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.
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