Super-wet liposuction vs tumescent: fluid ratios, blood loss and what the safety studies disagree on

Super-wet liposuction, or the superwet technique, is one of four liposuction techniques that a 2011 anaesthesia review classified by the volume of infiltration or wetting solution injected: dry, wet, superwet and tumescent[1]. A 2010 review described tumescent liposuction as a local anesthesia technique and superwet liposuction as a systemic anesthesia technique, and called them the most common methods[2]. A 2022 case report likewise described the super-wet and tumescent techniques as the ones used most frequently[3].

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What is super wet liposuction?

In the 2011 review’s list of four liposuction types based on the volume of wetting solution injected, super wet liposuction is listed between the wet and tumescent techniques[1]. That review described the wetting solution of the tumescent technique as large volumes of dilute local anaesthetic injected into the fat to facilitate anaesthesia and decrease blood loss[1].

A 2006 study on fluid management noted that different infiltration practices, such as the wet, superwet and tumescent techniques, require different fluid management guidelines[4]. A 2022 case report stated that both the super-wet and tumescent techniques serve to reduce collateral blood loss and facilitate the suctioning procedure[3].

For the dry and wet techniques, see our page on the wet technique.

How does the super-wet technique differ from tumescent liposuction?

A 2010 review and a 2022 case report describe the anaesthesia used with these two techniques differently[2][3]. The 2010 review called tumescent liposuction a local anesthesia technique and superwet liposuction a systemic anesthesia technique[2]. The 2022 case report, by contrast, said that both the super-wet and tumescent techniques provide local anesthesia[3].

Two studies from the 1990s grouped the two techniques together[5][6]. A 1994 study described the “tumescent” or “superwet” technique as infiltration of the targeted area with large amounts of dilute lidocaine with epinephrine[5]. A 1997 study measured adipsin, a protein present in high amounts in fat tissue, in 22 patients undergoing syringe-assisted liposuction using the superwet or tumescent technique[6].

The 2010 review rated the safety profile of both tumescent and superwet liposuction as excellent, while noting that local anesthesia avoids the specific risks associated with general anesthesia[2]. For more background, see our page on tumescent liposuction.

What infiltrate-to-aspirate ratio is used in superwet liposuction?

A 2006 study described its own infiltrate-to-total aspirate ratios as lower than those used for the superwet technique[4].

In that prospective study, 580 consecutive patients underwent liposuction with an average infiltrate-to-total aspirate ratio of 0.38[4]. The ratio ranged from 0.24 to 0.8 across the series[4].

The same study defined an intraoperative fluid ratio as intravenous fluid given during surgery plus the injected infiltrate, divided by the total aspirate[4]. That intraoperative fluid ratio ranged from 0.98 to 2.1, with an average of 1.25[4]. The average percentage of body weight aspirated was 5.2%, with a range of 1.76 to 7.02%[4].

Ask your surgeon how much fluid they plan to inject in relation to the amount of fat they expect to remove.

How is fluid managed during superwet and large-volume liposuction?

The 2006 study noted that, as surgeons have undertaken aspirations of four litres or more, the potential complications of hypovolemia and fluid overload have materialized[4]. In its 580 patients, the average postoperative heart rate was 92.16 beats per minute and the average postoperative mean blood pressure was 70.41 mmHg[4].

The 2006 authors presented a fluid management guideline that they described as safe, based on their 580 patients[4]. They also cautioned that volumes calculated from any formula should be viewed as educated guesses of the appropriate fluid load, and that clinical judgment is essential[4].

The 2011 anaesthesia review stated that, because a large volume of wetting solution is injected under the skin, fluid management during surgery has to be carefully titrated along with haemodynamic monitoring and temperature control[1]. The same review noted that blood loss is difficult to assess because it is mixed with the aspirated fat[1].

A 2024 review of large-volume liposuction in overweight patients said the superwet technique and ultrasonic-assisted liposuction are used to diminish blood loss, while keeping a keen awareness of the maximum volume of infiltration fluid permissible for safe infusion[7]. In a 2012 study of 322 consecutive patients having superwet ultrasonic liposuction and/or abdominoplasty and other combined procedures, the mean proportion of wetting solution removed by liposuction was 9.8 percent[8].

How much blood is lost with the super-wet technique?

A 1994 study reported dramatically reduced blood loss with the tumescent or superwet technique, but a 2012 study of superwet ultrasonic liposuction concluded that estimated blood loss is higher than previous estimates based on lipocrits[5][8].

In the 1994 study, 25 consecutive cases using the tumescent or superwet technique were investigated with hemoglobin measurements before and after surgery[5]. The mean fall in postoperative hemoglobin was 5.4% ± 4.9%[5]. The authors concluded that blood loss with the tumescent or superwet technique is dramatically reduced compared with the dry or classical “wet” technique[5].

In the 2012 study, abdominoplasty added to blood loss on average[8]. The same study reported that blood loss had been underestimated using the small volumes present in the aspirate[8].

One randomized, double-masked trial measured the effect of lidocaine in the tumescent solution on blood loss in 70 female patients having body liposuction as a single surgery between November 2005 and July 2007[9]. The group that received tumescent solution containing lidocaine and epinephrine had a mean hematocrit reduction of 10.8% ± 2.9%, compared with 8.8% ± 2.6% in the control group that received epinephrine only (P = 0.004)[9]. The authors concluded that lidocaine in the tumescent solution significantly increases postoperative anemia compared with epinephrine infiltration alone[9].

In a 1999 series of large-volume liposuction, blood loss was calculated in 45 patients treated with ultrasonic plus tumescent liposuction, from hematocrits taken before surgery and five days after[10]. In those patients, there was no correlation between aspirate volume and calculated blood loss, and most of the calculated blood loss was not in the canister[10].

What do large-volume liposuction studies report?

Large-volume series using the tumescent technique reported no deaths in one 1999 series and no major complications in two others[10][11][12]. In the 1999 series of 181 patients who had large-volume liposuction in a single procedure, using tumescent liposuction alone or combined with ultrasonic liposuction, no deaths occurred, but one patient had a deep venous thrombosis and two patients had pulmonary emboli[10].

In another 1999 study, 161 patients (152 female and 9 male) had large-volume circumferential tumescent liposuction over a four-year period[11]. Volumes between 5 and 22.3 litres were obtained, with a mean of 8.7 litres[11]. Hemoglobin fell by 3.8 g and hematocrit by 12 percent at one week after surgery[11].

That circumferential series reported no major complications, but 18 patients (11.2 percent) had seromas, which were drained, and two patients (1.2 percent) had superficial skin necrosis[11]. Palpable irregularities occurred in 24 patients (14.9 percent) and were visible in 8 patients (5 percent)[11].

A series of 870 liposuction cases performed between September 2000 and August 2008 used tumescent infiltration in all cases, and in 65% of cases the total aspirate was greater than 5 litres[12]. The authors reported no major complication, and blood transfusion was given on one occasion[12].

The 2024 review recommended that large-volume liposuction be performed in accredited hospitals or certified ambulatory surgery centers, with overnight admission for hemodynamic monitoring[7]. The same review listed hypothermia prevention, deep vein thrombosis prophylaxis and perioperative antibiotic prophylaxis among the evidence-based protocols it called paramount to reduce the risk of postoperative complications[7]. Read more in our article on large-volume liposuction.

Is super-wet liposuction as safe as tumescent liposuction?

Two reviews reached different conclusions: a 2010 review rated both techniques’ safety profile as excellent, while a 2019 systematic review listed the (super)wet technique among factors that contributed to increased serious complication and mortality risk[2][13].

The 2019 systematic review included 24 studies found in a literature search through April 2017[13]. Besides the (super)wet technique, the factors it linked to increased risk were systemic anesthetics (especially general anesthesia and intravenous sedation), execution by a plastic surgeon, execution in an operating room, and combination with other procedures[13]. It concluded that liposuction using tumescent local anesthesia has been shown to be the safest method of fat removal, especially if no or only minimal systemic anesthesia is used[13].

The 2012 study of superwet ultrasonic liposuction and combined procedures measured plasma levels of lidocaine, bupivacaine and epinephrine in a subset of 76 consecutive patients[8]. No clinical toxicity was encountered in that study[8]. Its authors concluded that combination procedures are safe[8].

In the 1997 adipsin study, only a very modest increase in adipsin was found during liposuction with the superwet or tumescent technique, and all values were within the range found in healthy blood donors[6].

A 2022 case report described life-threatening bleeding after liposuction as rare, and presented a healthy 51-year-old man admitted four days after tumescent liposuction at a day surgery center with tachycardia, weakness, abdominal pain and disseminated hematoma[3]. He was treated with a blood transfusion[3]. The report’s authors stated that improper patient selection, an inexperienced surgeon and an inadequate operating locale can all result in postoperative complications[3].

If you notice a racing heartbeat, weakness, chest pain, shortness of breath or a rapidly growing swelling after liposuction, contact your surgeon or emergency services right away.

Talking to a surgeon

Before surgery, consider asking a board-certified surgeon these questions:

  • Which infiltration technique do you use, and why do you prefer it for my case?
  • How much fluid do you plan to inject compared with the amount you expect to remove?
  • What type of anaesthesia will I have, and who will monitor my fluids and vital signs?
  • Where will the operation take place, and will I stay overnight?
  • How will you estimate and track my blood loss during and after surgery?

For more on safety, see our page on liposuction safety and complications.

Frequently asked questions

What is super wet liposuction?

Superwet is one of four liposuction techniques that a 2011 review grouped by the volume of wetting solution injected, alongside dry, wet and tumescent[1]. A 2010 review described superwet liposuction as a systemic anesthesia technique[2].

Is super-wet liposuction the same as tumescent liposuction?

A 1994 study grouped them together as the “tumescent” or “superwet” technique[5]. A 2010 review, however, called tumescent liposuction a local anesthesia technique and superwet liposuction a systemic anesthesia technique[2].

Does the super-wet technique reduce blood loss?

A 1994 study of 25 consecutive cases concluded that blood loss with the tumescent or superwet technique is dramatically reduced compared with the dry or classical wet technique[5]. A 2012 study of superwet ultrasonic liposuction found estimated blood loss higher than earlier estimates based on lipocrits[8].

Is super-wet liposuction safe?

A 2010 review rated the safety profile of both tumescent and superwet liposuction as excellent[2]. A 2019 systematic review of 24 studies listed the (super)wet technique among factors that contributed to increased serious complication and mortality risk[13].

References

  1. Liposuction: Anaesthesia challenges. Indian journal of anaesthesia. 2011. PubMed 21808392
  2. Liposuction. Obstetrics and gynecology clinics of North America. 2010. PubMed 21093746
  3. Severe Postoperative Bleeding Following Minor-to-Moderate Abdominal and Flank Liposuction Performed at a Day Surgery Center: A Case Report. The American journal of case reports. 2022. PubMed 35121723
  4. Fluid resuscitation in liposuction: a prospective analysis of infiltrate-to-total aspirate ratios lower than used for the superwet technique. Aesthetic plastic surgery. 2006. PubMed 17093883
  5. Blood loss during liposuction using the tumescent technique. Aesthetic plastic surgery. 1994. PubMed 8017219
  6. Modest release of adipsin/factor D by liposuction when using the superwet or tumescent technique. Plastic and reconstructive surgery. 1997. PubMed 9145127
  7. Lipoplasty in the Overweight Patient. Clinics in plastic surgery. 2024. PubMed 37945074
  8. Prospective study of lidocaine, bupivacaine, and epinephrine levels and blood loss in patients undergoing liposuction and abdominoplasty. Plastic and reconstructive surgery. 2012. PubMed 22929254
  9. Effect of subcutaneous lidocaine infiltration on blood loss secondary to corporal lipoaspiration: a prospective, randomized, double-masked clinical trial. Aesthetic plastic surgery. 2009. PubMed 19484178
  10. Large-volume liposuction in 181 patients. Aesthetic plastic surgery. 1999. PubMed 10022931
  11. Large-volume circumferential liposuction with tumescent technique: a sure and viable procedure. Plastic and reconstructive surgery. 1999. PubMed 10541195
  12. Liposuction. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India. 2008. PubMed 20174540
  13. Safety Studies in the Field of Liposuction: A Systematic Review. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2019. PubMed 30702445