percentage body fat can handle higher mg/kg doses (955 to 965 mg/kg). And safety at 35mg/kg and above depends on dosage as much as on the dilution.

Good Candidate Attributes

Patients should have stable body weights without being grossly overweight. They should be in good health and exhibit realistic expectations from the liposuction. Ideally, the fat deposits removed should be from diet-resistant areas.

Contraindications for tumescent liposuction are patients with a personal history or strong family history of DVT or PE; patients who are undergoing anticoagulant therapy; who have liver, heart, or kidney disease; and patients with compromised immune responses or connective tissue disease.

There have been deaths during tumescent liposuction among patients who had pulmonary emboli.

"We need to start taking family histories of patients who have had some sort of familial clotting pattern and eliminate those people as candidates until we can figure out a cost-effective way to screen them. For now, anyone who has a personal history or strong family history of deep vein thrombosis or pulmonary embolus is not a candidate for liposuction in my office," Dr. Donofrio said.

Check Family History

Dr. Donofrio also made the point that patients who have strong family or personal histories of breast cancer should be educated about what tram-flap reconstruction is, and how, if they undergo abdominal liposuction, they are no longer candidates for tram-flap reconstruction.

Preparation for the tumescent technique includes ceasing all NSAIDS one week before the operation. Patients should stop vitamin E, ginkgo biloba, and St. John's Wort therapy one week prior because there are hidden anticoagulants in many herbal remedies and vitamins.

Instruct patients to stop drinking alcohol two days before surgery, hold Synthroid the morning of surgery, and take no serotonin re-uptake inhibitors two weeks before.

The preparation includes a physical exam, medical clearance for patients older than 70, and a prescription for azithromycin (Zithromax), or Z-pak, started the day before surgery and continued for four days after. Preoperative lab work includes a CBC with diff and platelets; a chem panel; PT/PTT, hepatitis A, B and C panel; and an HIV test.

For anxious patients with normal blood pressure, Dr. Donofrio administers 0.1mg of oral clonidine (Catapres) and 5mg of midazolam (1M Versed). During surgery, patients should be monitered with a pulse oximeter, cardiac monitor, and by taking vitals every 15 minutes.

Special Requirements for Specific Areas

• Avoid suction of the volar arm during liposuction of the arm. Use microcannulas and stay deep to avoid ridging. Be prepared: Patients often experience prolonged edema after liposuction of the calves and ankles.

• For the saddlebags, make incisions superior and inferior to the bulge.

• Under-correct inner thighs and knees.

• Around the buttocks, suction superficial fat in the coccyx to suspend the buttocks. It is a good area to empty, Dr. Donofrio said.

• Make lower- and mid-abdomen incisions to sculpt the abdominal area.

• The neck area is tricky. Dermatologists have to be aggressive and dissect away the neck bands to allow the skin to redrape. Learning which patients require a platymalplasty and executing it is also helpful.

Liposuction Do's and Don'ts

Mark patients as they are standing up. Keep instrument tips clean. "Dermatologists don't traditionally do things 'sterile.' We do a clean operating procedure," Dr. Donofrio said. "Given the amount of fluid that's involved, it's very difficult to keep the environment sterile. The things that you do have to keep sterile are the tips of the instruments - keeping them on a sterile table, not touching them, and changing your gloves frequently throughout the procedure to keep the bacterial count as low as possible."

Do not skimp on the number of incisions. Another important point, Dr. Donofrio said, is to make as many incisions as possible to access the area - especially since surgeons today use small cannulas.

"There's a surgeon in my area who, in his advertisements, says 'One incision is needed to do liposuction of legs, abdomen and breast area.' That's not a drawing point. That's scary," Dr. Donofrio said.

On the Move

Keep patients moving postoperatively. Because of documented cases in the literature of vein thrombosis, encourage patients to get up and move around every hour. Experience counts with arms, calves, and ankles. These three are difficult liposuction areas and are not for beginners. "Liposuction should feel like playing the violin, not like shooting pool," Dr. Donofrio said.

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