Safety of Tumescent and Laser-Assisted Liposuction: Review of the Literature

resulting in contour deformity.^9-13 Importantly, liposuction is not a weight loss procedure, and it should be emphasized that patients seeking the goal of weight loss are not good candidates for the procedure.^9-13 The results of liposuction in all anatomic sites are limited by the existing bony structure, the texture and quality of the skin, the tone and build of muscle, and the pre-existing adiposity in areas not amenable to liposuction. Liposuction can help to achieve a more idealized and balanced body contour, and patients will largely vary in seeking correction of a single area or multiple anatomic sites to achieve their own personal optimal correction.

TL allows the removal of large volumes of fat with minimal blood loss or postoperative morbidity, excellent cosmesis, and a remarkable safety profile. TL technique with the use of a dilute epinephrine and anesthetic achieves the aims of hemostasis and anesthesia at the surgical site.^14-18 These advances have contributed to the enhanced safety profile and widespread growth in the popularity of the liposuction technique.^14-19

Advantages of the TL technique include a significant reduction in blood loss attributed to the vasoconstrictive effects of epinephrine. This can be quantified by comparing the aspirate from TL (containing 1-3% whole blood) with that from the procedure performed under general anesthesia (40% whole blood).¹⁶ Improved hemostasis results in both decreased blood loss as well as decreased bruising and discomfort for the patient in the postoperative phase.¹⁶ In addition, the anesthetic and vasoconstrictive effects of the local anesthetic are directed towards the sites being treated, resulting in prolonged anesthesia of several hours' duration as a result of the reservoir effect of anesthesia,^13-16 which results in decreased reliance upon postoperative narcotics.

The local anesthetic solution also results in a hydrodissection effect, whereby the pressure of the solution allows easier and more uniform penetration and removal of adipose tissue by the cannula.^4-8,13-16 Tumescent fluid enlarges, magnifies, and lifts targeted fat, allowing for more precise removal of fat.^4-8,13-16

With TL, patient convenience is significantly enhanced during the more rapid perioperative recovery period.^15-25 In contrast, recovery is much more prolonged after general anesthesia, both as a result of the after-effects of the anesthetic and from the increased bruising and discomfort associated with the procedure.^15-25 Complications with the TL technique include discomfort, swelling, bruising, temporary loss of sensation, postinflammatory hyperpigmentation, and minimal scarring at the incision sites, but these are significantly less than those associated with the procedure performed under general anesthesia.^15-25

With patient comforting and proper technique for infusion of the tumescent fluid, tumescent local anesthesia can be performed without ancillary sedation and IV or general anesthesia. With tumescent anesthesia, patient convenience is significantly enhanced during the peri-operative recovery period where there is more rapid recovery results after tumescent liposuction. In contrast, the recovery is much more prolonged after general anesthesia, both as a result of the after-effects of the anesthetic and form the increased bruising and discomfort associated with the procedure.

Complications with the tumescent technique include discomfort, swelling, bruising, temporary loss of sensation, postinflammatory hyperpigmentation, and minimal scarring at the incision site are significantly lesser than those associated with the procedure performed under general anesthesia.

Safety Studies
Liposuction under tumescent anesthesia is a procedure that was designed and developed by dermatologic surgeons.^6-25 It is a procedure with a documented safety record, longevity of results, and high levels of patient satisfaction. TL only in the office setting has a documented superior safety profile which has been documented in a number of studies in the dermatologic surgery literature by Bernstein, Hanke, Coleman, and Housman (Table 1).^6,20,25

Several of largest studies to date, the first by Hanke et al in 1995,⁶ reported data on 44,014 body areas treated with liposuction. There were no serious complications of death, emboli, hypovolemic shock, perforation of thorax or peritoneum, thrombophlebitis, seizures, or toxic reactions to drugs. Subsequently, in 2002, Housman et al²⁵ reported data on 66,570 liposuction procedures. No deaths were reported and the serious adverse event ratio was low at .68 per 1000. This study demonstrated that serious events were more common in nonaccredited offices compared to ambulatory surgery centers and hospitals. Additionally, greater adverse events occurred when tumescent anesthesia was combined with intravenous or intramuscular sedation than when combined with oral sedation or no sedation. In 2004, Hanke²⁸ surveyed 39 tumescent liposuction centers and 688 patients treated with the tumescent technique to examine liposuction practice and safety. The overall complication rate was .7 percent with the minor complication rate of .57 percent and the major complication rate of .14 percent (1/688 patients). This patient developed pneumothorax requiring hospitalization. Patient satisfaction was very high among the surveyed population where 91 percent of patients surveyed were positive about their decision to have liposuction and 84 percent had high levels of satisfaction with the procedure.

In contrast, in the plastic surgery literature (Table 1) the case fatality and complication rates were significantly higher for liposuction. In the largest study to date among plastic surgeons by Grazer and de Jong²⁹ in 2000 evaluating data on 496,245 procedures, the fatality rate was 19.1/100,000; where the most common causes of death included thromboembolism (23.1%), abdomen/viscus perforation (14.6%), anesthesia/sedation/medication (10%),