Plastic & Reconstructive Surgery 

(C)1999American Society of Plastic Surgeons

Volume 104(6), November 1999, pp 1903-1906

Lidocaine Is Not Necessary in Liposuction
[Discussion]

Klein, Jeffrey A. M.D., M.P.H.
30280 Rancho Viejo Road; San Juan Capistrano, Calif. 92675; jeffklein@hksurgical.com
Received for publication June 29, 1999.

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Outline

  Some Definitions

  Critique of Experimental Design

  Irrelevant References

  Apparent Bias

  Liposuction Deaths

  Dangers of Systemic Anesthesia

  Bias Regarding Type of Anesthesia

  Dogma and Fallacy

  Conclusions

  REFERENCES

Graphics

TABLE I Recommended ...

Lidocaine Is Not Necessary in Liposuction by Arthur W. Perry, M.D., Christine
Petti, M.D., and Marlene Rankin, Ph.D.

In this discussion of the article by Perry et al., I will critique the
experimental design and consider the relative safety of local anesthesia versus
systemic anesthesia for liposuction.

Among the 10 patients who had liposuction under general anesthesia or epidural
anesthesia together with subcutaneous dilute epinephrine, the addition of
lidocaine to one of two symmetric subcutaneous sites did not seem to improve
analgesia during the first 2 hours after surgery. The authors conclude that
dilute subcutaneous lidocaine is both unnecessary and relatively dangerous
compared with general anesthesia/epidural anesthesia. I will take this
opportunity to respectfully disagree with the authors' conclusions.

Some Definitions

Systemic anesthesia is any form of general anesthesia or conscious sedation/analgesia
that is likely to impair ventilation or protective airway reflexes. Tumescent
local anesthesia is subcutaneous infiltration of very dilute lidocaine (

Critique of Experimental Design

The assertion that "lidocaine is not necessary for liposuction" is obviously
true and does not require proof. The original published description of the
tumescent technique for liposuction stated, "When epinephrine-induced vasoconstriction
is the principal goal of the tumescent technique, lidocaine should be omitted
from the infiltrated solution."3 Nevertheless, it is instructive to consider
some of the deficiencies in the authors' experimental design.

First, the study failed to account for the fact that tumescent lidocaine can
provide post-liposuction analgesia for more than 18 to 24 hours, well beyond the
effects of systemic anesthesia. This fact alone might well justify the inclusion
of lidocaine in the tumescent solution. The experimental design overlooked this
important beneficial aspect of tumescent lidocaine.

Second, the authors used the "superwet technique" for liposuction, which
specifies a suboptimal concentration of lidocaine (250 mg/liter) and an
insufficient volume of the tumescent anesthetic solution. The superwet technique
is not intended to provide complete local anesthesia. The experimental design
was inappropriate in that it compared systemic anesthesia with and without a
suboptimal dose of lidocaine for post-operative analgesia. Tumescent liposuction
totally by local anesthesia typically employs 500 to 1250 mg/liter of lidocaine
and a larger volume of infiltrated tumescent solution. (See Table I). At these
concentrations, the benefits of tumescent lidocaine should be more apparent.

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      TABLE I Recommended Concentrations for Effective Tumescent Anesthesia for
Liposuction 
    
  

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Third, the authors failed to mention that the majority of their patients
received systemic narcotics or sedatives as part of the general anesthesia.
Narcotics can both mask the effects of local anesthesia and blunt mental acuity
in making subjective assessments for at least 2 hours beyond surgery. Thus, the
experimental design should have accounted for the residual effects of narcotics
and epidural anesthesia and extended the assessment of lidocaine effect well
beyond 2 hours.

Fourth, when an experimental end point of a clinical trial is a subjective
comparison rather than an objective measurement, all patients and clinicians
must be blinded to the identity of the treatments. The fact that the surgeon
knew which side received lidocaine abrogates the objectivity of the present
experiment. From a biostatistical perspective, this lack of objectivity reduces
the experimental design to the status of an anecdotal observation masquerading
as an objective clinical trial.

Fifth, the authors do not mention whether or not their patients received
prescriptions for postoperative narcotics. Because of the prolonged effects of
tumescent lidocaine, patients only require acetaminophen for postoperative
analgesia following tumescent liposuction totally by local anesthesia. In
contrast, surgeons who use the superwet technique with lidocaine concentrations
of 250 mg/liter often prescribe oral narcotic analgesics after liposuction. The
experimental design should have assessed the relative need for postoperative
narcotics.

Irrelevant References

The authors give three references in an apparent effort to validate their
statement that, "Over the past few years, there have been an increasing number
of deaths from liposuction procedures. One of the causes of death has been
lidocaine toxicity."4-6 Upon reading these references, one finds that the first
two articles contain absolutely no references to deaths of any sort. The third
reference, an editorial, merely refers to telephone conversations in which
deaths were discussed, but no specific examples of lidocaine toxicity are
provided.

Apparent Bias

The authors fail to objectively critique the safety of lidocaine relative to
systemic anesthesia. There is no doubt that lidocaine is potentially dangerous.
Yet although the authors assert lidocaine is dangerous, they provide no
objective documentation that tumescent liposuction totally by local anesthesia
has ever caused a single death. On the other hand, the dangers of systemic
anesthesia are ignored. There is no mention of the substantial evidence, as
described below, that virtually all liposuction deaths have been associated with
systemic anesthesia. Because of this apparent bias, the authors overlook
lidocaine's most valuable attribute: its ability to completely eliminate the
need for systemic anesthesia.

Liposuction Deaths

The greatest risks associated with liposuction under systemic anesthesia are (1)
the dose-dependent impairment of protective laryngeal reflexes and respiratory
depression,7 (2) the temptation to do too much liposuction on a single day, (3)
multiple unrelated cosmetic surgical procedures on the same day, (4) thromboembolism
associated with excessive surgical trauma, and (5) iatrogenic pulmonary edema
resulting from unnecessary use of intravenous fluids following tumescent
infiltration. When liposuction is done totally by local anesthesia, these risks
are virtually eliminated. Because of the limits on total lidocaine dosage, the
volume of liposuction is usually less than 3 liters of supranatant fat. As a
matter of both patient comfort and safety, other cosmetic procedures are usually
done on days that are separate from liposuction.

Dangers of Systemic Anesthesia

All reported liposuction deaths have been associated with systemic anesthesia.
There have been at least 100 liposuction deaths associated with surgeons who use
systemic anesthesia.8

A recent article by Rao et al. reported five deaths associated with liposuction
recorded by the New York Medical Examiner from 1993 to 1998 under systemic
anesthesia plus dilute subcutaneous lidocaine.9 Despite the fact that there was
no objective evidence of lidocaine toxicity, Rao et al. Implied that lidocaine
might have contributed to the five deaths. They did not discuss the possibility
that systemic anesthesia and excessive liposuction surgery were the real causes
of death. Tumescent liposuction totally by local anesthesia, with which there
has never been a reported death, routinely uses lidocaine doses greater than
those used in the cases reported by Rao et al.

It has been estimated that systemic anesthesia is used in 60 percent of
liposuction cases, whereas local anesthesia is used in 40 percent; yet,
virtually all liposuction-related malpractice cases are associated with systemic
anesthesia (99 percent), the majority of which were performed in hospital (70
percent).10 Thus, the incidence of liposuction-related malpractice litigation is
increased with the use of systemic anesthesia.

Bias Regarding Type of Anesthesia

As a dermatologic surgeon with a back-ground in epidemiology and clinical
pharmacology, I have a bias in favor of using local anesthesia instead of
systemic anesthesia whenever possible. Clinicians who have different training
have different biases. Residents in training for surgery and anesthesiology are
imbued with a faith in systemic anesthesia that prevents objective comparisons
with local anesthesia. During years of residency training, surgeons and
anesthesiologists are taught that systemic anesthesia is safe and is getting
safer all the time. They are unaware that there is a potential conflict of
interest in the statement that the convenience of general anesthesia outweighs
its risks.

Despite the evidence that liposuction under systemic anesthesia is more
dangerous than liposuction totally by local anesthesia, there are a number of
reasons that liposuction surgeons continue to use general anesthesia. For some
surgeons, the safety of general anesthesia is a matter of faith: "Although we
agree that avoiding any unnecessary procedure or medication is a benefit, we
believe that general anesthesia, as it is delivered today can be safe and
effective without undue patient risk."11 Some surgeons use general anesthesia
primarily because of the length of the operative procedure and costs.12
Unfortunately, the current fee-for-service nature of surgical remuneration
places a higher priority on economic efficiency rather than on safety; treatment
under local anesthesia takes longer and is therefore less economic.13 There is
no epidemiologic evidence that systemic anesthesia is safer than local
anesthesia for liposuction.

Dogma and Fallacy

Liposuction surgeons may not be aware of the fallacies that support the dogmatic
belief in the safety of systemic anesthesia. The consensus gentium fallacy is
the fallacy of concluding that an idea is true because everyone agrees it is
true. For example, there is the belief that, "Systemic anesthesia for liposuction
is the standard of care, and therefore any doubt about the safety and ethics of
using systemic anesthesia may be disregarded."

Another typical argument justifying systemic anesthesia for liposuction relies
on the improbability fallacy, the fallacy of concluding that a proposition is
true because all alternatives seem highly unlikely. For example, "None of my
patients has died from systemic anesthesia; therefore systemic anesthesia is
safe."

Conclusions

All liposuction surgeons should objectively evaluate and discuss the relative
safety of systemic versus local anesthesia. In this regard, Perry et al. are to
be congratulated on adding more information to this important debate. The
editors of this journal should be encouraged to accept articles dealing with
safety and iatrogenic complications of cosmetic surgery.

In dentistry, because of the well known dangers of systemic anesthesia, it is an
ethical imperative that routine dental procedures are preferably done under
local anesthesia. As evidenced by the above discussion, the same ethical
standards have yet to be applied to liposuction.

Jeffrey A. Klein, M.D., M.P.H.

30280 Rancho Viejo Road; San Juan Capistrano, Calif. 92675; jeffklein@hksurgical.com

REFERENCES

1. Klein, J. A. Tumescent technique for local anesthesia improves safety in
large volume liposuction. Plast. Reconstr. Surg. 92: 1085, 1993. Bibliographic
Links Library Holdings 

2. Klein, J. A. Tumescent Liposuction: Tumescent Anesthesia & Microcannular
Liposuction. St. Louis: Mosby (in press). 

3. Klein, J. A. The tumescent technique for lipo-suction surgery. Am. J.
Cosmetic Surg. 4: 263, 1987. 

4. Klein, J. A., and Kassardjian, N. Lidocaine toxicity with tumescent
liposuction. Dermatol. Surg. 23: 1169, 1997. 

5. Seigne, R. Lignocaine toxicity: A surgical surprise (Letter). Anaesthesia 52:
91, 1997. Ovid Full Text Bibliographic Links Library Holdings 

6. Grazer, F. M., and Meister, F. L. Complications of tumescent formula for
liposuction. Plast. Reconstr. Surg. 100: 1893, 1997. Ovid Full Text Full Text
Bibliographic Links Library Holdings 

7. Alexander, C. M., and Gross, J. B. Sedative doses of midazolam depress
hypoxic ventilatory responses in humans. Anesth. Analg. 67: 377, 1988. Ovid Full
Text Bibliographic Links Library Holdings 

8. Gorney, M. Presentation at the Stanford Ultrasound Assisted Lipoplasty of the
Face and Trunk Course. March 27, 1999. 

9. Rao, R. B., Ely, S. F., and Hoffman, R. S. Deaths related to liposuction. N.
Engl. J. Med. 340: 1471, 1999. Ovid Full Text Full Text Bibliographic Links
Library Holdings 

10. Coleman, W. P., III, Hanke, C. W., Lillis, P., Berstein, , and Narins, R.
Does the location of the surgery or the specialty of the physician affect
malpractice claims in liposuction? Dermatol. Surg. 25: 343, 1999. 

11. Rohrich, R. J., Beran, S. J., and Fodor, P. B. Intravenous fluids and
bupivacaine are contraindicated in tumescent liposuction (Reply to letter).
Plast. Reconstr. Surg. 102: 2518, 1998. Ovid Full Text Full Text Library
Holdings 

12. Burke, R. W., Guzman-Stein, G., and Vasconez, L. O. Lidocaine and epinephrine
levels in tumescent technique liposuction. Plast. Reconstr. Surg. 97: 1379,
1996. 

13. Cartwright, D. P. Death in the dental chair (Editorial). Anaesthesia 54:
105, 1999. 

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Accession Number: 00006534-199911000-00047


