Standards of Safety
Two Standards: Their Basic Difference
The tumescent technique for liposuction has evolved into two distinct but similar procedures, with two distinct standards of safety. The basic difference between these two standards is “the amount of liposuction that is considered to be safe”. The term “amount of liposuction” refers to both the volume of fat removed and the number of areas treated by liposuction on a single day or week. When compared to liposuction by general anesthesia, liposuction totally by local anesthesia is usually done more gently, with fewer areas treated and smaller total volumes removed, and fewer unrelated surgical procedures attempted on the same day. When liposuction is done under general anesthesia there is a temptation to maximize the total volume of fat remove, to treat too many areas, and to do other unrelated cosmetic surgical procedures on the same day.
The Dangerous Aspect of General Anesthesia
This is not the anesthesia but the use of general anesthesia to permit 1) excessive volumes of liposuction, 2) multiple unrelated cosmetic procedures on the same day resulting in excessive surgical trauma and prolonged exposure to general anesthesia. There are safety limits on the total amount of local anesthesia that one can use on a single day, which in turn limits the amount of liposuction on a single day. There are no clear limits on the amount of general anesthesia that can be used. The use of general anesthesia makes it easier to attempt excessive amounts of cosmetic surgery on a single day. Surgeons and anesthesiologists are both responsible for insisting on optimal patient safety and avoiding excessive cosmetic surgery on a single day. A patient who consents to doing “everything on a single day” might be exposing herself or himself to unnecessary risks and dangers. The real danger of general anesthesia is that it permits both patients and surgeons to foolishly attempt too much surgery on the same day.
Drugs Used for General Anesthesia
General anesthesia produces unconsciousness and insensibility to pain. A systemic anesthetic is any parenteral drug that can be expected to impair the patient’s respiration, impair protective airway reflexes, and impair the ability to communicate verbally at commonly administered doses. Systemic anesthesia includes general anesthesia given by inhalation of anesthetic gases such as halothane or isoflurane, intravenous (IV) drugs injected into a vein such as propofol (Diprivan), midazolam (Versed), ketamine (Ketalar) and narcotics such as meperidine (Demerol), or fentanyl (Sublimaze). All of these drugs are commonly used to achieve general anesthesia.
Which Form of Anesthesia is Safest?
If a routine surgical procedure can be done using either local anesthesia or general anesthesia then the choice of anesthetic technique depends upon several factors including safety, and convenience. Although dentists can do routine dental procedures using either local anesthesia or systemic anesthesia, they usually choose local anesthesia because of its superior safety. Local anesthesia is widely regarded as being safer than systemic anesthesia. Systemic anesthesia is safest when administered by an attentive anesthesiologist. The dangers of systemic anesthesia increase when either the surgeon or the anesthesiologist ignore the risks of excessive liposuction, or the risks of attempting multiple unrelated surgical procedures on the same day. It is in the patient’s best interest to tell the surgeon not to attempt an excessive amount of liposuction on the same day.
Convenience Versus Safety
When considering liposuction of a large volume of fat, one must weigh the safety against the convenience and economy of doing all the liposuction during a single day. Considering the expense associated with each use of general anesthesia, financial concerns may induce a patient to have multiple cosmetic surgery done on a single day. Doing one mega-session of cosmetic surgery only requires one recovery period, but dividing multiple cosmetic surgeries into separate days may allow shorter recovery periods and less total time away from work. Many patients and surgeons believe it is safer to 1) limit the amount of liposuction done in one day, and 2) avoid doing liposuction with unrelated cosmetic surgeries on the same day. It is up to the patient to make the choice.
Training for Tumescent Anesthesia
Without specific training, most surgeons are incapable of doing routine tumescent liposuction totally by local anesthesia without systemic anesthesia. Anesthesiologists are trained to provide systemic anesthesia, but they are not trained to inject tumescent local anesthesia without systemic anesthesia. Most surgeons who do liposuction using general anesthesia have no experience doing liposuction totally by local anesthesia unless they have had specific training.
Two Types of Excessive Liposuction
There are two forms of excessive liposuction: 1) removing too much fat on single day, and 2) treating too many areas on a single day. Some surgeons feel it is not excessive to remove more than 5 to 8 liters of fat under general anesthesia in one very prolonged liposuction procedure. Other surgeons feel it is excessive to remove more than 3 to 4 liters of fat on any one day. On the other hand, when treating a relatively thin patient, it might be extremely dangerous to remove as little as 2 liters of fat if the patient is subjected to total-body liposuction. When a patient desires liposuction of large volumes of fat, it may be safest to divide the liposuction into two or more separate procedures, separating sequential procedures by at least 3 to 4 weeks.
Excessive Liposuction is Dangerous
It is impossible to know the exact point at which too much of a safe procedure becomes dangerous. There is no distinct boundary line that defines the limits of safe surgery. When liposuction crosses into the domain of excessive surgical trauma, it changes from a benign cosmetic procedure into a potentially lethal process. Satisfying a desire to “do it all in one surgery” may be dangerous. There is no antidote for a toxic dose of surgical trauma. The only safe approach is prevention, which requires common sense, and prudent limits to the amount of surgery.
Excessive Surgical Trauma is Dangerous
The body can only survive a limited amount of surgical trauma before the risks of serious surgical complications increase dramatically. Too much surgical trauma in the form of total body liposuction on the same day can be fatal. It is also dangerous to attempt too many unrelated cosmetic surgical procedures on the same day. For example, a facelift, breast augmentation, facial laser resurfacing and large volume liposuction on the same day can be fatal. Cosmetic surgery is not emergency surgery. It far safer to subdivide a long list of desired cosmetic procedures in two or more separate days.
Contrasting Infiltration Techniques
Tumescent liposuction with general anesthesia is different from tumescent liposuction totally by local anesthesia. With general anesthesia the infiltration of the local anesthesia solution does not need to be thorough. Under general anesthesia the patient is unconscious and is not aware if there are areas of insufficient local anesthesia. In contrast, liposuction totally by local anesthesia requires training in order to skillfully produce 100% complete tumescent anesthesia.
Opinions Regarding Anesthesia Safety
A survey of plastic surgeons regarding preferences for anesthesia revealed a possible inconsistency. Among plastic surgeons who have had a cosmetic surgical procedure, 90% had chosen to have local anesthesia. In contrast, among the patients of these very same surgeons, only 40% received local anesthesia for the same cosmetic procedures. (Lecture delivered 1994, Cambridge, England by Kel Cohn, MD, Chairman, Department of Plastic Surgery, University of North Carolina).
ABC’s “20/20” television program in 1995 showed a patient awake and smiling while having tumescent liposuction totally by local anesthesia. The unqualified positive assessment on national television of the tumescent technique resulted in a consumer demand for “safe liposuction.” Across the country, whenever a prospective patient inquired about liposuction, the first question was “Do you use the tumescent technique?” Surgeons learned very quickly that patients demanded a positive answer. Not knowing how to do tumescent liposuction totally by local anesthesia, many surgeons simply replied, “We do a modified version of the tumescent technique.” Thus there emerged two standards of care for tumescent liposuction, each having distinctly different standards for safety.
Liposuction by either local or general anesthesia is regularly accomplished without serious morbidity. However, when attempting a very large volume of liposuction, there is a tendency for a surgeon to unwittingly exceed the limits of safety. In this sense, there are far greater risks with liposuction using general anesthesia. To the best of our knowledge, there have been no deaths associated with tumescent liposuction totally by local anesthesia when the surgeon used well recognized safe dose limits of local anesthesia.