2012 February | Connecticut Laser

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How to Maximize Patient Comfort During Tumescent Liposuction

Robert Langdon, MD
The Langdon Center for Laser and Cosmetic Surgery

Tumescent anesthesia is achieved by the introduction of relatively large volumes of dilute local anesthetic solution into the subcutaneous fat layer. The anesthetic solution is generally composed of buffered lidocaine (0.05% – 0.1%) and epinephrine (1:1,000,000) in normal saline. Large volumes (several liters) of his tumescent solution can be injected in a nearly painless manner with the lidocaine rapidly providing complete anesthesia for the subsequent liposuction procedure. With careful technique, the patient can be kept comfortable throughout the entire process of tumescent anesthesia and liposuction. Maximizing patient comfort will minimize the need for adjunctive analgesic and sedative medications during liposuction.

Keeping the Patient Warm

One of the most important components of patient comfort is warmth. Liposuction of body areas necessitates exposure to the air of relatively large areas of the patient’s skin. External heating greatly increases patient comfort, especially if the surgeon prefers that the operating room be kept somewhat cool. The ideal way to provide external heat is the use of a warming mat placed beneath the patient through which warm water is circulated. The warming mat is placed directly on the operating table, beneath the sterile field. A highly recommended unit for this purpose is the Gaymar T/Pump (Figures 1 and 2), which can be set to heat the circulating water to a temperature as high as 107°F.

Figure 1: Gaymar warming mat. Heated water is circulated through the mat.

Figure 2: Gaymar T/Pump. The pump unit heats the water that circulates through the warming mat.

The tumescent anesthetic solution should be warmed to approximately 37°C prior to infusion through a peristaltic (Klein) pump. The 1 L bags of tumescent solution can be conveniently heated in a microwave oven. Infusion of room temperature or, even worse, refrigerated anesthetic solution, can rapidly chill the patient.

Painlessly Injecting Tumescent Solution

The word injection is appropriate because the least painful method of administering tumescent anesthesia is through a 20-gauge needle, not a larger infusion cannula. A 3.5-inch spinal needle, attached to an infusion handle, is used (Figure 3). First, a small intra-dermal bleb of

Figure 3: Infusion handle with 20-gauge spinal needle attached.

buffered 1% lidocaine solution is placed in the dermis (a 3-cc syringe equipped with a 30-gauge needle is used). The spinal needle is then introduced through this dermal bleb into the superficial subcutaneous layer and the Klein pump is started. The needle tip is held stationary for 5 to 10 seconds as the solution tumesces a region several centimeters in diameter. The pressure provided by the peristaltic pump forces the anesthetic solution ahead of the needle tip into surrounding fat. The needle tip can be slowly advanced as long as the front of tumescent solution precedes the needle. A helpful sign that the anesthetic solution has completely filled the subcutaneous layer (and has anesthetized the overlying skin) is a peau d’orange (orange peel) appearance to the skin (Figure 4).

Figure 4: Peau d’orange (orange peel) appearance of overlying skin indicates completeness of tumescent anesthesia.

Obvious blanching of the skin is evident after epinephrine in the tumescent anesthetic has constricted blood vessels (Figure 5).

Figure 5: Blanching is evident after the thighs have been tumesced prior to liposuction.

This article is written and copyrighted by Robert Langdon, MD. You are welcome to link to this page or put this article on your website as long as you do not change it’s contents and as long as you give the Langdon Center credit with a live clickable link to www.langdoncenter.com.

Liposuction vs. Abdominoplasty (Tummy Tuck)

Robert Langdon, MD
The Langdon Center for Laser and Cosmetic Surgery

In the great majority of cases liposuction should be done before abdominoplasty (tummy tuck) is considered. In most cases, properly performed liposuction of the abdomen will provide satisfactory results such that abdominoplasty is not necessary.

In the abdomen, subcutaneous fat tends to be most prominent in the lower abdomen but in most cases is also significant in the upper abdomen. If thorough liposuction is performed in the lower abdomen, there will be significant post-operative contraction of the skin. Skin that has developed stretch marks may require laser-assisted liposuction (such as ProLipo laser or SlimLipo laser) to further enhance post-operative skin contraction; the laser procedure is performed at the same time as liposuction.

Even when abdominoplasty is a consideration, in nearly all cases liposuction is also necessary. Although properly performed tumescent liposuction is nearly 100% safe and free of serious complications, abdominoplasty carries much more significant risks, especially when done using general anesthesia. Even more hazardous is combining abdominoplasty with liposuction. This combination has accounted for most of the serious complications that have occurred following liposuction. Because liposuction is very likely to provide satisfactory improvement all by itself, it is a smart choice to first undergo liposuction before even considering abdominoplasty.

Another major disadvantage of abdominoplasty is the significant scarring that results from this procedure. Unlike areas such as the face where incisions for a facelift can be obscured and are not noticeable to onlookers, abdominoplasty nearly always produces significant and unsightly scarring. The skin in the lower abdomen is very prone to scars that spread or develop an uneven contour or color. Almost all patients who undergo abdominal surgery (such as removal of an appendix or gallbladder, or a hysterectomy), will develop significant and obvious scarring. This type of scarring is routine after abdominoplasty and is generally not acceptable for a purely cosmetic procedure. In contrast, liposuction performed with micro-cannulas produces virtually no visible scarring.

Because properly performed liposuction is very likely to provide satisfactory results in patients with excess fat (especially in the lower abdomen), and even in those with loose overlying skin, it makes sense always to proceed first with liposuction. In all likelihood a tummy tuck will not even be necessary and the patient will avoid the unsightly scarring that results from abdominoplasty.

1. Will a minimal incision be used?

A: The main advantage of a minimal incision is decreased visibility of scarring. The goal should be no noticeable scar to the casual observer. The minimal incision is made just in front of and within the ear, within the lower hairline of the sideburn and just behind the lower earlobe. In contrast, the traditional face lift incision extends higher in the temple and, even worse, in the scalp behind the ear. The behind-the-ear area is the most obvious scar and can be very visible when the hair is worn up.

In the Express-Lift, deep plane undermining (see Question 4 below) and tightening of the fascia in multiple directions enables significant improvement in gravitational sagging of the neck and lower face; all of this is achieved through a minimal skin incision.

2. What type of anesthesia will be used?

A: A facelift should be performed under local anesthesia for maximal safety and the quickest recovery. The local anesthetic contains a medication that constricts the blood vessels, thus greatly reducing bruising. Reduced bruising results in less swelling and a quicker recovery. A sedative will help relax the patient.

A tumescent type local anesthetic also increases safety because it expands the tissue, thus decreasing the risk of injury of underlying nerves.

3. Will liposuction of the neck and jowls also be done?

A: Liposuction, especially of the neck, greatly enhances the results of a facelift. Most people accumulate significant fat in the neck beneath the chin. Reducing this fat by liposuction improves the neck contour and stimulates tightening of the skin. The sagging muscle/fascia layer (see Question 4 below) of the neck is then tightened as part of the facelift.

The jowls are the part of the lower cheek just lateral to (outside of) the chin. There is a distinct fat pad underneath the skin in this area, causing the jowls to bulge. This relative increased volume, along with sagging due to gravity, causes the jowl to hang over (below) the jaw line, which interrupts the ideal straight line of the jaw. A sagging jowl also increases the perceived depth of the marionette fold (pre-jowl sulcus), the furrow between the chin and the jowl. Liposuction can reduce the fullness of the jowl; however, substantial improvement of a sagging jowl requires tightening of the underlying fascia (see Question 4 below).

4. Is the fascia (SMAS) mobilized (loosened so that it can be shifted in position)?

A: Long-term improvement in gravitational sagging of the face requires that the fascia, a connective tissue layer that lies beneath the subcutaneous fat, be lifted in an upward direction. This vertical vector of lifting counteracts the downward sagging caused by many years of living under the influence of gravity. The essence of modern face lift surgery is shifting the position of the fascia of the face (also referred to as the Superficial Musculo-Aponeurotic System, SMAS). The SMAS is a layer of connective tissue that varies in thickness in different parts of the face; it is in direct continuity with most of the superficial muscles whose contraction creates facial expressions. Vertical bands of connective tissue attach the overlying skin to the SMAS, enabling the overlying skin to move along with the muscles. In a few distinct locations, the SMAS is also attached to the underlying bones of the skull.

The most sophisticated face lift techniques include loosening the underlying attachments of the SMAS, especially those to the bone, in order to increase mobility of the fascia. The layer beneath the SMAS is referred to as the “deep plane;” such surgeries are called deep plane face lifts. The mobilized SMAS can be shifted more easily, and will heal by attaching to underlying structures, thus affording long-term improvement after the face lift.

5. How long does it take to do the procedure?

A: Avoid any face lift (such as the heavily promoted “Lifestyle Lift”) that supposedly is done in “about an hour.” This brief period may be adequate for obtaining a new pair of eyeglasses, but is not nearly enough for a satisfactory face lift. I have seen several patients who were disappointed after undergoing a Lifestyle Lift because the degree of improvement was minimal. It takes much longer (four or more hours) to accomplish the required undermining, mobilizing and suspending the fascia, trimming of excess skin and precise placement of stitches in the skin to achieve substantial improvement from a face lift.

6. How long is the expected recovery period after the face lift?

A: The key to a quick recovery is the type of anesthesia that is used for the face lift. Tumescent local anesthetic completely numbs the area of surgery and includes epinephrine, a medication that shrinks the blood vessels during the surgery, thus minimizing bruising. Less bruising results in less swelling and a quicker recovery. After an Express-Lift, most patients are presentable by one week, the time at which surface stitches are removed.

About Local Anesthesia

Dear Dr. Langdon,

Q: I am interested in receiving laser body sculpting at The Langdon Center in Guilford. However I have never had a local anesthetic before. I understand the risks associated with general anesthesia, but I am unsure about what to expect with local anesthesia and if it is safe…

Dr. Langdon, what do you think?

A. First, I think you would benefit from coming in for a consultation; it’s free, and I will gladly answer all your questions in detail.

I can assure you that when used by an educated and experienced surgeon, local anesthesia is perfectly safe and beneficial too.

During laser body sculpting I use what is called the tumescent technique. The tumescent technique is a method that provides local anesthesia to large volumes of subcutaneous fat and thus permits liposuction totally by local anesthesia. The tumescent technique eliminates both the need for general anesthesia and the need for IV narcotics and sedatives. The tumescent technique utilizes a natural saline solution containing a precise amount of local anesthetic (lidocaine) and adrenaline, which is injected into the fatty tissue. The injected area then becomes anesthetized (numb). Tumescent anesthesia constricts capillaries and prevents surgical blood loss, provides fluid to the body by subcutaneous injection so that no IV fluids are needed and provides the best post-operative pain control.

Local anesthesia offers a safe alternative to more risky general anesthesia. Local anesthesia is beneficial because it significantly decreases swelling and bruising after the procedure. It also makes the procedure virtually pain free. The vast majority of patients are able to resume their normal activity within 2-3 days with minimal swelling or bruising.

I encourage you to stop in for a free consultation and learn more about laser body sculpting and local anesthesia.

Sincerely, Dr. Langdon

To learn more call The Langdon Center at 203. 453.8625.

February Beauty Breakthroughs at The Langdon Center in Guilford

Join us this February at The Langdon Center for Laser and Cosmetic Surgery in Guilford, CT as we continue to explore beauty breakthroughs that sculpt the body and rejuvenate the face.

Enjoy special savings at The Langdon Center throughout the month of February on state-of-the-art procedures and treatments including laser body sculpting, ExpresS-Lift facelift, natural breast enhancement and fat transfer to the breasts, butt, face and hands. Dr. Langdon is a board-certified cosmetic surgeon and dermatologist who, with the help of his colleagues, developed a novel skin grafting method that has been adopted around the world. Dr. Langdon is a Clinical Associate Professor at Yale University School of Medicine and is a leading authority on laser surgery and cosmetic procedures. His expertise is recognized internationally and is available to those seeking to improve their face and body and who live in the Greater New Haven area.

Dr. Langdon says, “I encourage people who are interested in cosmetic improvements to take advantage of these savings. Each procedure and treatment I offer here at The Langdon Center is tailored for the needs and lifestyle of my patients. I stand by the efficacy of each service and am pleased to have such a loyal patient following.”

Join Dr. Langdon, Thursday, February 23 for Fact vs. Fiction, a complimentary seminar during which Dr. Langdon will explore beauty breakthrough techniques available at The Langdon Center in Guilford. Seminar topics will include laser body sculpting and facial rejuvenation, photo facials, fat transfer techniques, wrinkle reducing injectables like BOTOX and dermal fillers. There will be a lively Q & A session and before and after photos will be shown. Guests are encouraged to bring a friend and make a night of it! Seating is limited and guests are asked to RSVP at 203.453.8625.

To learn more about Dr. Langdon and The Langdon Center for Laser and Cosmetic Surgery, call 203.453.8625.