Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction

Perioperative Pain Management for Mastectomy in Dogs: A Narrative Review

Mammary tumours are the most common neoplasia in adult female dogs. Mastectomy leads to moderate to severe pain. Effective pain management is crucial in veterinary medicine. This review outlines analgesic techniques for managing perioperative pain in dogs undergoing mastectomy. A literature search on dog mastectomy analgesia was conducted from January 2001 to January 2025. Pre-emptive meloxicam reduces postoperative cardiovascular changes without affecting renal function. When combined with gabapentin, it lowers the need for rescue analgesic opioids, similar to robenacoxib. With regard to tramadol, it offers contrasting analgesia in the studies considered when used alone, while its effect appears enhanced when used in combination with meloxicam/dipyrone. However, methadone provides superior pain control, especially when given preoperatively or intraoperatively. The combination of ketamine, lidocaine, and maropitant enhances pain management, while fentanyl, alone or with lidocaine and ketamine, is effective for intraoperative pain control. Local infiltration with lidocaine/bupivacaine provides effective pain control, and devices like Comfont-in® or WSC facilitate this process. Tumescent anaesthesia using lidocaine/ropivacaine allows for extensive infiltration of the mammary gland. Epidural analgesia, paravertebral blocks, and TAP blocks are beneficial in multimodal protocols. Transdermal patches containing fentanyl/buprenorphine offer prolonged analgesia, while electroacupuncture can help reduce the need for rescue analgesics. Multimodal analgesic protocols are crucial for effective pain management in dog mastectomy surgeries, minimising the need for rescue opioids.

Part 2: Management of intraoperative and perioperative bleeding

With an increase in number of patients on antithrombotic therapies, management of bleeding during dermatologic surgery is increasingly important. As described in Part 1, perioperative discontinuation of antithrombotic therapies may increase the risk of embolic events thus the risks and benefits must be weighed carefully when deciding whether to continue or suspend therapy. However, continuing oral anticoagulants may result in increased intraoperative and postoperative bleeding. Here we describe various methods to effectively achieve hemostasis which include (1) mechanical methods to compress the vasculature, (2) pharmacologic agents that induce vasoconstriction, (3) physiologic agents that augment clot formation, and (4) physical agents that promote platelet aggregation.

Lipoplasty in the Overweight Patient

The practice of large volume liposuction, when executed by board-certified plastic surgeons using a variety of energy-assisted liposuction devices, has been substantiated as a secure procedure, yielding enhanced aesthetic results and minimal complications. Techniques including the superwet technique and ultrasonic-assisted liposuction are utilized to diminish blood loss, while also maintaining a keen awareness of the maximum volume of infiltration fluid permissible for safe infusion. Adherence to evidence-based protocols is of paramount importance to reduce the risk of postoperative complications. These protocols encompass hypothermia prevention, deep vein thrombosis (DVT) prophylaxis, and perioperative antibiotic prophylaxis. To ensure the highest quality of care, it is recommended that large volume liposuction procedures be performed in accredited hospitals or certified ambulatory surgery centers. Postoperative procedures should include overnight admission of patients to facilitate proper hemodynamic monitoring. While the employment of multiple devices such as VASERLipo and Renuvion has been noted to augment skin and soft tissue contraction, it is worth noting that there may be a heightened risk of seroma formation (at 2.27%) and subcutaneous emphysema (at 1.47%). Consequently, prudent use of these advanced medical devices is essential to avoid any potential adverse events.

Back to the future: breast surgery with tumescent local anesthesia (TLA)?

PURPOSE

Breast surgery is usually performed under general anesthesia. Tumescent local anesthesia (TLA) offers the possibility to anesthetize large areas with highly diluted local anesthetic.

METHODS

In this paper, the implementation, and experiences with TLA in the field of breast surgery are discussed.

CONCLUSION

For carefully selected indications, breast surgery in TLA represents an alternative to ITN.

A 16-Year Review of Clinical Practice Patterns in Liposuction Based on Continuous Certification by the American Board of Plastic Surgery

BACKGROUND

The American Board of Plastic Surgery has collected data on cosmetic surgery tracers as part of the Continuous Certification process since 2005. The current study was performed to analyze evolving trends in liposuction from the American Board of Plastic Surgery database.

METHODS

Tracer data from 2005 through 2021 were reviewed and grouped into an early cohort (EC) (2005-2014) and a recent cohort (RC) (2015-2021). Fisher exact tests and two-sample t tests were used to compare patient demographics, techniques, and complications.

RESULTS

A total of 2810 suction-assisted liposuction cases were included (1150 EC, 1660 RC). In-office procedures increased (36% EC versus 41% RC). The use of general anesthesia remained the same (63% EC versus 62% RC). The use of power-assisted liposuction increased (24% EC versus 40% RC) and use of ultrasound-assisted liposuction decreased (5% versus 2%). With respect to body areas treated, liposuction of the abdomen (64% EC versus 69% RC), flanks (60% EC versus 64% RC), and back (22% EC versus 34% RC) increased; treatments of thighs (36% EC versus 23% RC), and knees (8% EC versus 5% RC) decreased. Intraoperative position changes are more common (30% EC versus 37% RC), as is liposuction of multiple areas in one case (28% EC versus 36% RC). The volume of lipoaspirate also increased (1150 cc EC versus 1660 cc RC).

CONCLUSIONS

This study highlights evolving trends in liposuction over 16 years. Liposuction is becoming more common as an outpatient procedure performed concomitantly with other procedures. Despite multiple emerging technologies, the popularity of power-assisted liposuction is increasing. Although adverse events have not significantly increased with these changes, the authors stress careful preoperative evaluation of patients to identify factors that increase the risk of complications.

Updates on Enhanced Recovery after Surgery protocols for plastic surgery of the breast and future directions

Introduction

Perioperative pain control is an important component of any plastic surgery practice. Due to the incorporation of Enhanced Recovery after Surgery (ERAS) protocols, reported pain level, opioid consumption, and hospital length of stay numbers have decreased significantly. This article provides an up-to-date review of current ERAS protocols in use, reviews individual aspects of ERAS protocols, and discusses future directions for the continual improvement of ERAS protocols and control of postoperative pain.

ERAS components

ERAS protocols have proven to be excellent methods of decreasing patient pain, opioid consumption, and postanesthesia care unit (PACU) and/or inpatient length of stay. ERAS protocols have three phases: preoperative education and pre-habilitation, intraoperative anesthetic blocks, and a postoperative multimodal analgesia regimen. Intraoperative blocks consist of local anesthetic field blocks and a variety of regional blocks, with lidocaine or lidocaine cocktails. Various studies throughout the surgical literature have demonstrated the efficacy of these aspects and their relevance to the overall goal of decreasing patient pain, both in plastic surgery and other surgical fields. In addition to the individual ERAS phases, ERAS protocols have shown promise in both the inpatient and outpatient sectors of plastic surgery of the breast.

Conclusion

ERAS protocols have repeatedly been shown to provide improved patient pain control, decreased hospital or PACU length of stay, decreased opioid use, and cost savings. Although protocols have most commonly been utilized in inpatient plastic surgery procedures of the breast, emerging evidence points towards similar efficacy when used in outpatient procedures. Furthermore, this review demonstrates the efficacy of local anesthetic blocks in controlling patient pain.

Multimodal Analgesia in the Aesthetic Plastic Surgery: Concepts and Strategies

Postoperative pain management is crucial for aesthetic plastic surgery procedures. Poorly controlled postoperative pain results in negative physiologic effects and can affect length of stay and patient satisfaction. In light of the growing opioid epidemic, plastic surgeons must be keenly familiar with opioid-sparing multimodal analgesia regimens to optimize postoperative pain control.

Methods

A review study based on multimodal analgesia was conducted.

Results

We present an overview of pain management strategies pertaining to aesthetic plastic surgery and offer a multimodal analgesia model for outpatient aesthetic surgery practices.

Conclusion

This review article presents an evidence-based approach to multimodal pain management for aesthetic plastic surgery.

The 100 Most-Cited Articles in Liposuction: A Bibliometric Analysis

BACKGROUND

Liposuction is one of the most common cosmetic surgical procedures performed worldwide. Despite previous citation analyses in plastic surgery, the most-cited works in liposuction have not yet been qualitatively or quantitatively appraised. We hypothesized that use of validated outcome measures and levels of evidence would be low among these articles. Thus, we performed a bibliometric analysis aiming to comprehensively review the most-cited liposuction literature, evaluating characteristics and quality of the top 100 articles.

METHODS

The 100 most-cited articles in liposuction were identified on Web of Science, across all available journals and years (1950-2020). Study details, including the citation count, main subject, and outcome measures, were extracted from each article by 2 independent reviewers. The level of evidence of each study was also assessed.

RESULTS

The 100 most-cited articles in liposuction were cited by a total of 4809 articles. Citations per article ranged from 602 to 45 (mean, 92). Most articles were level of evidence 4 (n = 33) or 5 (n = 35), representative of the large number of case series, expert-opinion articles, and narrative reviews. Ten articles achieved level of evidence 3, 22 articles achieved level of evidence 2, and none reached level 1. The main subject was operative technique in 63 articles, followed by outcomes in 32 articles. Five articles assessed the metabolic effects of liposuction. Only 1 article used a validated objective cosmetic outcome measure, and none used validated patient-reported outcome measures.

CONCLUSIONS

This analysis provides an overview of the top cited liposuction literature. Overall, level of evidence was low, and no articles achieved the highest level of evidence. Improving the quality of literature requires prioritization of better-designed studies and incorporation of validated outcome measures, which will increase patient satisfaction and ensure provision of excellent, reproducible clinical care.

Update on Liposuction: What All Plastic Surgeons Should Know

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the types of tumescence available for liposuction. 2. Explain the various modalities available for liposuction. 3. Describe the patient selection, staging, and complications associated with debulking liposuction. 4. Describe ways to optimize outpatient liposuction.

SUMMARY

Liposuction is one of the most common procedures performed by board-certified plastic surgeons and is likely greatly underestimated, given underreporting of office procedures and the number of non-plastic surgeons performing these operations. With the ever-increasing popularity of liposuction, various methodologies and technology have been designed to make this task simpler and faster for the surgeon and hasten the recovery for the patient. In the past 10 years, over 50 devices or techniques have been released to assist, refine, or altogether replace liposuction. With the advent of these newer tools, a thorough Continuing Medical Education study was performed to review the available literature.

Tumescent local anesthesia versus general anesthesia for subcutaneous implantable cardioverter-defibrillator implantation

BACKGROUND

Subcutaneous implantable cardioverter-defibrillator (S-ICD) is an effective alternative to transvenous implantable cardioverter-defibrillator. General anesthesia (GA) is considered the standard sedation approach because of the pain caused by the manipulation of subcutaneous tissue with S-ICD implantation. However, GA carries several limitations, including additional risk of adverse events, prolonged in-room times, and increased costs.

OBJECTIVE

The purpose of this study was to define the effectiveness and safety of tumescent local anesthesia (TLA) in comparison to GA in patients undergoing S-ICD implantation.

METHODS

We performed a prospective, nonrandomized, controlled, multicenter study of patients referred for S-ICD implantation between 2019 and 2020. Patients were allocated to either TLA or GA on the basis of patient's preferences and/or anesthesia service availability. TLA was prepared using lidocaine, epinephrine, sodium bicarbonate, and sodium chloride. All patients provided written informed consent, and the institutional review board at each site provided approval for the study.

RESULTS

Sixty patients underwent successful S-ICD implantation from July 2019 to November 2020. Thirty patients (50%) received TLA, and the rest GA. There were no differences between groups with regard to baseline characteristics. In-room and procedural times were significantly shorter with TLA (107.6 minutes vs 186 minutes; P < .0001 and 53.2 minutes vs 153.7 minutes; P < .0001, respectively). Pain was reported less frequently by patients who received TLA. The use of opioids was significantly reduced in patients who received TLA (23% vs 62%; P = .002).

CONCLUSION

TLA is an effective and safe alternative to GA in S-ICD implantation. The use of TLA is associated with shorter in-room and procedural times, less postprocedural pain, and reduced usage of opioids and acetaminophen for analgesia.

[Liposuctions in the ambulatory setting]

BACKGROUND

 Liposuctions are among the most frequently performed operations in plastic surgery worldwide. They are offered as inpatient as well as outpatient procedures. In the outpatient setting, tumescent anaesthesia is used in various forms. There is ambiguity about the amount of lipoaspirate that can be removed safely in an outpatient setting, and also about the monitoring of parameters and the duration of postoperative care.

MATERIAL AND METHODS

 A systematic literature review was conducted with the help of the MEDLINE data base of the U. S. National Library of Medicine (NLM) and the bibliographic search engine Google Scholar (https://scholar.google.com) of Google LLC. The key words "Liposuction Anesthesia" and "Liposuction Guidelines" were used. All items resulting from the search were checked for thematic concordance and further analysed by their level of evidence, significance and availability.

RESULTS

 After the literature review, a total of 197 items were identified for further analysis. The analysis of the international and German literature yielded a systematic overview of recommendations.

CONCLUSIONS

 Tumescence anaesthesia in an outpatient setting has various advantages, e. g. cost reduction for provider and patient as well as avoidance of the risk profile of general anaesthesia. Also patients can change their position autonomously, which can be beneficial for surgery. However, there are limitations in terms of the lipoaspirate volume that can be removed safely. With increasing lipoaspirate volumes, more local anaesthetic is needed, which also increases the postoperative monitoring time. In the authors view, tumescent anaesthesia should only be used for small-volume and localised liposuctions. Liposuction in general anaesthesia offers more advantages, especially with increasing lipoaspirate volumes.

A randomised controlled trial of perivenous tumescent anaesthesia in addition to general anaesthesia for surgical ligation and stripping of the great saphenous vein

INTRODUCTION

Open surgical ligation and stripping of the great saphenous vein is a highly cost-effective treatment when compared with conservative management and foam sclerotherapy but has limitations including post-operative morbidity and pain. This study aims to identify if the addition of tumescent anaesthesia could improve patient outcomes following treatment.

METHODS

Patients with primary superficial venous incompetence undergoing open surgical ligation and stripping of the great saphenous vein were randomised to either General Anaesthesia (GA) alone (GA) procedure or the addition of tumescent (G + T). The primary outcome was bodily pain (within SF-36) at one week. Additional outcomes included post-procedural pain score (100 mm visual analogue scale), complications and quality of life.

RESULTS

A total of 90 patients were randomised for inclusion. There was no significant difference in primary outcome; bodily pain at one week. Secondary outcome of 4-h post-procedural scores were significantly lower in the G + T group (32 (20-54) mm vs. (GA alone) 56 (24-70) mm (P = 0.016)). Complications were minor and equivalent. Both groups saw a significant increase (worsening) in Aberdeen Varicose Vein Questionnaire scores at week 1 with the G + T group faring worse at six weeks (10.0 (Interquartile Range [IQR] 5.6-17.9) vs. 4.3 (IQR 2.7-7.9) P = 0.004).

CONCLUSION

The G + T group did not demonstrate a significant difference in the one-week bodily pain domain. The addition of tumescent anaesthesia does improve immediate post-operative pain but appears to negatively impact on six-week quality of life. EudraCT Number: 2011-005574-39.

Optimizing Patient Outcomes and Safety With Liposuction

Since its advent in the early 1980s, liposuction has made tremendous advancements, making it the most popular aesthetic surgery performed today. The goal of this Continuing Medical Education (CME) article is to provide a foundation of knowledge of the relevant anatomy, preoperative evaluation, intraoperative technique, and postoperative management for surgeons performing liposuction. Finally, the prevention and management of potential complications will be reviewed along with measures to optimize patient safety and outcomes.

Autologous fat grafting: Harvesting techniques

Autologous fat grafting is widely used for soft-tissue augmentation and replacement in reconstructive and aesthetic surgery providing a biocompatible, natural and inexpensive method. Multiple approaches have been developed in the past years, varying in the location of adipose tissue donor-sites, use of wetting solutions, harvesting, processing and placing techniques. Despite many advances in this subject, the lack of standardization in the protocols and the unpredictability of the resorption of the grafted tissue pose a significant limitation for graft retention and subsequent filling. In this review, we discuss several approaches and methods described over the last years concerning the harvesting of autologous fat grafts. We focus on contents such as the best donor-site, differences between existing harvesting techniques (namely tissue resection, hand aspiration or liposuction techniques), recommended harvesting cannula diameters, pressure application and volume of wetting solution injected prior aspiration. Results and comparisons between methods tend to vary according to the outcome measured, thus posing a limitation to pinpoint the most efficient methods to apply in fat grafting. Additionally, the lack of a standard assay to determine viability or volume augmentation of fat grafting remains another limitation to obtain universally accepted grafting procedures and protocols.

•

Distinct harvesting procedures associate with different outcomes of fat graft take.

•

Flank, abdomen, thigh and knee are the more consistently used donor-sites for fat.

•

Higher vacuum pressures in liposuction are more traumatic for the tissue.

•

The tumescent technique is a safer procedure with improved aesthetic results.

•

Comparing harvesting techniques is a big challenge given the multiple variables.

Tumescent anaesthesia: its applications and well tolerated use in the out-of-operating room setting

PURPOSE OF REVIEW

Tumescent anaesthesia is a method of administering dilute local anaesthetic into the subcutaneous tissue. Many anaesthesiologists are unfamiliar with the technique, its applications and potential risks.

RECENT FINDINGS

The maximum safe dose of lidocaine with epinephrine in tumescent anaesthesia for liposuction is probably between 35 and 55 mg/kg. Without liposuction, the maximum dose of lidocaine with epinephrine should be no more than 28 mg/kg. After tumescent infiltration for liposuction, serum lidocaine concentrations peak between 12 and 16 h after injection. When tumescent lidocaine without epinephrine is used for endovenous laser therapy, peak serum lidocaine concentrations are observed much earlier, between 1 and 2 h after injection. Slow administration of more dilute concentrations of local anaesthetic decreases the risk of local anaesthetic systemic toxicity.

SUMMARY

Although appealing because of its ability to provide prolonged analgesia, high doses of local anaesthetic are frequently administered using the tumescent technique, and absorption of local anaesthetic from the subcutaneous tissue is variable. When caring for patients having procedures in which tumescent anaesthesia is used, the risk of local anaesthetic toxicity should be acknowledged and lipid emulsion should be available for prompt treatment if needed.

A Prospective Randomized Study Comparing Bupivacaine Hydrochloride Versus Bupivacaine Liposome for Pain Management After Distal Radius Fracture Repair Surgery

PURPOSE

To compare pain experience and opioid use after distal radius fracture repair surgery performed with perioperative infiltration of the local anesthesia bupivacaine hydrochloride (Marcaine; Pfizer, New York, NY) or bupivacaine liposome (Exparel; Pacira, Parsippany, NJ).

METHODS

We conducted a prospective comparison of consecutive patients scheduled to undergo distal radius fracture repair surgery. Patients were randomized to either Marcaine or Exparel. Patients in the Marcaine group received 20 mL 0.5% bupivacaine without epinephrine into the incision and surgical site before incision. Patients in the Exparel group first received 10 mL 0.5% Marcaine with no epinephrine into the incision and surgical site before incision; then, upon completion of the surgery and wound closure, they also received 10 mL Exparel into the same site that had been preinjected with Marcaine. All operations were performed with the same surgical technique. Daily opioid pill consumption, pain levels, and any adverse reactions were recorded from postoperative days 0 to 5.

RESULTS

On the day of surgery, patients in the Exparel group reported significantly lower pain levels (3.9 vs 5.8) and consumed significantly fewer prescribed opioid pills (1.2 vs 2.0) compared with patients in the Marcaine group. However, there were no other significant differences between the Exparel and Marcaine groups on any subsequent days or in the total number of pills consumed at the end of the study period (7.5 vs 8.9 pills, respectively). No major adverse reactions were noted in either group.

CONCLUSIONS

Exparel use was found to result in decreased pain and opioid consumption only on the day of surgery and not thereafter.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Strategies for Reducing Fatal Complications in Liposuction

BACKGROUND

Liposuction has become one of the most common cosmetic surgical procedures, and severe complications secondary to this procedure have also increased significantly. That is why we carry out a research work to know the most frequent severe complications reported in the scientific literature to indicate criteria for prevention.

METHODS

English-language scientific publications about liposuction and its complications were analyzed using the PubMed.gov, from the beginning of PubMed's history through June 10, 2017. Five terms were used to define liposuction and its complications: "liposuction," "liposuction AND complications," liposuction AND major complications," "liposuction AND complications AND death," and "liposuction AND death." The quantities of results for the 5 phrases were analyzed, along with their contents.

RESULTS

One thousand sixty-three results were obtained from 1973 through June 10, 2017 for the phrase "Liposuction and Complications" in humans; for "Liposuction and Major Complications," 153 articles were found; for "Liposuction and Deaths," 89 articles were found; and 42 articles were obtained with the terms "Liposuction and Major Complications and Deaths." After final depuration, all those that were not specific to severe liposuction complications were eliminated, leaving a total of 39 articles that were included in our study. Five problems proved to be the most serious complications when performing liposuction: Thromboembolic disease, fat embolism, pulmonary edema, lidocaine intoxication, and intraabdominal visceral lesion.

CONCLUSIONS

The 5 most important complications that can cause death in liposuction are easily preventable using simple measures and proper safety protocols that are described in this work.

On Beyond Lidocaine: Reconsidering Local Anesthetics in Tumescent Liposuction-A Critical Review

The use of tumescent solution in liposuction is now considered standard of care; however, much debate still exists regarding its ideal components, especially surrounding the inclusion of local anesthetics. This article reviews the discussion regarding the use of local anesthetics in tumescent liposuction and how it may evolve in the future. The need for local anesthetic additives in tumescent liposuction has been questioned, and the use of longer-acting agents discouraged; however, increasing number of reports in recent years have described the increasingly widespread use of tumescent anesthesia where a wetting solution is infiltrated to achieve anesthesia in an operative field for procedures other than liposuction. More high-level evidence, such as randomized controlled clinical trials, will be required; however, it should be possible to develop a useful standardized algorithm that can guide surgeons to optimize patient safety as well as patient experience.

Safety of Local Intracutaneous Lidocaine Anesthesia Used by Dermatologic Surgeons for Skin Cancer Excision and Postcancer Reconstruction: Quantification of Standard Injection Volumes and Adverse Event Rates

BACKGROUND

Intracutaneous lidocaine is used for anesthesia in dermatologic surgery for skin cancer excision and repair with exceedingly low incidence of reported adverse events.

OBJECTIVE

To measure (1) the quantity of lidocaine typically used for facial skin cancer excision and reconstruction; and (2) the frequency and character of associated adverse events.

METHODS

Survey study of dermatologic surgeons with longitudinal reporting. Reported practice during 10 business days: (1) mean volume of 1% lidocaine per skin cancer excision; (2) maximum per excision; (3) mean per reconstruction; and (4) maximum per reconstruction.

RESULTS

A total of 437 of 1,175 subjects contacted (37.2%) responded. Mean per excision was 3.44 mL (SD: 2.97), and reconstruction 11.70 mL (10.14). Maximum per excision was 6.54 mL (4.23), and reconstruction was 15.85 mL (10.39). No cases of lidocaine toxicity were reported, diagnosed, or treated. Incidence of adverse events possibly anesthesia related was >0.15%, with most (0.13%) being mild cases of dizziness, drowsiness, or lightheadedness from epinephrine tachycardia.

CONCLUSION

Toxicity associated with local anesthesia other than lidocaine was not studied. Volumes of lidocaine in skin cancer excision and repair are modest and within safe limits. Lidocaine toxicity is exceedingly rare to entirely absent. For comparable indications, lidocaine is safer than conscious sedation or general anesthesia.

A Review of Local Anesthetics: Minimizing Risk and Side Effects in Cutaneous Surgery

BACKGROUND

The specialty of dermatology relies heavily on local anesthesia for diagnosis and management of skin disease. The appropriate selection, preparation, administration, and monitoring of these medications affect surgical outcome and patient safety and satisfaction.

OBJECTIVE

To perform a comprehensive literature review of the side effects and risks associated with local anesthetics used in cutaneous surgery. Current recommendations to reduce risk and minimize side effects are reviewed.

MATERIALS AND METHODS

A comprehensive review of the English-language medical literature search was performed.

RESULTS

No current review articles of the side effects and risks of local anesthetics were identified. This review serves to discuss local anesthetics commonly used in dermatology and cutaneous surgery along with practical information regarding prevention of adverse outcomes and addressing local and systemic reactions when they arise.

CONCLUSION

Local anesthetics commonly used in cutaneous surgery have potential risks and side effects. Appropriate selection and utilization of local anesthetics and knowledge of the means to prevent and address these risks can impact surgical outcomes, patient satisfaction and safety, and ultimately patient experience in the dermatology clinic.

Tumescent mastectomy: the current indications and operative tips and tricks

Background

Tumescent mastectomy refers to usage of a mixture of lidocaine and epinephrine in a diluting saline solution that makes flaps firm and tense, thus minimizing systemic drugs toxicity and making surgery possible with minimal bleeding. This technique is very useful in elder women and those with American Society of Anesthesiologists; score III and IV. The objective was to establish an alternative safe technique to general anesthesia in some selected mastectomy patients.

Patients and methods

Twenty candidate women for total mastectomy and axillary dissection were enrolled and consented to participate. After preparation, an anatomically directed infiltration was made under sedation, using a cocktail of lidocaine, bupivacaine, and epinephrine, followed after 20 minutes by the surgical incision and completion of mastectomy. All intraoperative and postoperative outcomes were recorded.

Results

Although 7 cases required added analgesic medications, no conversion for general anesthesia was recorded. Mean operative time was 81±15.8 minutes. Mean blood loss was 95.8±47.5 mL. There was no recorded intraoperative hemodynamic instability. Postoperative visual analog score was not exceeding 4 till the end of the first 24 hours. Opioids were not required in any case, and the mean dosage of Ketorolac used was 30±8.75 mg. Drains output and the incidence of postoperative complications were acceptable.

Conclusion

We can consider tumescent mastectomy in well-selected patients a safe alternative for performing mastectomy when general anesthesia is hazardous, with minimal blood loss and long lasting postoperative analgesia without an additive effect on the operative time, hospital stay, and intraoperative and postoperative complications.

1997 Guidelines for Liposuction Surgery

A joint Ad Hoc Committee of the American Society of Liposuction Surgery (ASLS) and the American Academy of Cosmetic Surgery (AACS) was formed to create the following guidelines for liposuction surgery. The members of this committee include: Robert Alexander, M.D., D.M.D.; Guillermo Castillo, M.D.; Robert Jackson, M.D.; Jeffrey Klein, M.D.; Melvin Shiffman, M.D.; and Howard Tobin, M.D. These guidelines were presented to and passed by the ASLS and AACS Board of Trustees on October 16, 1997.

Eliminating Lidocaine from Large-Volume Tumescent Liposuction

Introduction:

The introduction of tumescent anesthesia in 1987 was a major milestone in liposuction history. The technique provided local anesthesia for large areas of liposuction as well as virtually eliminating significant blood loss. With the acceptance of tumescence as a standard in liposuction surgery, surgeons have begun infusing ever-increasing amounts of tumescent fluid and aspirating volumes of fat considered impossible to remove only a decade ago. Large-volume tumescent infusion delivered concomitantly large loads of lidocaine, almost an order of magnitude greater than the maximum load recommended in the Physicians' Desk Reference. Complications are inevitable with lidocaine levels this high. Large-volume liposuction can result in lidocaine toxicity with tumescent anesthesia. This study evaluated whether removing lidocaine from the tumescent formula increases the safety and extends the efficacy of large-volume liposuction by eliminating the danger of lidocaine toxicity.

Methods and Materials:

A retrospective review of 105 patients undergoing large-volume liposuction with a tumescent infusion of greater than 10 L was performed. A high incidence (71%) of nausea and vomiting was noted in 24 patients undergoing large-volume liposuction under tumescent anesthesia with Klein solution. Because of the possibility of toxicity, lidocaine was eliminated from the tumescent formula and anesthesia was provided with epidural block.

Results:

A total of 105 patients undergoing large-volume liposuction were studied; 24 had tumescent anesthesia and 81 had epidural anesthesia and tumescent infusion of epinephrine 1:1000 000 concentration without lidocaine. The incidence of nausea and vomiting dropped from 71% to 14% when lidocaine was removed.

Conclusion:

The possibility of toxicity is virtually eliminated when lidocaine is removed from the tumescent formula and when regional or general anesthesia is used. This allows the surgeon to infuse a greater volume of tumescent solution and remove a larger volume of fat with increased safety.

Intramuscular Stadol for Analgesia during Tumescent Liposuction

Introduction:

Narcotics may be required during tumescent liposuction. Typically, Demerol (meperidine) is utilized intravenously (IV) or intramuscularly (IM). Intramuscular Stadol (butorphanol tartrate) represents an excellent analgesic because of rapid onset and minimal risk of significant respiratory depression at the low dosing utilized during tumescent liposuction. Stadol is not classified as a controlled substance, so no triplicate forms, logs, or special double-lock storage is required. Stadol is a partial agonist that reduces risks of respiratory depression and postoperative nausea compared to meperidine. This study evaluates the safety and dosing of an IM Stadol and antihistamine combination with and without additional Versed in tumescent liposuction patients and reviews the authors' experience and recommendations for this drug.

Materials and Methods:

In this retrospective study, 2 groups of patients totaling 101 tumescent liposuction patients composed of 70 of the authors' patients and 31 additional patients from the University of California-Los Angeles (UCLA) were given varying doses of oral Valium or Halcion, intramuscular (IM) Stadol, and antihistamine (diphenhydramine or hydroxyzine) IM. One to two milligrams of intravenous (IV) Versed was given in 13 patients. All patients were monitored with pulse oximetry, blood pressure, and electrocardiography (EKG). The two groups of patients were studied separately to avoid single-author bias. Total IM Stadol dosing ranged from 0.5 to 4 mg IM over the entire liposuction, with an average total dose of 1.47 mg in the authors' patients and 2.25 mg in the UCLA group. Initial doses ranged from 0.5 to 2.0 mg IM, with supplemental injections needed hourly or less frequently. Average Valium was 7.5 mg sublingual, or Halcion 0.25 mg PO, and average antihistamine was 50 mg IM. There were 99 females and 2 males, age range 20–71. Areas treated were 63 abdomens, 50 flanks, 2 buttocks, 63 thighs, 4 chins, 1 tibia, 8 backs, 14 knees, 1 breast, 4 upper arms, and 1 axilla. Average liposuction was 1350 mL fat (range 50–4125 mL). Infusion lidocaine concentration average was 0.07% (range 0.05–0.1%). Maximum tumescence was 55 mg/kg of Klein formulation. The authors' 70 patients were given Stadol and antihistamine only if needed and no Versed. The UCLA group differed in that all patients were premedicated with Halcion 0.25, Stadol 2 mg IM, and diphenhydramine 50 mg IM, and Versed is subsequently given if needed.

Results:

In all patients who did not receive Versed (total 88), vital signs remained stable. Pulse oximetry was within 5% of baseline (90–100) for all patients, with the exception of a single transient reading of 88 in a healthy nonsmoking 25 year old given 1 mg Stadol, 25 mg Benadryl, and 10 mg Valium sublingual having liposuction of the upper arms only. In the 13 patients given Versed, a 21-year-old healthy female experienced a single pulse oximetry reading of 82 without other alteration of vital signs or level of consciousness. This patient had been given 2 mg Stadol IM, Benadryl 50 mg IM, 0.25 mg Halcion, and 2 mg Versed IV for liposuction of the abdomen, flanks, and thighs, total 2950 mL fat removed.

Conclusion:

Based on this study, IM Stadol appears to be a safe, effective medication with low risk and minimal postoperative effects, and it avoids the need for special logs, storage, and triplicate forms.

Estimated Maximal Safe Dosages of Tumescent Lidocaine

Supplemental Digital Content is available in the text.

Published ahead of print February 18, 2016

BACKGROUND:

Tumescent lidocaine anesthesia consists of subcutaneous injection of relatively large volumes (up to 4 L or more) of dilute lidocaine (≤1 g/L) and epinephrine (≤1 mg/L). Although tumescent lidocaine anesthesia is used for an increasing variety of surgical procedures, the maximum safe dosage is unknown. Our primary aim in this study was to measure serum lidocaine concentrations after subcutaneous administration of tumescent lidocaine with and without liposuction. Our hypotheses were that even with large doses (i.e., >30 mg/kg), serum lidocaine concentrations would be below levels associated with mild toxicity and that the concentration-time profile would be lower after liposuction than without liposuction.

METHODS:

Volunteers participated in 1 to 2 infiltration studies without liposuction and then one study with tumescent liposuction totally by local anesthesia. Serum lidocaine concentrations were measured at 0, 2, 4, 6, 8, 10, 12, 14, 16, 18, and 24 hours after each tumescent lidocaine infiltration. Area under the curve (AUC∞) of the serum lidocaine concentration-time profiles and peak serum lidocaine concentrations (Cmax) were determined with and without liposuction. For any given milligram per kilogram dosage, the probability that Cmax >6 μg/mL, the threshold for mild lidocaine toxicity was estimated using tolerance interval analysis.

RESULTS:

In 41 tumescent infiltration procedures among 14 volunteer subjects, tumescent lidocaine dosages ranged from 19.2 to 52 mg/kg. Measured serum lidocaine concentrations were all <6 μg/mL over the 24-hour study period. AUC∞s with liposuction were significantly less than those without liposuction (P = 0.001). The estimated risk of lidocaine toxicity without liposuction at a dose of 28 mg/kg and with liposuction at a dose of 45 mg/kg was ≤1 per 2000.

CONCLUSIONS:

Preliminary estimates for maximum safe dosages of tumescent lidocaine are 28 mg/kg without liposuction and 45 mg/kg with liposuction. As a result of delayed systemic absorption, these dosages yield serum lidocaine concentrations below levels associated with mild toxicity and are a nonsignificant risk of harm to patients.

Defining the optimum tumescent anaesthesia solution in endovenous laser ablation

Objectives To produce a tumescent anaesthesia solution with physiological pH for endovenous thermal ablation and evaluate its influence on peri- and postoperative pain, clinical and quality of life outcomes, and technical success. Methods Tumescent anaesthetic solution (0.1% lidocaine with 1:2,000,000 epinephrine) was titrated to physiological pH by buffering with 2 ml incremental aliquots of 8.4% sodium bicarbonate. Patients undergoing great saphenous vein endovenous laser ablation and ambulatory phlebectomy were studied before and after introduction of buffered tumescent anaesthetic. Primary outcome was perioperative pain measured on a 10 cm visual analogue scale. Secondary outcomes were daily pain scores during the first postoperative week, complications, time to return to normal activity, patient satisfaction, generic and disease-specific quality of life, and technical success. Patients were assessed at baseline, and at 1, 6 and 12 weeks following the procedure. Results A physiological pH was achieved with the addition of 10 ml of 8.4% sodium bicarbonate to 1 l of standard tumescent anaesthetic solution. Sixty-two patients undergoing great saphenous vein endovenous laser ablation with phlebectomy were recruited before and after the introduction of buffered tumescent anaesthetic solution. Baseline and operative characteristics were well matched. The buffered solution was associated with significantly lower (median (interquartile range)) periprocedural pain scores (1 (0.25-2.25) versus 4 (3-6), p < 0.001) and postoperative pain score at the end of the treatment day (1.8 (0.3-2.8) versus 3.0 (1.2-5.2), p = 0.033). There were no significant differences in postoperative pain scores between the groups at any other time. There were no significant differences in other clinical outcomes between the groups. Both groups demonstrated significant improvements in generic and disease-specific quality of life, with no intergroup differences. Both groups demonstrated 100% ultrasonographic technical success at all time points. Conclusions Buffering of tumescent anaesthetic solution during endovenous thermal ablation is a simple, safe, inexpensive and effective means of reducing perioperative and early postoperative pain.

Guidelines for the use of local anesthesia in office-based dermatologic surgery

There are an increasing number and variety of dermatologic surgical procedures performed safely in the office setting. This evidence-based guideline addresses important clinical questions that arise regarding the use and safety of local anesthesia for dermatologic office-based procedures. In addition to recommendations for dermatologists, this guideline also takes into account patient preferences while optimizing their safety and quality of care. The clinical recommendations presented here are based on the best evidence available as well as expert opinion.

Tumescent technique without epinephrine for endovenous laser therapy and serum lidocaine concentration

OBJECTIVE

Endovenous laser therapy (EVLT) requires tumescent lidocaine anesthesia. Although it is well known that the absorption of local anesthetic varies according to the injection site, little evidence exists establishing the maximum recommended safe dose for extravascular injections such as those used for EVLT. The aim of this study was to evaluate plasma concentration of lidocaine over time after administration of tumescent lidocaine during EVLT procedures in healthy volunteers.

METHODS

Between January 2011 and February 2013, 10 healthy patients scheduled for an EVLT procedure performed in a hospital setting were recruited to participate in an observational study. For each subject, a total of 10 venous samples were obtained for analysis after surgical injection of the tumescent lidocaine solution (0.1% concentration). Samples were collected at baseline (before the surgical procedure start) and then every 30 minutes for the first 2 hours after the initial lidocaine injection. Thereafter, venous samples were obtained every 2 hours, with the last sample drawn 12 hours after the surgeon's initial lidocaine injection. All specimens were drawn from a dedicated intravenous catheter, immediately placed in a heparinized blood collection tube, and centrifuged for 10 minutes at 3000 rpm. Plasma was then removed with a pipette and stored at -70 °C until analyzed. Total and free plasma lidocaine concentrations were determined by immunoassay. Plasma lidocaine concentrations were normalized by peak concentration for statistical comparisons.

RESULTS

Laboratory data were available for nine of the 10 volunteers. The mean total lidocaine dose administered was 6.38 (± 2.2) mg/kg (range, 3.57-10.7 mg/kg). The total lidocaine blood levels ranged from 0.48 (± 0.28) to 1.3 (± 0.49) mcg/mL. The free lidocaine blood levels ranged from nondetectable to 0.76 (± 0.43) mcg/mL. The average total time of injection for the group was 32.8 (± 10.0) minutes (range, 21-49 minutes). Among all dose ranges, both total and free lidocaine peak blood level ratios occurred at times 60 to 120 minutes (P < .05). No value considered in the statistical analysis exceeded 5 mcg/mL at any time.

CONCLUSIONS

Tumescent lidocaine without epinephrine for EVLT procedures produces a peak serum concentration at 60 to 120 minutes. The peak plasma concentration as observed with the standard institutional dosing of tumescent lidocaine appeared below the threshold for human toxicity.

Anaesthetic complications in plastic surgery

Anaesthesia related complications in plastic surgeries are fortunately rare, but potentially catastrophic. Maintaining patient safety in the operating room is a major concern of anaesthesiologists, surgeons, hospitals and surgical facilities. Circumventing preventable complications is essential and pressure to avoid these complications in cosmetic surgery is increasing. Key aspects of patient safety in the operating room are outlined, including patient positioning, airway management and issues related to some specific conditions, essential for minimizing post-operative morbidity. Risks associated with extremes of age in the plastic surgery population, may be minimised by a better understanding of the physiologic changes as well as the pre-operative and post-operative considerations in caring for this special group of patients. An understanding of the anaesthesiologist's concerns during paediatric plastic surgical procedures can facilitate the coordination of efforts between the multiple services involved in the care of these children. Finally, the reader will have a better understanding of the perioperative care of unique populations including the morbidly obese and the elderly. Attention to detail in these aspects of patient safety can help avoid unnecessary complication and significantly improve the patients’ experience and surgical outcome.

Perioperative evaluation of tumescent anaesthesia technique in bitches submitted to unilateral mastectomy

BACKGROUND

Tumescent anaesthesia (TA) is a widely used technique in oncologic surgeries necessitating large resection margins. This technique produces transoperative and postoperative analgesia, reduces surgical bleeding, and facilitates tissue divulsion. This prospective, randomised, blind study evaluated the use of TA in bitches submitted to mastectomy and compared the effect of TA with an intravenous fentanyl bolus. A 2.5-mcg/kg intravenous fentanyl bolus (n = 10) was compared with TA using 0.275% lidocaine (n = 10) in bitches submitted to unilateral mastectomy. Sedation was performed by intramuscular (IM) injection of 0.05 mg/kg of acepromazine combined with 2 mg/kg of meperidine. Anaesthesia was induced with 5 mg/kg of intravenous propofol and maintained with isoflurane/O2. Heart and respiratory rates; systolic, mean, and diastolic arterial blood pressures; central venous pressure; SpO2; ETCO2; inspired and expired isoflurane concentrations; and temperature were measured transoperatively. Visual analogue scales for sedation and pain and the Glasgow composite and Melbourne pain scales were used for postoperative assessment. The surgeon investigated the quality of the surgical approach, considering bleeding and resection ability, and the incidence of postoperative wound complications.

RESULTS

The heart rate was lower and the end-tidal isoflurane concentration was higher in dogs treated with fentanyl than in dogs treated with TA. A fentanyl bolus was administered to 8 of 10 dogs treated with fentanyl and to none treated with TA. Intraoperative bleeding and the mammary gland excision time were lower in dogs treated with TA. The maximal mean and individual plasma lidocaine concentrations were 1426 ± 502 ng/ml and 2443 ng/ml at 90 minutes after infiltration, respectively. The Glasgow Composite Pain Scale scores were higher in dogs treated with fentanyl than in dogs treated with TA until 2 hours after extubation.

CONCLUSIONS

Compared with intravenous fentanyl, TA in bitches: may be easily performed in non-inflamed, ulcerated, adhered mammary tumours; has an isoflurane-sparing effect; improves transoperative and immediate postoperative analgesia; is apparently safe for use in clinical conditions as evidenced by the fact that it did not produce any adverse signs or lidocaine plasma concentrations compatible with toxicity; does not modify the recovery time; and facilitates the surgical procedure without interfering with wound healing.

Tumescent anaesthesia

Tumescent anaesthesia describes the practice of injecting a very dilute solution of local anaesthetic combined with epinephrine and sodium bicarbonate into tissue until it becomes firm and tense (tumescent). It was initially described in the field of liposuction but now surgical applications for the technique are widely varied ranging across vascular surgery, breast surgery, plastic surgery and ENT procedures. It is widely used in both hospital- and office-based environments and may form the sole method of anaesthesia for surgery. Advantages include a reduction in blood loss through both epinephrine-induced vasoconstriction as well as hydrostatic compression from the tumescent effect. Sodium bicarbonate reduces pain associated with the injection of an acidic local anaesthetic solution. Due to the unique pharmacokinetic profile of this technique lidocaine doses of 35 mg/kg bodyweight have been shown to be safe for liposuction procedures. Tumescent lidocaine is absorbed very slowly from subcutaneous tissues producing lower, and more delayed, peak blood levels compared to other routes, as well as extended postoperative analgesia. Slow systemic absorption allows the rapid hepatic plasma clearance of lidocaine to maintain safe local anaesthetic blood levels. This slow absorption from subcutaneous tissue has been likened to a depot injection. Careful attention must be given to appropriate local anaesthetic dosage alterations in cases of co-administration with agents affecting hepatic drug clearance or conditions reducing liver blood supply. Adherence to these pharmacological principles has produced an exemplary safety record for this technique to date.

The Prophylactic Use of Lipid Emulsion Therapy in the Excision of Invasive Malignant Melanoma under Local Anaesthetic in a Morbidly Obese Patient

We present the first reported case of the prophylactic use of lipid emulsion therapy in the removal of an extensive, circumferential malignant melanoma in a morbidly obese patient, under local anaesthetic. The advantages of this technique allowed the patient to avoid intraoperative invasive monitoring and postoperative critical care admission and assisted during the operation by rotating her leg when needed. This is a useful technique that can be employed in urgent cases where there is a need to excise extensive skin malignancies in patients who are unsuitable for general or regional anaesthesia.