Estimated Maximal Safe Dosages of Tumescent Lidocaine

New Frontiers in Wide-Awake Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Explain the most important benefits of wide-awake surgery to patients. 2. Tumesce large parts of the body with minimal pain local anesthesia injection technique to eliminate the need for sedation for many operations. 3. Apply tourniquet-free surgery to upper and lower limb operations to avoid the sedation required to tolerate tourniquet pain. 4. Move many procedures out of the main operating room to minor procedure rooms with no increase in infection rates to decrease unnecessary cost and solid waste in surgery.

SUMMARY

Three disruptive innovations are changing the landscape of surgery: (1) minimally painful injection of large-volume, low-concentration tumescent local anesthesia eliminates the need for sedation for many procedures over the entire body; (2) epinephrine vasoconstriction in tumescent local anesthesia is a good alternative to the tourniquet and proximal nerve blocks in extremity surgery (sedation for tourniquet pain is no longer required for many procedures); and (3) evidence-based sterility and the elimination of sedation enable many larger procedures to move out of the main operating room into minor procedure rooms with no increase in infection rates. This continuing medical education article explores some of the new frontiers in which these changes affect surgery all over the body.

Relationship between Postoperative Complications and Ratio of Amount of Wetting Solution to Ideal Body Weight in Liposuction Procedures

BACKGROUND

The use of wetting solutions (WSs) during high-volume liposuction is standard; however, the optimal amount of WS and its components and their effect on postoperative complications are unclear. We evaluated the effect of a WS and its components, calculated according to ideal body weight (IBW), on postoperative complications.

METHODS

High-volume liposuction with a WS containing 0.5 g of lidocaine and 0.5 mg of epinephrine in each liter was performed in 192 patients. Patients who received ≤90 mL/kg of WS were designated as group I and those who received >90 mL/kg of WS as group II. Postoperative complications and adverse events that occurred until discharge were recorded.

RESULTS

The mean total amount of epinephrine in the WS was significantly higher for group II (3.5 mg; range, 3.0-4.0 mg) than for group I (2.0 mg; range, 1.8-2.5 mg; p < 0.001), as was the mean total amount of lidocaine (3.5 g [range, 3.5-4.3 g] vs. 2.0 g [range, 1.8-2.5 g], respectively; p < 0.001). No major cardiac or pulmonary complications occurred in either group. Administration of >90 mL/kg of WS increased the median risk of postoperative nausea 5.3-fold (range, 1.8- to 15.6-fold), that of hypertension 4.9-fold (range, 1.1- to 17.7-fold), and that of hypothermia 4.2-fold (range, 1.1- to 18.5-fold). The two groups had similar postoperative pain scores and blood transfusion rates.

CONCLUSIONS

The risks of postoperative nausea, vomiting, hypothermia, and hypertension may increase in patients who receive >90 mL/kg of WS calculated according to IBW during high-volume liposuction.

Enhancing Safety in Tumescent Liposuction: Managing Sedation-Related Respiratory Issues and Serious Complications Under Deep Sedation with the Propofol-Ketamine Protocol

BACKGROUND

Over the past 4 years, aesthetic surgery, notably liposuction, has substantially increased. Tumescent liposuction, a popular technique, has two variants-true tumescent liposuction (TTL) and semi-tumescent liposuction. While TTL reduces risks, it has limitations. There is no literature reported on semi-tumescent liposuction under deep sedation using the propofol-ketamine protocol, which is proposed as a potentially safe alternative.

METHODS

The retrospective analysis covered 8 years and included 3094 patients performed for tumescent liposuction under deep sedation, utilizing the propofol-ketamine protocol. The evaluation of patient safety involved an examination of potential adverse events with a specific focus on respiratory issues related to sedation, including instances of mask ventilation.

RESULTS

Among the 3094 cases, no fatalities were recorded. Noteworthy events included 43 mask ventilation instances, primarily occurring in the initial 10 min. Twelve cases experienced surgery cancellation due to various factors, including respiratory issues. Three patients were transferred to upper-level hospitals, while another three required blood transfusions. Vigilant management prevented significant complications, and other adverse events like venous thromboembolism (VTE), fat embolism, severe lidocaine toxicity, and so on were not observed.

CONCLUSIONS

The analysis of 3094 tumescent liposuction cases highlighted the overall safety profile of the propofol-ketamine protocol under deep sedation. The scarcity of severe complications underscores its viability. The study emphasizes the significance of thorough preoperative assessments, careful patient selection, and awareness of potential complications. Prompt interventions, particularly in addressing sedation-related respiratory issues, further contribute to positive outcomes for patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Local Anesthetic Systemic Toxicity (LAST): More Common Than You Think

The number of anesthetic body procedures in the United States is rapidly increasing, with many being performed on an outpatient basis. These procedures are advertised as being safe, and many times the serious complications may not be discussed. Although local anesthetic systemic toxicity is a rare complication, it is associated with an increase in morbidity. The emergency department staff should be aware of the possibility of this rare complication, as well as the variety of resulting symptoms (from minor to severe), potential sequelae, and appropriate management for patients who have undergone an outpatient anesthetic body procedure. Multiple factors contribute to the development of local anesthetic systemic toxicity, resulting in life-threatening effects on the neurologic and cardiovascular systems. Also, the site of administration, along with the local anesthetic agent used, can impact the risk of the development of local anesthetic systemic toxicity. To minimize the risk and ensure the best possible outcome for these patients, emergency department staff must be highly aware of the mechanisms, risk factors, prevention, and management/treatment of local anesthetic systemic toxicity.

Clinical Investigation of Large Volume Subcutaneous Delivery up to 25 mL for Lean and Non-Lean Subjects

PURPOSE

To evaluate the clinical feasibility and tolerability of large volume subcutaneous delivery at different injection depths for lean and non-lean subjects.

METHODS

A single-center, randomized, subject-blinded, crossover study in 62 healthy subjects was conducted to evaluate delivery of a 10-cP solution containing hyaluronic acid. Subjects were separated into lean and non-lean cohort by SC thickness. A syringe pump was used to study the effect of different volumes (5, 12, 25 mL) of a viscous placebo solution and needle lengths (6, 9 and 12 mm) delivered at 0.5 mL/min.

RESULTS

Across all treatments, injection sites were observed to have negligible leakage, ~34 kPa of back pressure, and VAS of mild pain with higher pain from needle insertion than during injection. While mild to moderate erythema was the most frequently reported ISR and edema was most prominent for 25 mL injections, all ISRs were resolved within 4 hours post injection. Subjects were unbothered by ISRs across all treatments and rated them as low distress scores (average 1.0-1.5 out of 6).

CONCLUSION

SC injection of 25 mL is feasible and tolerable using a low-pain formulation for abdomen injection irrespective of subcutaneous thickness and injection depths at a delivery rate of 0.5 mL/min.

The Development and Implementation of an Evidence-Based Tumescent Liposuction Protocol, Online Educational Course for Perioperative Staff, and Discharge Instructions: A Quality Improvement Project

PURPOSE

The purpose of this quality improvement project was to improve perioperative management of patients undergoing tumescent liposuction (TL) through the development and implementation of a perioperative evidence-based protocol, educational course for perioperative staff, and patient discharge instructions.

DESIGN

The TL protocol was validated using the modified Delphi process. The educational course and discharge instructions used a pre and postimplementation design.

METHODS

An evidence-based protocol, an educational course for perioperative staff, and readable discharge instructions for patients undergoing TL were developed in accordance with best practice guidelines. The protocol was validated by subject matter experts at the facility and submitted for adoption. The evidence-based educational course was implemented, and the effectiveness of the course was evaluated for improving providers' knowledge and self-confidence. The evidence-based discharge instructions were implemented and evaluated for patient satisfaction and readability.

FINDINGS

Three items were removed from the protocol, 2 items were modified, and 25 items were accepted with no change from modified Delphi analysis. Provider knowledge scores improved from 85.7% ± 16.18 to 97.1% ± 4.88; however, this was not statistically significant (P = .066). There was a trend toward improved confidence scores (P = .180). Overall patient satisfaction scores slightly improved postimplementation; results were not statistically significant (P > .05).

CONCLUSIONS

All three phases of perioperative care in patients receiving TL were evaluated, reflecting best practice guidelines and successful adoption. There was no statistically significant improvement in provider knowledge, provider self-confidence, or patient satisfaction. A small sample size was a significant limiting factor.

Enhanced Recovery After Surgery (ERAS) Pathways for Aesthetic Breast Surgery: A Prospective Cohort Study on Patient-Reported Outcomes

BACKGROUND

Patients' expectations of an anticipated timeline of recovery and fear of anesthesia in aesthetic breast surgery have not been studied.

OBJECTIVE

This study aims to assess patient anxiety, expectations, and satisfaction after Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery and the progress of postoperative recovery.

MATERIALS AND METHODS

All consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022 were included in this single-center prospective cohort study. The ERAS protocol consists of more than 20 individual measures in the pre-, intra-, and postoperative period. Epidemiological data, expectations, and recovery were systematically assessed with standardized self-assessment questionnaires, including the International Pain Outcome Questionnaire (IPO), the BREAST-Q or BODY-Q, and data collection forms.

RESULTS

In total, 48 patients with a median of 30 years of age were included. Patients returned to most daily activities within 5 days. Eighty-eight percent of patients were able to accomplish daily activities sooner than expected. The time of return to normal daily activities was similar across all procedure types. There was no statistically significant difference regarding postoperative satisfaction between patients who recovered slower (12%) and patients who recovered as fast or faster (88%) than anticipated (p=0.180). Patients reporting fear of anesthesia in the form of conscious sedation significantly diminished from 17 to 4% postoperatively (p<0.001).

CONCLUSION

Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery are associated with rapid recovery and high patient satisfaction. This survey study provides valuable insight into patients' concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Wound Healing Complications With Tranexamic Acid: Not the Silver Bullet After All

Tranexamic acid (TXA) has been popularized as an adjunct to decrease the risk of bleeding and subsequent bruising and edema in aesthetic surgery. The most notable risks of TXA are thrombus and seizures, which are associated with higher plasma concentrations of the acid. In an effort to mitigate these risks, surgeons have begun using TXA locally, either as a topical irrigation or mixed into the local anesthetic. Although local use is thought to be safer from a side-effect standpoint, because there is decreased systemic absorption, its use is not without risk. We present 4 patients who developed wound healing complications thought to be related to locally administered TXA. One patient had TXA delivered topically, and 3 patients had TXA mixed into their local anesthetic. These adverse events have not been published in the literature previously. This case report serves as a warning to other surgeons about using locally administered TXA.

LEVEL OF EVIDENCE: 4

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.

Pulmonary Embolism after Liposuction Totally by Tumescent Local Anesthesia in a Patient with Large Uterine Fibroids

A fatal pulmonary embolism occurred in a 43-year-old black woman after tumescent liposuction totally by local anesthesia. An autopsy revealed large uterine fibroids, peri-uterine vascular thrombi, and a large saddle pulmonary embolism. Large uterine fibroids are a risk factor for postsurgical venous thromboembolism. Fatal outcomes after tumescent liposuction totally by local anesthesia are exceedingly rare.

Reduced Intraoperative Blood Loss and Hypothermia in Burn Surgery using Cardiopulmonary Bypass Pumps

Objective: Patients presenting with total body surface area (TBSA) >40% burns require significant surgical treatment. Two substantial challenges during these surgeries are limiting blood loss and maintaining core temperatures. To overcome these challenges, several techniques have been developed, ranging from the Pitkin syringe method to the pneumatic tourniquet strategy for large-volume hyperthermic insufflation. Here, we compare the pneumatic tourniquet method to a roller pump method for maintenance of intraoperative normothermia and control of bleeding. Methods: We conducted a retrospective chart review of 20 patients presenting with TBSA >40% burns, 10 of whom were treated with the rapid infusion roller pump and 10 of whom were treated with the pneumatic tourniquet technique. Patients from each group were controlled for % TBSA, presence of inhalation injury, age, and date of admission. We reviewed transfusion requirement and the intraoperative temperatures, as well as the average intraoperative drop in temperature. Results: We observed improvement in the infusion volume, operative time, intraoperative temperature drop, minimum intraoperative temperature, estimated blood loss, and amount of required transfusion. Conclusions: Our study suggests that the rapid infusion roller pump technique is capable of achieving superior intraoperative bleeding control and temperature maintenance compared to the pneumatic tourniquet technique, resulting in decreased transfusion requirement.

Guidelines for Wide-Awake Local Anesthesia Surgery with No Tourniquet in the Office Setting Using Field Preparation Sterility

SUMMARY

Wide-awake local anesthesia surgery with no tourniquet, or WALANT, has become popular in surgery, especially among hand surgeons. With the increasing number of surgeons performing office-based procedures, this article provides guidelines that may be used in the office setting to help transition more traditional hospital operating room-based procedures to the office setting. This article outlines the benefits of performing office-based wide-awake local anesthesia surgery with no tourniquet and provides a step-by-step guide to performing procedures that can be easily incorporated into any hand surgeon's practice successfully and safely.

Risk analysis of systemic side effects of tumescent local anaesthesia in the surgical treatment of geriatric and multimorbid patients with skin cancer

BACKGROUND

Due to demographic change and increased UV exposure, the number of dermatosurgical procedures in the elderly is increasing. Data on the occurrence of systemic side effects during and after treatment with tumescent local anaesthesia are limited and do not refer to details such as volume and composition of local anaesthetics or epinephrine additive.

OBJECTIVES

The aim of this study was to investigate the risk of systemic side effects in elderly patients undergoing skin tumour surgery with tumescent local anaesthesia.

METHODS

Investigation of systemic complications in patients (≥75 years) who underwent head and neck skin tumour surgery under tumescent local anaesthesia at the Department of Dermatology, University Medical Centre Tübingen, between October 2018 and March 2020.

RESULTS

In total 782 patients (479 males, 303 females) with a mean age of 83.3 years (range: 75.1-102.2 years) could be included. A total of 2940 procedures were performed. Patients were assigned to two groups. The old-old group (≥75-84 years) included 491 patients and the oldest-old group (≥85 years) included 291 patients. The total inpatient stay and thus mean follow-up period was 4.9 days (range 1-28 days). 92.0% (719/782) suffered from pre-existing comorbidities. Systemic complications occurred in 10.2% (80/782; old-olds: 8.6%, oldest-olds: 13.1%). Hypertensive crisis (>180/120 mmHg) requiring intervention (6.7%) that occurred intraoperatively or during the inpatient stay was the most frequent systemic complication. Cardiac arrhythmias occurred postoperatively in 0.8% of cases. No life-threatening complications directly related to tumescent local anaesthesia were found.

CONCLUSIONS

Skin tumour surgery in tumescent local anaesthesia for the elderly is safe, and complications caused by general anaesthesia can be avoided. Systemic complications can occur, but are usually mild, are caused by pre-existing diseases and perioperative excitement, and can be rapidly detected and well treated by monitoring. There is no direct correlation of complications to high-tumescent concentrations or volume quantities.

The effect of tranexamic acid on blood loss in liposuction: a randomized controlled study

Background

Liposuction is one of the most common procedures in the practice of plastic surgery. Since it evolved, continuous modifications have been to decrease blood loss so that patients are hemodynamically stable intra- and postoperatively. Tranexamic acid (TXA) has long been used for its antifibrinolytic properties that were beneficial in reducing blood loss, rate of transfusion, and hemoglobin drop in major trauma and surgeries. Its use in plastic surgery, however, is still limited. In this study, we aim to illustrate the effect of intravenous (IV) and local infiltration of TXA on blood loss in liposuction surgery.

Methods

Between April 2019 and April 2021, 90 patients who requested liposuction for various body parts were randomly allocated into 3 equal groups: control group, IV TXA, and local infiltration of TXA. A sample was taken from infranatant and sent for hematocrit calculation. Volume of blood in lipoaspirate was then calculated. Patients were assessed for blood loss and postoperative bruising.

Results

Volume of blood loss in lipoaspirate was considerably lower in the TXA groups, with 60% decrease in blood loss for the local TXA group in comparison with the control group. TXA has also been shown to markedly decrease bruising tendency in postoperative liposuction patients.

Conclusions

TXA can be used to decrease blood loss in large-volume liposuction, modify the need for blood transfusion intra- and postoperative, and improve the results of liposuction procedure without the need for multiple sessions.

Level of evidence

Level II, Risk/Prognostic Study.

Enhanced Recovery After Aesthetic Breast Surgery Under Sedation, Intercostal Block and Tumescent Anaesthesia: A Prospective Cohort Study of the Early Postoperative Phase

BACKGROUND

Comfort and recovery are major concerns of patients seeking aesthetic surgery. This study aimed to assess postoperative pain and recovery after outpatient breast surgery under sedation, intercostal block, and local anaesthesia.

METHODS

This prospective cohort study included all consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022. Epidemiological data, anaesthesia, pain, and patients' satisfaction were systematically assessed with standardized self-assessment questionnaires.

RESULTS

Altogether, 48 patients [median (IQR) age: 30 (36-25)] were included. The most frequent surgery was mastopexy. 69% of surgeries involved additional procedures. The mean intercostal block and local anaesthesia time was 15 min. Patients received a median (IQR) of 19 (34-2) mg/kg lidocaine and 2.3 (2.5-2.0) mg/kg ropivacaine. The median (IQR) consumption of propofol and alfentanil was, respectively, 4.89 (5.48-4.26) mg/kg/h and 0.27 (0.39-0.19) µg/kg/min. No conversion to general anaesthesia or unplanned hospital admission occurred. Patients were discharged after a median (IQR) of 2:40 (3:43-1:58) hours. Within the first 24 postoperative hours, 17% required once an antiemetic medication and 38% an opioid. Patients were very satisfied with the anaesthesia and 90% of the patients had not wished more analgesia in the first 24 h.

CONCLUSIONS

Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia can safely be performed as an ambulatory procedure and is associated with minimal intra- and postoperative opioid consumption and high patient satisfaction. These data may be used to inform patients and clinicians and improve the overall quality of care.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A 7-Step Guide to High-Definition Liposuction

BACKGROUND

High-Definition (HD) Liposuction refers to the most advanced body contouring technique, offering an athletic and healthy body appearance. The latest available devices, the criteria of proper selection, and an expert surgeon's tips are highlighted in a 7-step guide approach.

METHODS

A retrospective study of prospectively maintained database was conducted from 2015 to 2020. Demographic information, personal history, outcomes, complications were collected and analyzed from 568 patients who underwent the same surgical procedure.

RESULTS

568 patients (247 male and 321 female) were included in the study with a mean BMI of 25.6 (range 21-29 kg/m2) and follow up time ranging from 1 to 48 months. The first 50 procedures represented the initial learning curve, during which most complications had occurred (14 patients/50 patients). Using the 7-step guide, we managed to minimize the overall complications to a rate of 3%.

CONCLUSION

The outlined steps have been simplified in a 7-step guide for plastic surgeons to understand, practice and refine HD liposuction in a contemporaneous, efficient, and reproducible manner.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Erector Spinae Plane Block is Equivalent to Tumescent Local Anesthesia for Perioperative Pain Control with Abdominal Harvest for Fat Grafting

There is increasing evidence that lidocaine is toxic to adipocytes and their precursors, which can contribute to the variability in fat graft resorption. Erector spinae plane (ESP) block is a new technique to provide analgesia of the trunk and would avoid lidocaine at the fat graft donor site. The aim of this study was to compare the efficacy of ESP block versus tumescent local anesthesia (TLA).

Methods

A retrospective review was performed for all patients who underwent autologous fat grafting from the abdomen at the University of New Mexico Hospital between February 2016 and March 2019. These patients received either ESP block or TLA during abdominal fat harvest. The primary endpoints were intraoperative, postoperative, and total morphine equivalents.

Results

There was no difference in the mean intraoperative, postoperative, and total morphine equivalents administered between the ESP and TLA groups.

Conclusions

ESP block is equivalent to TLA for analgesia when using an abdominal donor site for fat harvest. ESP block should be considered in fat-grafting cases to avoid the potential toxicity of lidocaine to the viability of adipocytes and preadipocytes.

Low Negative Pressure Combined With Supertumescence Microliposuction as a New Method for Repairing Facial Fat Overfilling: A Case Series of 32 Patients

BACKGROUND

Face fat overfilling sometimes occurs and is unfortunately very difficult to repair.

OBJECTIVES

The aim of this study was to report initial experience of microliposuction with low negative pressure combined with supertumescence (LNPST) in a case series of 32 patients.

METHODS

The LNPST microliposuction was performed in 32 patients aged 22 to 41 years (mean [standard deviation] age, 29.6 [4.9] years) with facial overfilling. Discomfort and bleeding were monitored intraoperatively by 2 independent plastic surgeons, who used a grading system to record the results. All patients were followed-up for hematoma within 1 week postoperatively and for skin numbness and muscle paralysis at 1 week and 3 months postoperatively. In addition, at 6 months postoperatively, patient satisfaction with the postoperative aesthetic effects was analyzed by FACE-Q questionnaire.

RESULTS

All patients successfully completed the operation under local anesthesia. The mean intraoperative discomfort and blood-loss scores were 1.69 [0.62] and 1.22 [0.41], respectively. The hematoma score was 1.13 [0.34] within 1 week. Other scores included postoperative skin numbness (1 week, 1.96 [0.62]; 3 months, 1.13 [0.33]) and postoperative muscle paralysis (1 week, 1.22 [0.51]; 3 months, 1.0 [0]). Overall, neither skin necrosis nor serious complications requiring revision surgery occurred. Seventy-two percent of the patients (n = 23) answered the FACE-Q questionnaire and the score was 21.8 (1.7), covering satisfaction with the outcome score into a standard score (81.7 [15.1], from 0 to 100), which verified the high satisfaction rate.

CONCLUSIONS

LNPST technology is a safe and effective method for repair of facial fat overfilling, with less bleeding, less nerve injury, fewer complications, and high patient satisfaction.

LEVEL OF EVIDENCE: 4

Liposuction-Like Sclerotherapy Technique for Microcystic Lymphatic Malformation

Background

The treatment for microcystic lymphatic malformation (LM) remains challenging. We describe the liposuction-like sclerotherapy technique, a new treatment for extensive microcystic LM.

Methods

LM data was retrospectively reviewed. This study included patients with a microcystic LM component treated by liposuction-like technique with bleomycin sclerotherapy.

Results

Between June 2016 and October 2019, 39 consecutive patients (male/female ratio: 21:18; mean age, 33.6 months; range: 5 months to 15 years) with microcystic LM were treated by liposuction-like sclerotherapy (LS-LS) technique. Fifty-six sessions of LS-LS were performed (mean of 1.44 sessions per patient; range: one to four sessions). Follow-up ranged 6-30 months (mean of 21 months). We observed no major complications. Transient minor complications included: postoperative noninfectious fever, vomiting, temporary skin edema, pigmentation, mild local depressions, and/or irregularities, and a small hyperpigmented scar at the incision. No postoperative infection, skin ulcer, or necrosis occurred. The patients’ symptoms were successfully resolved or stable. A sub-complete response and partial response were observed for 26 (76%) and 13 patients (33%), respectively.

Conclusion

The LS-LS technique for microcystic LMs is safe, feasible, and effective. This technique is an effective intervention with which it is possible to manage and potentially cure microcystic LM clinically.

Protective effects of lidocaine on polycystic ovary syndrome through modulating ovarian granulosa cell physiology via PI3K/AKT/mTOR pathway

Polycystic ovary syndrome (PCOS) is a common endocrine condition in women that causes adverse reproductive and metabolic effects. PCOS is a heterogeneous disorder and its pathogenesis is affected by different factors. Thus, the criteria for diagnosing PCOS, disease and availability of treatment options vary widely across different countries. Lidocaine has been proven to inhibit the proliferation of a variety of cancer cell types, and can be used alone or in combination with other drugs for the treatment of numerous types of disease. The present study aimed to determine whether lidocaine was able to reduce human ovarian granulosa cell tumor cell line KGN cell proliferation and provide a novel insight into potential therapeutic strategies for PCOS. KGN cells were treated alone with lidocaine at different concentrations, or with lidocaine and insulin-like growth factor-1 (IGF-1; a phosphoinositide 3-kinase (PI3K)/Protein kinase B (AKT) signaling pathway agonist) in combination for 48 h. The proliferative ability of KGN cells was detected using an 3-(45)-dimethylthiahiazo (-z-y1)-35-di- phenytetrazoliumromide (MTT) assay, and cell apoptosis was detected using flow cytometry. The expression levels of proteins and mRNAs were measured using western blotting and reverse transcription-quantitative polymerase chain reaction (RT-qPCR), respectively. The results of the present study revealed that lidocaine significantly suppressed KGN cell proliferation and increased apoptosis. Lidocaine significantly downregulated the protein expression levels of phosphorylated (p)-AKT and p-mTOR, but had no effect on their transcriptional levels. Treatment with IGF-1, could reverse the lidocaine-induced abnormal expression of PI3K/AKT signaling pathway-related proteins. Moreover, treatment with IGF-1 could reverse all the effects of lidocaine on KGN cells. In conclusion, the findings of the present study indicated that lidocaine may inhibit KGN cell proliferation and induce apoptosis by inhibiting the activation of the PI3K/AKT/mTOR signaling pathway. These results revealed the potential inhibitory effect of lidocaine on the proliferation of KGN cells and its underlying mechanism of action, providing a novel insight into potential therapeutic strategies for PCOS.

Limited Dilute Lidocaine Anesthesia: A Useful Technique with Many Practical Applications

BACKGROUND

Limited dilute lidocaine infiltration facilitates a comfortable procedure and a rapid recovery process following a novel intervention for reduction of cellulite. Infiltration of dilute lidocaine has many other practical applications in dermatologic surgery.

OBJECTIVES

This article describes a safe, effective technique for local infiltration of limited volume dilute lidocaine anesthesia in a cellulite reduction procedure.

METHODS

The limited dilute lidocaine technique was utilized in studies of a novel device designed to reduce the appearance of cellulite by focal release of fibrous septa in a minimally-invasive procedure. No sedation was used. A small (27- to 30-gauge) needle was used to deliver anesthesia to the entry sites. Then, a 20-gauge spinal needle was tunneled under the skin in the superficial plane to manually deliver anesthetic along the advancement pathway of the device and marked cellulite targets.

RESULTS

During the initial studies, the mean delivered anesthesia volume was 357.2 mL (range, 250-525 mL) or 18.7 mg/kg (range, 11.1-28.4 mg/kg). The mean anesthesia time was 16 minutes (range, 8-32 minutes). The mean number of cellulite depressions treated was 19.8 (range, 11-34). Adverse events were closely monitored, and there were no signs of toxicity in any study patients. There were very low levels of discomfort; all patients reported the procedure was tolerable. This technique facilitates a time-efficient procedure and minimizes weeping of excess fluid during recovery.

CONCLUSIONS

When administered with care and skill, the limited dilute anesthesia technique is a safe, effective approach for local anesthesia with many practical applications in dermatologic surgery.

Aesthetic Outcome of Gynecomastia Management with Conventional Liposuction and Cross-Chest Liposuction: A Prospective Comparative Study

Background

Liposuction is the most accepted technique for treatment of gynecomastia at present with or without residual gland tissue excision. Conventional liposuction uses incisions for introduction of cannula, made usually at the inframammary crease or axilla resulting in consequent scars. Cross-chest liposuction technique was introduced to avoid these additional scars and improve the aesthetic outcome. This study aimed to evaluate the difference between aesthetic outcome of conventional liposuction and cross-chest liposuction in treatment of gynecomastia.

Method

A prospective comparative study between 2 groups with 15 patients in each was conducted, one with conventional and the other cross-chest liposuction. Excision of residual gland tissue was performed through circum-areolar incision in both the groups. Aesthetic outcome was evaluated in both the groups using Likert scale and compared.

Result

The mean age of the patients was 22.6 years and the mean duration of presentation was 8.13 years. Satisfaction rate with conventional and cross-chest liposuction was 80% and 86%, respectively, as assessed by the patients. The rate was 80% and 77%, respectively, in both the groups as assessed by independent observer. The complication rate was 13.3% in conventional and 20% in cross-chest group. The difference in outcome was not statistically significant between two groups. Difference between the mean Likert scores of pre-operative and post-operative satisfaction was statistically significant for both the techniques.

Conclusion

The conventional and the cross-chest liposuction, both yield comparable results when used for treatment of gynecomastia in terms of aesthetic outcome.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266

The Use of Tranexamic Acid in Facial Cosmetic Surgery Procedures: A Technical Note

Tranexamic acid (TXA) has been widely used as an antifibrinolytic in dentoalveolar surgery and only recently has its effects been explored in facial procedures. Multiple studies have reported the use of TXA in facial cosmetic surgery; and to date, only a limited number of them utilized TXA as a local infiltrative technique for rhytidectomy procedures. We present a technical note to using lower concentrations of TXA in tumescent anesthesia for an array of facial cosmetic procedures. Our experience thus far has shown improved hemostasis, reduction of intraoperative bleeding and a more profound reduction in postoperative ecchymosis, edema and seroma formation.

Safety of Tumescent Liposuction Under Local Anesthesia in 9,002 Consecutive Patients

BACKGROUND

Liposuction has become one of the most popular aesthetic procedures today. Among the different anesthesia methods, tumescent local anesthesia (TLA) has been shown to be the safest. Liposuction is typically performed as an outpatient procedure under minimal oral sedation and without the need for any intravenous (IV) fluid administration.

OBJECTIVE

To record complications in a larger series of patients undergoing liposuction in TLA.

MATERIALS AND METHODS

Between 2003 and 2020, 9,002 consecutive patients underwent liposuction in TLA with the same team of surgeons. The occurrence of complications was recorded in detail.

RESULTS

There were neither fatal complications nor damage to deeper structures such as nerves, blood vessels, muscles, lungs, abdominal organs, nor permanent lymphedema. A total of 19 of the following side effects, mainly minor, required closer follow-up or intervention: allergic drug reaction to doxycycline (0.06%), seroma (0.04%), large hematoma (0.03%), erysipelas (0.02%), transient acrocyanosis (0.02%), deep vein thrombosis (0.01%), skin necrosis (0.01%), and generalized edema (0.01%).

CONCLUSION

Liposuction in TLA is a reliable and safe procedure if it is performed by an experienced surgeon and the guidelines of care are strictly followed.

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.

Lidocaine attenuates CFA-induced inflammatory pain in rats by regulating the MAPK/ERK/NF-κB signaling pathway

Lidocaine is a commonly used local anesthetic that also confers analgesic effects, resistance to hyperalgesia and anti-inflammatory properties. The present study aimed to explore the effects of lidocaine on complete Freund's adjuvant (CFA)-induced inflammatory pain. In the present study, rats were subcutaneously injected with CFA to investigate the molecular mechanisms associated with lidocaine in an inflammation-induced pain model. Firstly, CFA was subcutaneously injected into the paws of Sprague-Dawley rats, following which lidocaine or saline and the ERK agonist recombinant human epidermal growth factor (rh-EGF) were injected via the tail vein. Rat behavior was then assessed at 0 and 4 h, 1, 4, 7 and 14 days after CFA treatment. Proinflammatory cytokine levels in the serum were measured using ELISA. Western blotting was performed to detect the protein levels of phosphorylated (p)-ERK1/2, ERK1/2 and NF-κB subunits p-p65 and p65. Reverse transcription-quantitative PCR was used to measure the mRNA expression of ERK1/2 and p65 in rat spinal cord tissues. The results showed that injection of CFA significantly reduced the mechanical withdrawal threshold, thermal withdrawal latency and the frequency of responses to cold stimulation in rats, whilst promoting tumor necrosis factor-α, interleukin (IL)-1β, IL-6 levels in addition to ERK1/2, p65 protein phosphorylation. These effects were alleviated by lidocaine treatment. Furthermore, treatment with rh-EGF reversed the protective effects of lidocaine on inflammatory pain caused by CFA. In conclusion, lidocaine inhibits the inflammatory response and pain through the MAPK/ERK/NF-κB pathway in a rat model of pain induced by CFA.

Updates in our understanding of local anaesthetic systemic toxicity: a narrative review

Despite advances in clinical practice, local anaesthetic systemic toxicity continues to occur with the therapeutic use of local anaesthesia. Patterns of presentation have evolved over recent years due in part to the increasing use of ultrasound which has been demonstrated to reduce risk. Onset of toxicity is increasingly delayed, a greater proportion of clinical reports are secondary to fascial plane blocks, and cases are increasing where non-anaesthetist providers are involved. The evolving clinical context presents a challenge for diagnosis and requires education of all physicians, nurses and allied health professionals about these changing patterns and risks. This review discusses: mechanisms; prevention; diagnosis; and treatment of local anaesthetic systemic toxicity. The local anaesthetic and dose used, site of injection and block conduct and technique are all important determinants of local anaesthetic systemic toxicity, as are various patient factors. Risk mitigation is discussed including the care of at-risk groups, such as: those at the extremes of age; patients with cardiac, hepatic and specific metabolic diseases; and those who are pregnant. Advances in the changing clinical landscape with novel applications and settings for the use of local anaesthesia are also described. Finally, we signpost future directions to potentially improve the management of local anaesthetic systemic toxicity. The utility of local anaesthetics remains unquestionable in clinical practice, and thus maximising the safe and appropriate use of these drugs should translate to improvements in patient care.

Three-step tumescent local anesthesia technique for inguinal hernia repair

The optimal method of anesthesia for inguinal hernia repair is still controversial. We have developed "three-step tumescent local anesthesia (TLA) technique" for inguinal hernia repair, and recently showed that this technique is acceptable in view of short- and long-term clinical outcomes. Our study included 273 consecutive cases (290 sides) of elective inguinal hernia repair performed under the newly developed technique between September 2003 and May 2019, and overall clinical outcomes were considered to be safe and feasible. Herein, we report the surgical procedure of "three-step TLA technique." Briefly, we rapidly inject the diluted solution of local anesthetic and epinephrine step-by-step into the three following closed tissue space. Initially, 80 mL injection into the subcutaneous tissue before skin incision (Step 1). After the external oblique fascia is exposed, injection of 20 mL into the inguinal canal before the external oblique fascia is incised and opened (Step 2). The hernia sac and spermatic cord are then dissected, and the blunt dissection of the preperitoneal space is made by injecting 20 mL under the internal inguinal ring (Step 3), followed by placing a gauze into the preperitoneal space, creating the space for mesh placement. We consider that the most important point of this technique is achieved through the rapid injection of TLA solution into each closed tissue space, which makes for easier dissection, hemostasis, and good pain control.

BIS Monitoring Transformed Opioid-Free Propofol Ketamine Anesthesia From Art to Science for Ambulatory Cosmetic Surgery

Measurement is the essence of science. The BIS™ brain monitor provides direct propofol response measurement. Measuring transformed the propofol ketamine technique from a qualitative approach to a quantitatively reproducible one. Propofol was originally titrated with an IV bag and a micro-drip IV set. Propofol response was titrated to clinical signs. An infusion pump later replaced the IV bag, enabling the propofol dose enumeration. The propofol effect was measured with a BIS.™ A statistically significant 30% propofol reduction was achieved with BIS™ monitoring. Patient movement occurred during propofol sedation. Secondary EMG trending to BIS™ enabled the differentiation of cortically based movement (i.e., deeper sedation indicated) from spinal cord-based movement (i.e., more local indicated). Outcomes were improved when surgeons re-injected vasoconstricted field with patient movement. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Value of Tumescent Infiltration in Bilateral Breast Reduction: Optimizing Vasoconstriction

Surgical adjuncts should improve surgical outcomes but should not increase complications. Epinephrine reduces bleeding in breast reduction, but various doses and volumes have been used. The ideal dose of epinephrine is still debated. The aim of this study was to assess blood loss after infiltration of 1 L of tumescent fluid containing epinephrine at a concentration of 1 in 100,000 (1 in 10⁵) and 1200 mg of lignocaine in patients undergoing bilateral breast reduction.

Plastic Surgery Complications: A Review for Emergency Clinicians

The number of aesthetic surgical procedures performed in the United States is increasing rapidly. Over 1.5 million surgical procedures and over three million nonsurgical procedures were performed in 2015 alone. Of these, the most common procedures included surgeries of the breast and abdominal wall, specifically implants, liposuction, and subcutaneous injections. Emergency clinicians may be tasked with the management of postoperative complications of cosmetic surgeries including postoperative infections, thromboembolic events, skin necrosis, hemorrhage, pulmonary edema, fat embolism syndrome, bowel cavity perforation, intra-abdominal injury, local seroma formation, and local anesthetic systemic toxicity. This review provides several guiding principles for management of acute complications. Understanding these complications and approach to their management is essential to optimizing patient care.

Update of the SFMV (French society of vascular medicine) guidelines on the conditions and safety measures necessary for thermal ablation of the saphenous veins and proposals for unresolved issues

Venous insufficiency is a very common disease affecting about 25% of the French population (if we combine all stages of its progression). It is a complex disease and its aetiology has not yet been fully elucidated. Some of its causes are well known, such as valvular dysfunction, vein wall defect, and the suctioning effect common to all varicose veins. These factors are generally associated and together lead to dysfunction of one or more of the saphenous veins. Saphenous vein dysfunction is revealed by ultrasound scan, a reflux lasting more than 0.5 seconds indicating venous incompetence. The potential consequences of saphenous vein dysfunction over time include: symptoms (heaviness, swellings, restlessness, cramps, itching of the lower limbs), acute complications (superficial venous thrombosis, varicose bleeding), chronic complications (changes in skin texture and colour, stasis dermatitis, eczema, vein atresia, leg ulcer), and appearance of unaesthetic varicose veins. It is not possible to repair an incompetent saphenous vein. The only therapeutic options at present are ultrasound-guided foam sclerotherapy, physical removal of the vein (saphenous stripping), or its thermal ablation (by laser or radiofrequency treatment), the latter strategy having now become the gold standard as recommended by international guidelines. Recommendations concerning thermal ablation of saphenous veins were published in 2014 by the Société française de médecine vasculaire. Our society has now decided to update these recommendations, taking this opportunity to discuss unresolved issues and issues not addressed in the original guidelines. Thermal ablation of an incompetent saphenous vein consists in destroying this by means of a heating element introduced via ultrasound-guided venous puncture. The heating element comprises either a laser fibre or a radiofrequency catheter. The practitioner must provide the patient with full information about the procedure and obtain his/her consent prior to its implementation. The checklist concerning the interventional procedure issued by the HAS should be validated for each patient (see the appended document).

Local Anesthetic Toxicity in the Geriatric Population

This article provides a concise overview of local anesthetic systemic toxicity, its history, mechanisms, risk factors, prevention, clinical presentation, and treatment, with a special emphasis on issues specific to the geriatric population. The authors used MEDLINE, Scopus, and Google Scholar to search for original research articles (human and animal studies), registries data, case reports, review articles, and pertinent online publications using the combinations of the following search terms: local anesthetics, local anesthetic systemic toxicity, intralipid, lipid emulsion, Exparel, ultrasound-guidance, regional anesthesia, lidocaine, bupivacaine, ropivacaine, cocaine, procaine, tetracaine, levobupivacaine, liposomal bupivacaine, lignocaine. Local anesthetic systemic toxicity continues to occur despite the use of putatively less cardiotoxic formulations of local anesthetics and more common use of ultrasound guidance. The elderly appear to be at a disproportionately increased risk for toxicity owing to the presence of relevant comorbidities and decreased muscle mass. Examination of recent case reports involving patients over the age of 65 years demonstrates that inadvertent overdosing is responsible for some cases of local anesthetic systemic toxicity. Elderly patients are at increased risk of local anesthetic systemic toxicity. When considering use of local anesthetics in older patients, special attention should be paid to the presence of systemic disease and muscle wasting. The safety of regional anesthesia and multi-modal analgesia among these at-risk patients will be improved by educating physicians and staff to recognize and manage local anesthetic systemic toxicity.

Effectiveness of tumescent solution combined with negative pressure wound therapy in traditional high ligation and stripping of the great saphenous vein

Traditional high ligation and stripping (THLS) is a routine operation for varicose veins. However, THLS is accompanied with postoperative subcutaneous ecchymosis and pain. In this current study, we aimed to explore the effect of tumescence solution (TS) combined with negative pressure wound therapy (NPWT) on the relief of subcutaneous ecchymosis and pain after THLS of great saphenous vein.A total of 180 patients receiving THLS were enrolled in group A, and 120 patients undergoing THLS and TS combined with NPWT were assigned into group B. The occurrences of subcutaneous ecchymosis and pain were recorded. Moreover, the total area of subcutaneous ecchymosis was estimated by the grid method. Visual analogue scale (VAS) score was used to assess the pain level of both groups.Preoperative characteristics were not significantly different between 2 groups. Postoperative ecchymosis occurred in 112 cases (62.2%) of group A and 41 cases (34.2%) of group B. The area of ecchymosis in group A (66.6 ± 44.5) cm was larger than that in group B (25.2 ± 19.9) cm. The number of patients without obvious pain in group A (57, 31.7%) was significantly less than that in group B (77, 64.2%) after operation. In addition, VAS score in group A (3.1 ± 2.6) was higher than that in group B (2.2 ± 1.9).In conclusion, the application of TS combined with NPWT in THLS can not only alleviate subcutaneous ecchymosis and pain, but also prevent the occurrence of subcutaneous ecchymosis and pain after operation. Therefore, it is conducive to postoperative recovery and is suitable for clinical application.

Safety of local anesthetics

Local anesthetics are essential medications for the conduction of dermatological procedures. They stop the depolarization of nerve fibers and are divided into two main categories, the amide and ester types. Systemic toxicity with reflex on the central nervous and cardiovascular systems is their most feared adverse reactions, and the anaphylactic reaction is the most concerning one. Although potentially fatal, these events are extremely rare, so local anesthetics are considered safe for use in in-office procedures.

Takotsubo Cardiomyopathy Induced by Epinephrine Infiltration for Liposuction: Broken Heart Syndrome

Broken heart syndrome, more commonly known as Takotsubo cardiomyopathy (TCM), is an acute cardiac condition. It is characterized by regional cardiac wall motion abnormalities triggered by physical or emotional stress or administration of catecholamines such as epinephrine. The initial clinical presentation is similar to an acute coronary syndrome and must be ruled out. Visualization of the characteristic wall motion will trigger the diagnosis of TCM. In this case report, we present a 50-year-old woman with additional liposuction and fat grafting after autologous breast reconstruction. Shortly after infiltration with a solution containing epinephrine to achieve vasoconstriction, hypotension and bradycardia was noticed. This escalated into full asystole for which cardiac resuscitation was required. ST-elevations and a decrease in systolic function were clear indicators for urgent coronarography and ventriculography. These confirmed the diagnosis of TCM. Infiltration with epinephrine-containing products to achieve local vasoconstriction is used routinely. Medical professionals should be aware that this can trigger a TCM with an estimated mortality rate of 5%. No evidence of a specific preventive measure currently exists. We know that women with a neurologic or psychiatric comorbidity and high levels of stress are more at risk. Reducing stress and anxiolytic medication prior to surgery could be useful. We also know that the cardiac wall motion abnormality is mainly related to β-adrenoreceptors. The use of a selective α-adrenoreceptor agonist could be considered. Further research in the pathophysiology and incidence of TCM could improve identification of patients at risk and lead to more effective prevention and treatment.

LEVEL OF EVIDENCE: 5

Cardiac Arrest Following Liposuction: A Case Report of Lidocaine Toxicity

We report a case of a patient presenting to the emergency department in cardiac arrest following a liposuction procedure, which was performed in a physician office using lidocaine anesthesia. During liposuction of the thighs, using the power-assisted technique, the patient was given a subcutaneous dose of lidocaine equal to 71 mg/kg without any noticeable intraoperative complication. Two hours later, the patient experienced dizziness, a rapid decline in mental status, tonic-clonic seizure, and cardiac arrest. The patient was successfully resuscitated in the emergency department with the return of spontaneous circulation after 22 minutes of continuous advanced cardiovascular life support resuscitation. The patient suffered from subsequent severe hypoxic-ischemic brain injury, and a complicated hospital stay, including brain edema, electrolytes disturbances, and nosocomial infections contributed to her death two months later due to septic shock.