History of Tumescent Liposuction
The tumescent liposuction technique uses large volumes of very dilute solutions of local anesthesia that is gently injected into subcutaneous fat. Tumescent liposuction is the only technique that permits liposuction to be accomplished totally by local anesthesia. It is also the only technique that virtually eliminates both the need for general anesthesia and surgical blood loss as a routine problem of liposuction. Some surgeons use a modified version of tumescent liposuction consisting of general anesthesia or heavy IV sedation and tumescent infiltration for eliminating blood loss. Tumescent liposuction was invented by Jeffrey Klein, M.D., a dermatologist in San Juan Capistrano, California.
Traditional Assumptions
Traditional assumptions were not correct. In many ways, the effect of the tumescent technique for local anesthesia is just the opposite of what one might predict using “common-sense” assumptions and traditional surgical teachings.
- One might suspect that by diluting a solution of local anesthetic (containing lidocaine and epinephrine) the anesthesia would be less effective; instead the dilution permits a larger volume of local anesthesia that can spread more widely and produce larger areas of anesthesia.
- Although microcannulas remove less fat per minute compared to larger traditional cannulas, microcannulas permit the removal of a greater total volume of fat and produce much smoother results.
- During liposuction by local anesthesia, patients are awake, but experience less pain than patients who have liposuction under general anesthesia. After awakening from general anesthesia patients require narcotic analgesia, whereas local anesthesia persists for many hours after surgery so that patients only require acetaminophen (Tylenol).
Official FDA Lidocaine Dose Limits
Official FDA lidocaine dose limits were established by the FDA in 1948 at a time when the United States Food and Drug Administration (FDA) did not require objective data before approving a drug company’s dosage recommendations. The 7 mg/kg of lidocaine dose limit was approved by the FDA without supporting scientific data. In fact, the official dose limits for lidocaine were established in 1948 in a brief letter to the FDA from the drug’s manufacturer which simply stated that “the maximum safe dose of lidocaine is probably the same as that for procainamide.”
No FDA Data on Subcutaneous Lidocaine
Under the Freedom of Information Act, the FDA has stated that it has no further data upon which to support its current recommendations. The FDA has no data regarding maximum safe doses of lidocaine with epinephrine when injected under the skin. The only data the FDA has relate to the use of local anesthesia injected into deeper tissue such as around the spine. In fact, data published in scientific medical journals and years of experience has shown that the safe upper limits for dilute tumescent lidocaine with epinephrine is approximately 45 mg/kg.
General Anesthesia Might Be Used Unnecessarily
General anesthesia might be used unnecessarily when anesthesiologists are unaware that the FDA limits on lidocaine were designed exclusively for epidural anesthesia (7 mg/kg) and that the limits for tumescent local anesthesia are much higher (45 mg/kg). In effect, the underestimation of the maximum safe dosage of dilute lidocaine and epinephrine when injected under the skin has encouraged the use of general anesthesia in some situations where it is not necessary.
Liposuction Before Tumescent Technique
For many years, general anesthesia was an absolute requirement for liposuction. The standard cannulas of the 1980’s were huge, having diameters of 6 to 10 mm and cross sectional areas 9 to 25 times greater than today’s 2 mm microcannulas. The first written description of liposuction was published by Fischer of Italy in 1977. Soon afterwards, the French surgeons Illouz and Fournier popularized liposuction using blunt-tipped cannulas. Preoperative infiltration of a small volume of a vasoconstrictive solution of epinephrine into the targeted fat was termed the wet technique. Using no preoperative infiltration was known as the dry technique. In 1982, several American dermatologists, plastic and cosmetic surgeons visited France to observe Illouz do liposuction. By 1983, Americans were doing liposuction using general anesthesia, epidural regional anesthesia, or heavy IV sedation supplemented by small volumes of local anesthesia. In the 1980’s and early 1990’s, among surgeons who did not use the tumescent technique, liposuction was frequently associated with excessive bleeding, prolonged recovery time, and disfiguring irregularities of the skin.
The Inventor of Tumescent Liposuction
The tumescent technique was invented by Jeffrey A. Klein, M.D., a dermatologist who now practices in San Juan Capistrano, California. Dr. Klein attended medical school at University of California San Francisco. After medical school, he obtained training and board certification in Internal Medicine at UCLA and Dermatology at UC Irvine. Additional studies included a masters degree in biostatistics at UC Berkeley, and a National Institutes of Health (NIH) research fellowship in clinical pharmacology. Dr. Klein started his private practice of dermatology in November of 1984.
Invention of the Tumescent Technique
In February, 1985, Dr. Jeffrey Klein attended a liposuction course where all of the faculty did liposuction using general anesthesia. Liposuction by local anesthesia was thought to be impossible. However, to Dr. Klein it seemed obvious that one could at least do a small volume of liposuction by local anesthesia. The real question was “How much liposuction could be done using local anesthesia?” He decided to determine how much fat could be removed with the use of a maximum of 500 mg of lidocaine, and 0.5 mg of epinephrine. Dr. Klein observed that each increase in the dilution of the lidocaine and epinephrine permitted local anesthesia of a greater volume of subcutaneous. It only remained to determine the ideal dilution, and to estimate a safe maximum total dosage of lidocaine.
The First Tumescent Liposuction Patient
On April 5, 1985, Dr. Klein performed his first liposuction procedure. The patient had a localized accumulation of fat on the lower abdomen above a transverse hysterectomy scar. The liposuction was accomplished using undiluted commercially available concentrations of local anesthesia (500 mg of lidocaine and 1 mg of epinephrine in 50 milliliters), and only a small volume of fat (less than 100 ml) was removed. This first patient experienced absolutely no pain during the liposuction, and also no surgical bleeding because the epinephrine caused capillary vasoconstriction. However, the injection did cause a stinging pain and there was a rapid heart rate (tachycardia) after completing the injection as a result of the high concentration of epinephrine (also known as adrenalin).
Early Tumescent Liposuction Patients
Each successive patient received a solution of lidocaine and epinephrine that was more dilute than that of the preceding patient. Surprisingly, Dr Klein observed no change in the degree of local anesthesia, but there was less stinging with the injection and there was less tachycardia (rapid heart rate) after the injection. Furthermore, each successive dilution provided a larger volume of local anesthesia, which allowed local anesthesia over a larger and larger volume of subcutaneous fat. By the end of 1985, an elementary form of the tumescent liposuction had evolved. The optimal concentration of tumescent solution of local anesthesia was found to be between 500 mg to 1250 mg of lidocaine, and 0.5 and 1.0 mg of epinephrine per liter of solution.
First Publication of the Tumescent Technique
The first public description of the tumescent technique was a lecture by Dr. Klein in Philadelphia in June of 1986. The first article describing the tumescent technique was published in the American Journal of Cosmetic Surgery in January of 1987 (Klein JA, The tumescent technique for liposuction surgery. American Journal of Cosmetic Surgery, 1987, volume 4, pages 263-267).
Improved Anesthesia
Continual process of refinement and improvement of the tumescent technique over the years now allows liposuction to be done with exceptional finesse and gentleness and totally by local anesthesia. The stinging pain originally associated with infiltration of local anesthesia (the result of the acidic pH of commercially available lidocaine) has been eliminated by adding sodium bicarbonate (NaC03) to the anesthetic solution. The incidence of rapid heart rate resulting from the epinephrine in the tumescent anesthetic solution has been almost eliminated by the use of clonidine (0.1 mg) taken by mouth immediately prior to surgery.
Maximum Safe Dose of Tumescent Lidocaine
Having established the feasibility and safety of liposuction using large volumes of tumescent local anesthesia containing lidocaine the final step was to find an estimate of the maximum safe dose of lidocaine. A dose of lidocaine is considered to be excessive and potentially toxic if the concentration of lidocaine in the blood exceeds 6 milligrams per liter. By repeatedly measuring lidocaine concentration in the blood after tumescent infiltration, Dr. Klein discovered that the peak lidocaine concentration in the blood occurs at approximately 12 hours after initiating the tumescent infiltration. This finding was unprecedented. The prevailing belief was that peak lidocaine blood levels occur less than 2 hours after infiltration. By graphing the magnitude of the peak concentrations as a function of the lidocaine dosage (mg/kg), a safe dosage for tumescent lidocaine was shown to be 35 mg/kg to 50 mg/kg. (Klein JA, Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. Journal of Dermatologic Surgery and Oncology 16:248-263,1990).