Dear Patient ,

I am glad to hear that you have chosen to consider one of the most exciting advancements in minimally invasive surgery, Tumescent Anesthesia Liposuction. This is the safest, easiest and least expensive way to remove those unwanted fatty trouble shots. And we all have them and we all know that they don’t go away no matter how many sit-ups we do or how many miles we travel on the tread mill!

This is why I am so excited about Tumescent Anesthesia Liposuction. It uses minimally invasive techniques with very small suction cannulas (tubes) so there is less damage to tissues and that means less pain, bruising and swelling, and quicker recovery—usually only two to three days! It is done right in the office using anesthetic techniques that have been carefully perfected over fifteen years of use that provide a painless experience. And since there are no operating room or anesthesia fees Tumescent Anesthesia Liposuction is also less expensive than other types of liposuction. My hope is that this will allow the benefits of this procedure to be available to more people than ever. You no longer have to be rich and famous to get rid of those trouble spots!

And finally a word about fat and beauty. Liposuction is designed to remove fat deposits that are unsightly or out of proportion to the rest of you. It is not a weight loss tool. If you want to lose weight talk to your doctor about healthy ways to shed those extra pounds. Liposuction also will not make you beautiful. It is a trap to believe that you will only be attractive if you look like the images in the magazines. I believe beauty is a condition of the heart that radiates out through your personality no matter what your shape or size. My hope is that getting rid of the bulges that make you self conscious will make you feel better about yourself allowing your true inner beauty to shine through.

My staff and I look forward to helping you experience a safe and comfortable procedure that helps unlock your inner beauty.

Clark Gerhart, MD

Minimally Invasive Surgeon
Surgical Specialists of Wyoming Valley
200 South River Street
Plains, PA 18705
570-821-1100

We all have a thin layer of fat covering our entire body that protects and insulates us. The distribution of body fat is affected by weight gain and loss but is also determined by genetics. This is why we all have those troubling areas that seem to accumulate fat no mater what we do. And it only gets worse with age. “Love handles”, “Saddle bags”, and “Beer Bellies” seem to stay no matter how much we diet or exercise because our bodies have been genetically predetermined to accumulate fat in a different way for each of us. Liposuction is one of the only ways to direct weight loss efforts right to those trouble spots where we tend to deposit fat the most.

Liposuction is just what it sounds like. Fat (lipo) is suctioned out of the body using small tubes called cannulas which are hooked to a suction device. It is done by surgeons using standard surgical techniques to provide pain relief and prevent infection during the procedure. The suction cannulas are placed under the skin where the fat exists just outside the muscle layer. The fat layer is thinned out allowing the muscle contours to be seen more clearly producing a more attractive silhouette.

Since fat exists under the skin over the entire body virtually any area can be treated using liposuction in both men and women. The most common areas that people want treated are the typical trouble spots where fat tends to accumulate with age. The bulging bellies, love handles, outer thighs (saddle bags) and the double chin are some of the most common. Arms, back (below the bra line) and inner thighs are common also. Breast reduction is also a sought after procedure to add a more youthful look and remove back and neck strain.

When you gain weight you grow adipocytes (fat cells) that fill with lipid (fat) and when you lose weight those fat cells empty out the lipid but stay in place. So they are there to simply fill again making you gain weight. This is one of the reasons why it is easy to gain weight and why repeated gaining and losing weight with dieting makes it harder to stay trim in the long run. You fill up with fat cells.

Unlike dieting, liposuction removes those fat cells permanently in addition to the lipid. It puts that area of your body back in sync with the rest of you so that even if you again gain weight it will be more evenly distributed because the excess cells in your trouble area are gone for good. In fact, a number of patients have had liposuction and have subsequently gained weight. The areas originally treated by liposuction have maintained their new shape, and even though they are heavier they still have a more desirable silhouette.

Patients considering liposuction must first be in good health. Chronic illness such as diabetes or poorly controlled hypertension or heart disease may exclude you from liposuction. There is no definite age limit. Older folks can be good candidates if they are in good health. Younger patients need to be mature enough to make a responsible decision about their health and appearance. There also is not a weight limit for patients who are otherwise good candidates for liposuction. Most of our patients are of normal weight with localized accumulations of fat. However, some of our happiest patients have been individuals who are somewhat obese. It is important to emphasize that liposuction is not a treatment for general obesity. Liposuction surgery is not a substitute for a prudent diet, good nutrition, and regular exercise and should not be seen as a last resort for people who are unable to lose weight. However, an overweight person whose weight has been stable for many years and has certain problems areas of fat may be an excellent candidate for liposuction and are some of the most satisfied patients.

A liposuction surgery is a success when the patient is happy with the results. The surgeon’s goal is to achieve an optimal aesthetically appealing result rather than to maximize the amount of fat removed. The cosmetic success of liposuction relies on removing inches rather than pounds. For example, removing an amount of fat equivalent to a half-pound of butter from a woman’s saddlebag area or from a man’s love handle areas would result in dramatic change in silhouette, but would not significantly change the person’s weight. Although the results of liposuction are often quite spectacular, it is not realistic to expect perfection. Some minor irregularities exist after a successful procedure. It is also impossible to guarantee the precise amount of improvement that will result from liposuction but patients will generally see a minimum of a 50% improvement (50% improvement is intentionally a vague measure to indicate a definite perceptible improvement, but something short of perfection.) If at least a 50% improvement would make you happy, then it is likely that you will be very happy with the result of this procedure since our patients generally achieve more than a 50% improvement. For the perfectionist, or for liposuction of a very large area, maximum improvement may require a second procedure for which there would be an additional fee.

Although liposuction is a relatively new form of cosmetic surgery, there have been several recent improvements in the technique. One of the most significant improvements has been the introduction of the Tumescent Technique, developed by Dr. Jeffrey A Klein, M.D. in 1985. It permits liposuction totally by local anesthesia instead of general anesthesia. This technique is now considered the safest form of liposuction for removing very large amounts of fat because there is virtually no blood loss. Not only has the Tumescent Technique proven to be safer than the standard technique using general anesthesia but it also has proven to be less painful, has minimized post operative recovery time and has produced optimal cosmetic results. The Tumescent Technique has been used for many years and is well tested. It was first presented by Dr. Klein in 1986 at the Second World Congress of Liposuction Surgery in Philadelphia. His article that first described the technique appeared in the American Journal of Cosmetic Surgery in 1987.

The word tumescent means swollen and firm. The Tumescent Technique uses large volumes of a dilute solution of lidocaine, a local anesthetic, in combination with the vasoconstrictive drug epinephrine, which temporarily shrinks capillaries. Local anesthesia used in the Tumescent Technique for liposuction is so effective that patients no longer need intravenous sedatives, narcotic analgesics, nor general anesthesia. After the infusion of the local anesthesia the procedure is virtually painless. Patients generally chat with staff or nap during the procedure. Compared with general anesthesia the Tumescent Technique is less painful, avoid nausea and constipation associated with sedatives and anesthetic medications and it allows quicker recovery. An added benefit is that it is also usually less expensive since there is no added expense of hospital or anesthesia personnel fees.

As a result of the widespread capillary construction caused by the epinephrine in the anesthetic solution, there is minimal bleeding during and after surgery. This is a major improvement in the liposuction technique compared to older methods that simply use general anesthesia. In a recent medical study of large volume liposuction in 112 patients, each of whom had between 1,500 ml to 3,400 ml (1.5 quarts to nearly 1 gallon) of fat removed using the tumescent technique. None of these patients required a blood transfusion. In fact, the average patient lost approximately three teaspoons (15 ml) of blood. The Tumescent Technique is so effective at minimizing blood loss that the majority of patients with large volume liposuction lose less blood during the surgery than they do at the time of their routine pre-operative laboratory studies. Because of the minimal blood loss associated with the Tumescent Technique, there is no need for blood transfusions.

There is dramatically less bruising using local anesthesia for liposuction as compared to general anesthesia. There are two reasons for this: First, because there is so little bleeding with the tumescent technique, there is almost no blood that remains beneath the skin after surgery to cause bruising. The second reason for decreased bruising is that the tumescent technique uses only small punctures to introduce the suction cannulas which are so small that they do not require stitches and these wounds are open for two to three days after the surgery permitting most of the residual anesthetic solution and blood to drain out. This minimizes bruising and swelling and accelerates the rate of healing.

The drugs that are used to produce general anesthesia are relatively dangerous compared to those used for local anesthesia. It is estimated that fatal complications associated with general anesthesia occur somewhere in the neighborhood between 1 in every 2,500 patients to 1 in every 10,000 patients. The severe complications associated with general anesthesia are completely eliminated with the tumescent liposuction technique since it uses only local anesthesia. It is well recognized that local anesthesia is considerably safer than general anesthesia.

During the tumescent technique infiltrating the local anesthesia is associated with minimal discomfort. Once the area has been completely numbed, surgery in the area is essentially painless. In addition, because the local anesthesia persists in the treated area for more than 12 hours, there is no pain immediately after the surgery. Normal healing after tumescent liposuction involves a limited but definite degree of soreness, swelling, bruising, itching and lumpy firmness. A temporary mild numbness, itching or burning of the skin may persist for 2 to 10 months. This is usually drastically less than what is experienced after standard liposuction. Some patients have had liposuction by another surgeon using general anesthesia prior to having liposuction using the Tumescent Technique. Virtually every one of these patients has said that liposuction by the Tumescent Technique is a dramatically less painful experience that with general anesthesia.

Since Tumescent Anesthesia Liposuction uses very small cannulas (tubes) to suction the fat there is less damage to the tissues. This results in less inflammation and less pain. Without the side effects of sedatives there is no dizziness, tiredness, nausea, or constipation. The result is that most people have mild discomfort or aching only and return to normal activities in just 2 to 3 days. This includes work, housework and light exercise. Many patients have gone shopping or to watch sporting events the evening of their procedure.

Infections are extremely rare, but irrespective of whether or not the anesthetic technique is that of general anesthesia or local anesthesia infection can occur any time the skin is cut allowing bacteria to enter. Although there have been reports in the medical literature of patients who have had serious infections following liposuction surgery, to the best of our knowledge, there has never been any patients who have had an infection following liposuction totally by local anesthesia using the tumescent technique. One reason is that lidocaine, the local anesthetic that is used for the tumescent technique kills bacteria. Another is that since the small puncture used for the procedure are left open to drain, there is a constant flow of fluid out through the skin washing away any bacteria that may try to enter. We also use preventative antibiotics to prevent those few infections that might otherwise occur.

The liposuction cannulas which have been specifically designed for the tumescent technique are 2.5 and 3.1 mm in diameter (about the size of the ink chamber inside of a ballpoint pen). They remove fat efficiently so the same amount of fat can be removed as with other liposuction techniques. The tumescent technique with small cannulas, however, produces smooth satisfying contours since large volumes of dilute anesthetics infiltrated into the fatty tissue cause the tissue to become swollen and firm, or tumescent. This magnifies the fatty area that is be treated by liposuction. If there is an area that has not been completely treated, this is more easily detected because the area is swollen and enlarged. Thus the risk of post-surgical irregularities and unevenness is minimized. Also, the small cannulas remove fat more slowly and evenly than large cannulas leaving less grooves or lumps. Because the small cannulas simply make small tunnels through the fat, there remain multiple connections between the skin and the underlying tissue. These fibrous connections contract with the healing process and maintain the skin in its natural position. So you don’t get loose hanging skin that you might expect. Patients who previously would have required a surgical excision of skin, called a tummy tuck, can now have excellent results simply by having liposuction.

As with any surgical procedure, liposuction is associated with certain common side effects such as bleeding, infection, scaring, or injury. However, tumescent liposuction has an amazingly good safety record. A recent survey involving over 15,000 patients who had tumescent liposuction without general anesthesia revealed no serious complications, no serious infection, no hospitalizations, no blood transfusions, and no deaths. The greatest risks of liposuction are those associated with general anesthesia. By eliminating general anesthesia, the risks of liposuction are dramatically reduced. Patients can minimize the risk of surgical complications by not taking medications or over-the-counter preparations that might adversely affect the surgery. Patients should inform the surgeon of any medications being taken either regularly, or occasionally, including herbal remedies and dietary supplements. With the human body anything can happen anytime but Tumescent Anesthesia Liposuction is tremendously safe.

As we have already said, bleeding with Tumescent Anesthesia Liposuction is minimal. When blood accumulates under the skin it is called a hematoma and this occurs occasionally with standard liposuction. Since the tiny punctures are left open any bloody fluid drains out preventing hematoma formation. Internal bleeding or bleeding out through the skin has not been reported with this procedure.

Any time the skin is opened germs can enter causing infection. Since the small punctures used for Tumescent Anesthesia Liposuction are left open fluid is draining out after the procedure preventing germs from entering the wounds making infection very rare. Since infection could cause unsightly scaring, however, preventative antibiotics are prescribed to prevent even the rare infections that might occur.

Medications used for Tumescent Anesthesia Liposuction include lidocaine, epinephrine, lorezepam, clonidine, and an antibiotic. The lidocaine is used for the local anesthesia and can reach toxic levels that result in muscle weakness, slurred speech or seizures. The dose curves for this medication have been carefully analyzed over more than fifteen years of use in liposuction and any adverse effects can be avoided by appropriately dosing the lidocaine based on patient weight, and by having the patient avoid any other medication that may increase the dose of lidocaine in the body. These other medications will be carefully reviewed with each patient. Epinephrine is used to limit bleeding and can cause rapid heart rate and increased blood pressure. Patient ‘s heart rate and rhythm and blood pressure are carefully monitored during the procedure and patients are checked for heart problems before their procedure to avoid any problems. Clonidine is given to slow the heart and lower the blood pressure to counter the affects of epinephrine. Lorezepam is used to help the patient relax for the procedure and antibiotics prevent infection. Patients with any history of sensitivity to any of these medications should notify our staff before their procedure. Unknown allergies or sensitivities to these medications can occur without warning and result in serious side effects.

Incisions for liposuction may result in scarring. Tiny (1 to 2 millimeter) round holes in the skin are used for inserting the micro-cannulas through the skin and into the fat. Typically, when the tiny punctures heal they become virtually invisible. Although you may be able to find them upon close examination, most other people would not be able to see them. Some patients may experience temporary hyper-pigmentation (darkening) that usually fades after several months but can be permanent. Certain areas of the body, such as the back or upper flanks, may be more likely to have pigmentation changes. Darker skinned people are more prone to developing darker scars. Some patients may have a genetic predisposition for persistent discoloration or over growth of scar at incision sites. Any one who has previously experienced abnormal scaring of the skin in the past might expect to also experience it with liposuction punctures. Even in the case of poor healing, however, scaring from the small punctures is often completely unrecognizable since the scars are small round dots that resemble normal skin blemishes rather than straight incisions used with other liposuction.

Injury to the skin can occur with liposuction by damaging the underside of the dermis (the supportive underside of the skin) with the suction cannulas. Since micro cannulas are used in the tumescent technique this risk is minimized but some skin changes can occur. Discoloration of the skin or wrinkling may rarely occur. If severe damage happens necrosis (skin death) and ulceration can result requiring the need for surgical repair and resultant scaring. This again is greatly minimized with the tumescent technique but is a possible occurrence with any liposuction procedure.

Occasionally you will hear of dramatic complications of liposuction in the news media where other organs are punctured or nerve damage occurs with the large cannulas used with standard liposuction. While these very rare complications are probably over dramatized, even for standard liposuction, with Tumescent Anesthesia Liposuction they are nearly impossible. The reason is that the patient is completely awake. If the tip of a cannula should stray from its intended area or hit a nerve the patient will immediately feel discomfort and the surgeon will stop and redirect the cannula. In our experience here and in over fifteen years of practice Dr. Klein, the originator of the technique, has never had a major nerve or internal organ injury.

Although the results of liposuction are often quite spectacular, it is not realistic to expect perfection. The human body is not perfectly symmetrical to begin with so there is no reason to expect it to be after liposuction. Some asymmetry, lumpiness and irregularities may occur that are noticeable to the patient looking at themselves carefully in a mirror but a casual observer should not notice any evidence of surgical irregularities. However, it is possible that noticeable irregularities may result. If this occurs, it may require a corrective procedure for which there will be a fee to cover the operating room and nursing staff expenses.

Because skin tends to lose some of its elasticity with increasing age and with cumulative sun exposure, older patients may notice an increase of fine wrinkles in areas such as the upper abdomen after liposuction. Liposuction of the thighs, while improving the silhouette, does not necessarily eliminate the subtle puckering of the skin that is often referred to as cellulite. Liposuction with the tumescent technique does reduce the degree of cellulite but it is unlikely to eliminate it.

If you arrive during office hours, please check-in at the Reception desk after which you will be directed to the liposuction coordinator’s office and waiting area. There you will have opportunity to ask any questions and we will review the procedure you are having and update any changes in your medical history. Then you will change into a surgical gown, and be escorted to the bathroom. Your weight will be recorded, a pregnancy test will be done if indicated, and your pre-operative studies will be reviewed.

In the operating room pre-operative photographs will be taken and then the areas on your body to be treated with liposuction are marked with a blue felt-tip pen. Additional photos of the markings on the body will be taken, and the patient will be asked to initial these photos to confirm agreement with the areas to be treated by liposuction. This process of preoperative documentation typically requires approximately 30 minutes before beginning the infiltration of the tumescent local anesthesia. For safety purposes we routinely place an intravenous (IV) access in your arm; it consists of a small plastic IV tube with a rubber stopper on the outside through which medication can be injected if needed. The IV access is much like the car seat-belt; it is put in place routinely but it is only rarely needed. A blood pressure cuff is placed on your opposite arm, a blood oxygen monitor clipped to your finger, and cardiac monitor leads are placed on your chest.

Using the smallest needles available, the doctor or the nurse will anesthetize the skin at sites through which the longer needles or cannulas will be inserted to anesthetize the subcutaneous fat. Patients usually experience a slight pricking sensation as the skin becomes numb. A large volume of dilute tumescent anesthetic solution is carefully and gently injected into the targeted fat. Once an area has been well infiltrated with the anesthetic solution, the fat is usually completely numb. The infiltration of the local anesthetic is a slow careful process that can take as long to complete as the liposuction itself, roughly 45 to 60 minutes. After the infiltration of the anesthetic is complete, but before beginning liposuction, you will be escorted to the bathroom one more time and then wait for another half hour while the anesthetic takes its full affect.

Experience has shown that giving a sedative by mouth permits better local anesthesia than when intravenous sedatives are used. This is because an alert patient is more capable of detecting subtle areas of incomplete anesthesia. A patient who is too sedated might easily ignore an incompletely anesthetized area, and then feel more discomfort later during liposuction. Therefore avoiding excessive sedation actually maximizes patient comfort during liposuction.

Liposuction is accomplished through tiny (1 to 2 millimeter) round holes in the skin. The tiny punctures, which are made in the skin with 1 to 2 mm biopsy punches, are so small that they need not be closed with stitches. After surgery, the tiny holes remain open for 2 to 5 days and facilitate the post-operative drainage of residual blood-tinged anesthetic solution.

After completing liposuction, patients are offered a snack and absorbent pads are placed over the adits. Finally, after the Tumescent Liposuction Compression Garments are pulled on, and the IV access is discontinued, you are ready to get up and go home. Because of residual local anesthesia, it is several hours after completing the liposuction before any significant soreness begins. The tumescent technique minimizes post-operative discomfort. Because the residual local anesthesia lasts for over 18 to 24 hours, plain Tylenol is usually sufficient to treat post-operative discomfort. Post-operative nausea is unusual after tumescent liposuction. When nausea or vomiting does occur, it typically happens 6 to 12 hours after surgery after the patient awakens from a nap. This type of nausea and vomiting usually lasts for only one to three hours.

Patients are not permitted to drive themselves home after liposuction except in the case of an especially small amount of liposuction where the patient has not received sedation. Although most patients feel well enough to drive a car immediately after surgery, you must not do so because the large amounts of local anesthesia may cause some drowsiness. The patient must be discharged home under the care of a responsible adult who is known to the patient. The person who will be driving you home should have a flexible schedule for the afternoon, although patients are typically discharged in the mid or late afternoon, the exact time cannot be precisely predicted. Your driver need not wait during the procedure. If they wish they can leave and we will call them roughly 30 minutes before they need to come pick you up.

“I finally feel normal now”
~ Joan (After a chin cheek lipo)

“I felt great , went to a hockey game that night”
~ Daria (Abdomen)

“I feel skinny”
~ Tammy (Upper abdomen)

“My old jeans are baggy”
~ Laurie (Inner thighs)

“Sometimes it still doesn’t look like me when dressed and looking in the mirror, my pants size went from a size 14 to 10”
~ Kathleen (Inner and outer thighs)

“Some Blouses and blazers that were too tight are not binding at all , it’s a relief to try on a blouse and not have the sleeves tight”
~ Kathleen (Arms)

Most patients receive lorazepam (Ativan®) 1 mg PO the night before surgery, and again one the day of surgery (after signing their “informed consent form”). Also, just before surgery, patients are typically given clonidine (Catapress®) 0.1 mg PO, provided that the patient’s pulse rate is >60/minute, and the blood pressure is > 100/60. This combination provides excellent relief of anxiety, with virtually no respiratory depression.

Patients who give a history of any prior episode of fainting no matter what the precipitating event, or any episode of light-headedness associated with a medical procedure (e.g. blood drawing) are given atropine 0.3 mg IV as soon as the pre-op IV access is established.

Patients must have enough emotional and psychological development to make a mature decision about their health. Since many young people have this, (and a few adults do not) the minimum age is not entirely based on how old a patient is. Patients must, however, be old enough to give informed consent which generally requires that they are 18 or older.

Maximum age limits are dependent on medical readiness to withstand a surgical procedure.

It must also be clearly understood that liposuction is not designed to be a weight loss tool. It is designed to reshape the body and removed abnormal deposits of fat to produce a more normal distribution and more pleasing contour.

Patients who are truly obese (body mass index grater than 35) have a significant physical, emotional or behavioral problem that will not be helped by liposuction, so I am reluctant to do liposuction on obese patients. Occasionally I will consider doing one area on an obese patient if I am convinced that treating that area will 1) offer the patient longer-term cosmetic benefits, 2) be safe and (3) the person commits to a weight loss program to provide a true health benefit.

A small percentage of patients represent a higher risk of problems and will be refused for liposuction.

Liposuction is not medically necessary so it is unwise, even unethical to perform it on patients with significant medical problems that may raise the risk of developing a complication. This includes, but is not limited to, people with diabetes, liver disease, unstable hypertension, severe heart disease, bleeding disorders, immune compromise (auto immune disease, HIV), and others.

There also are some emotional issues that can be affected by surgery. Psychiatric illness, severe depression, panic attacks, and drug addiction may make it very difficult for a patient to cooperate with their treatments. Perfectionists who may not be satisfied with results, no matter how successful, and people demonstrating addiction to cosmetic surgery may not be good candidates. People who experience significant resistance from a spouse or other loved one should also carefully consider the decision to proceed with liposuction.

Yes. On several occasions, after having initially decided to accept a prospective patient for liposuction, I have reversed my decision to do liposuction during the preoperative assessment and examination. Reasons for declining to do a patient have included a history of multiple spontaneous miscarriages (lupus anticoagulant), diabetes, radiation therapy affecting the skin overlying a targeted fat compartment, and dishonesty in giving historical data that contradicts the physical examination. For example, if a patient denies previous liposuction, but physical examination reveals indisputable evidence of prior liposuction, then I will refuse to accept the patient for liposuction. I always refuse to do surgery on a patient who has treated my staff with disrespect or arrogance.

Canceling a surgery after having previously agreed to do liposuction on a patient does require a certain degree of adroitness, sensitivity, and strategy. I have developed a effective tactic. I simply tell the patient, “Upon careful consideration of your case, I am now convinced that I do not have the technical skills to achieve what you would like me accomplish. Therefore it would be unethical for me to perform this surgery on you.” I give no further explanation. I then refund any money they have paid. On more than one occasion these rejected patients have gone elsewhere to have liposuction and file malpractice claims against the unperceptive surgeon.

Upon arrival on the day of surgery we do urine pregnancy tests on all women of child-bearing potential. If it indicates a woman is pregnant the procedure will be cancelled.

New information such as discovering a family history of malignant hyperthermia, recent aspirin ingestion, and most importantly, information that revealed dramatically unrealistic expectations could result in cancellation. Disrespectful behavior and foul language from a patient or signs of alcohol or drug usage on the day of surgery will also result in cancellation.

Yes. First, such patients require considerably more time and effort. Thus I routinely charge more for my services in such situations. Because of the increased fibrosis I tend to use slightly higher concentrations of lidocaine and epinephrine. For example, where I typically employ 750 mg of lidocaine and 0.75 mg of epinephrine per liter of saline, I might use 1000 mg of lidocaine and 1 mg of epinephrine per liter. I also tend to use a 16 gauge (1.7 mm) Capistrano micro-cannula more extensively in the initial stage of the liposuction procedure in order to penetrate the excessively fibrous tissue more easily and thereby prepare the way for using larger and more efficient 14 gauge (2 mm) and 12 gauge (2.8 mm) cannulas.

Micro-cannula liposuctions are significantly safer and allow less tissue damage producing less pain, bleeding and swelling. In general, power assisted liposuction cannulas (grinding devices, lasers, ultrasound tips) are only beneficial with cannulas that are greater 3.5 mm diameter or greater. However these larger cannulas cause significantly more pain. Virtually 100% of surgeons who use power assisted cannulas also concomitant IM or IV narcotics and sedatives, as well as sometimes using nitrous oxide which in turn makes liposuction more dangerous. Most of the more serious complications result from the general anesthesia and the greater tissue trauma that occurs when a patient is sedated. Using the tumescent (local anesthesia technique prevents these complications.

Smaller cannulas are not only safer but I feel micro-cannulas (diameter <2.8 mm) give better (smoother) results and result in far fewer touch-up procedures (only about 3 percent of patients have touch-up procedures).

Mild lidocaine toxicity rarely occurs and is recognized by transient dysarthria (difficulty speaking) and ataxia (difficulty walking). On of the few cases reported in the medical literature (Dermatologic Surgery journal. Klein JA, Kassardjian N. Lidocaine Toxicity with Tumescent Liposuction, a case report of probable drug interactions. Derm. Surg. J 24:1169-1174,1997) showed that the patient received 60 mg/kg of dilute lidocaine and epinephrine on two different occasions. This is much higher than the 45 mg/kg dose used routinely and she was taking sertroline (Zoloft®) which raises blood levels of lidocaine. Approximately twelve hours after her second liposuction she developed nausea, slightly slurred speech and an unsteady gait. Upon admission to hospital of observation she had a serum lidocaine of 6.2 micrograms per milliliter, where 6 micrograms/ml is considered the threshold for lidocaine toxicity. The next morning she was asymptomatic, her serum lidocaine levels were significantly lower, and she was discharged. This case revealed potential for drug interactions between lidocaine and drugs such as sertroline, erythromycin, amiodarone, and ketoconazole that inhibit lidocaine metabolism by inhibiting the hepatic microsomal enzymes cytochrome P450 3A4.

Yes. There have been several hundred patients who had traditional liposuction without the tumescent technique, and subsequently had tumescent liposuction totally by local anesthesia. These patients have uniformly commented that tumescent liposuction was easier (less discomforting) with virtually no hypothermia, no nausea and no vomiting, and postoperatively the bruising, swelling and tenderness were dramatically less intense. Virtually all patients returned to work and normal activities sooner than following liposuction under general anesthesia.

Surgeons who use general anesthesia typically use less than half of the volume of tumescent local anesthesia compared to surgeons who perform liposuction totally by local anesthesia. This is because after achieving tumescence, the optimal conditions for liposuction are attained after waiting 20 to 30 minutes to allow some de-tumescence to occur. Most surgeons who choose to use general anesthesia typically infiltrate the minimum volume of tumescent fluid in order to be able to begin doing liposuction immediately after completing the infiltration. The result is suboptimal hemostasis (control of bleeding), excessive ecchymosis (bruising), swelling and tenderness, compared to the unhurried approach to tumescent liposuction totally by local anesthesia.

We monitor our patients intra-operatively using continuous cardiac rhythm monitor, and automatic blood pressure monitor. We only use pulse oximetry (oxygen measurement) when a patient has been given an IV sedative that might impair respirations, or when doing infiltration or liposuction near the thorax. Patients who have any history of prior episodes of fainting or lightheadedness are given 0.3 mg of atropine. Atropine prevents vasovagal reactions (fainting) and the associated bradycardia and hypotension during surgery. A preoperative dose of 0.1 mg of clonidine PO prevents the tachycardia associated with the epinephrine in the tumescent anesthetic solution.

Our patients typically wear post-operative compression garments for less than one week. We have found that it is possible to minimize postoperative soreness, swelling and bruising by maximizing the postoperative drainage of residual blood-tinged tumescent fluid. This is accomplished by using the following techniques. 1) A technique of open drainage is used wherein none of the incisions are closed by sutures, and all incisions consist of round holes produced using small skin biopsy punches. The small punctures remain open and permit more complete drainage. 2) The use of special super-absorbent compression pads (HK Pads) to catch the fluid drainage and prevent leakage of bloody drainage onto clothes or furniture. 3) Our compression garments are specifically designed to maximize both the rate of open drainage and optimize patient comfort. I believe excessive post-operative compression of the lower extremities causes stasis, and pedal edema, and may also increase the risk of deep vein thrombosis.

Very, very few patients develop a seroma thanks to the exclusive use of micro-cannulas and to the use of the “open drainage” technique for post-liposuction care, wherein we use 1) small round holes (adits) made by 1.0 mm, 1.5 mm, and 2.0 mm skin biopsy punches which are not closed with sutures, and special compression pads and compression garments, all of which are designed to maximize the immediate post-op drainage of residual blood-tinged tumescent fluid.

Nevertheless many seromas occur in patients who have liposuction with either 1) closed drainage where all incisions were closed with sutures, 2) large diameter cannulas associated with excessive fat removal, or 3) ultrasonic assisted liposuction (UAL). Seroma is a frequent side effect of UAL.

No. I believe the use of external ultrasound in conjunction with liposuction is an example of placebo-based and not evidence-based medicine.

I recommend 1) using small cannulas, 2) avoid doing too many areas or excessively large volume on a single patient, and 3) avoid multiple liposuction patients on a single day. I typically do one case per day, and do liposuction about four cases per week. So far I have had no problem with fatigue or injury.

Yes. Patients who understand the use of liposuction to improve contour and have realistic expectations are very happy with the results and see noticeable, often dramatic changes in their appearance.

The human body, however, is not perfect and neither are surgeons, so those few patients that expect to achieve perfection will be disappointed. I only promise a 50 percent improvement, while I routinely deliver a far greater improvement. Small irregularities, minor lumpiness, and asymmetry (difference from one side to the other) exist in normal people before liposuction and to some extent will also exist afterwards. In fact, having these small irregularities provides a natural appearance. Accepting these minor imperfections allows the patient to see the greater good that is produced by the procedure. And in reality the minor imperfections are generally only seen on close inspection and those around you see what a great improvement you have made with the liposuction

To the best of my knowledge there has never been a death associated with tumescent liposuction totally by local anesthesia. Virtually every published report of a death associated with liposuction has been associated with the use of general anesthesia, or the use of heavy IV sedation and narcotics, or multiple concomitant unrelated surgical procedures, or excessively large-volume liposuction.

From the surgeon’s point of view it takes much less time to do the surgery when general anesthesia is used. This is probably one of the most significant factors in determining which technique the surgeon will use. There are other factors involved as well, however, such as training. Almost all dermatologic surgeons who perform liposuction use local anesthesia by Tumescent Technique. Most American cosmetic and plastic surgeons were trained to used the technique of general anesthesia. Currently, there is an increasing trend toward the use of the Tumescent Technique by all specialists as surgeons become trained in the newer tumescent technique.

Yes. We have a number of patients who travel from out-of-state and from abroad to have liposuction totally by local anesthesia and other advanced minimally invasive techniques. Our staff will be happy to help with the special arrangements for our out—of—town patients.

See www.Liposuction.Com For additional and more detailed information.

Special thanks to Dr. Jeffrey Klein, the originator of the tumescent liposuction technique, for supplying much of the information found here.