Beyond Liposuction: Evolving Applications for Tumescent Anesthesia

January 2022 | Volume 21 | Issue 1 | 86 | Copyright © January 2022


Published online December 13, 2021

C. William Hanke MD MPH, Michael S. Dent MD

Laser and Skin Surgery Center of Indiana, Indianapolis, IN
Ascension St. Vincent Hospital, Indianapolis, IN

Abstract
Tumescent anesthesia was initially developed as a safer and more effective alternative to general anesthesia in performing liposuction. Today, it is used extensively for a wide variety of surgical procedures performed by various specialties. As more surgeons have become exposed to tumescent anesthesia with its associated advantages over general anesthesia, the number of applications for this unique form of local anesthesia has skyrocketed. In this article, we will briefly discuss the basics of tumescent anesthesia, followed by a discussion of the many applications that are now being performed by various specialties.

J Drugs Dermatol. 2022;21(1):86-89. doi:10.36849/JDD.6279

INTRODUCTION

The tumescent technique was first described in the literature by Dr. Jeffrey A. Klein in 1987.1 He developed this technique to provide a safer and more effective method for liposuction. The tumescent technique involves the infiltration of large volumes of fluids with dilute amounts of local anesthetic agents and epinephrine, all performed without general anesthesia or significant conscious sedation. Since 1987, several terms have been used interchangeably, including the tumescent technique, tumescent anesthesia (TA,) and tumescent local anesthesia (TLA.) The term "tumescent local anesthesia" was first used in the literature in 1999.2 We prefer TLA as it implies no general anesthesia or significant conscious sedation. We do realize that many surgeons apply these terms differently and that some combine general anesthesia with tumescent anesthesia solution for the improved hemostasis provided. In general, benefits of TLA include the following:

1. Avoiding general anesthesia, with the associated complications, high costs, and lengthened recovery periods.
2. Improved hemostasis. TLA allows for a relatively bloodless surgical field and significantly decreases the likelihood of post-surgical bleeding complications.
3. Wide awake patients. It is often beneficial for patients to be awake, able to move, and to change positions multiple times as needed during a procedure.
4. Significantly increased maximum safe amount of local anesthetic.
5. Prolonged effect of local anesthesia. Not only are patients comfortable during procedures, but the anesthetic effects of TLA can last for 24 hours, which leads to reduced post-operative pain.3

While the risk of serious complications using tumescent anesthesia is extremely low, there is the potential for toxicity.4 Lidocaine is the most common local anesthetic used. The FDA-approved recommended safe dosage of lidocaine with epinephrine for local anesthesia is 7 mg/kg. However, the safe dose of lidocaine for TLA is much higher, with recommendations between 28-55mg/kg.5,6,7 Liposuction, in particular, appears to remove between 20-25% of the lidocaine before it is absorbed, so the maximum safe dose of lidocaine during liposuction is going to be on the higher end of that range, 45–55mg/kg.5,8 Due to the constriction of blood vessels and the redistribution of lidocaine to peripheral tissue with increased molecular bonding, the absorption of lidocaine into the blood is significantly delayed. Thus, the peak serum concentrations stay below the threshold for mild lidocaine toxicity (6 ug/ml) despite the higher overall amount lidocaine in the tumescent solution.5,8

Since Klein first pioneered the tumescent technique as applied to liposuction, TLA has gained momentum in multiple specialties for various procedures. Dermatology, plastic surgery, vascular surgery, general surgery, and orthopedics have all applied the tumescent technique to procedures that were once only performed under general anesthesia. We will now review the growing list of procedures that are being performed using TLA.

Applications in Dermatology
Dermatologists have been involved with TLA from the start. While liposuction remains the most common use for this technique, dermatologists have since applied TLA to a growing list of procedures.

Facial resurfacing procedures are often painful and can be quite