Tumescent Anesthesia: A Brief History Regarding the Evolution of Tumescent Solution

The term tumescence, by definition, is the state of being swollen. When we speak of tumescent anesthesia, we broaden this to include swollen tissue with various amounts of analgesics and vasoconstrictive agents. The general concept is an old one. In fact, the idea that large volumes of fluid may be introduced into subcutaneous tissue in order to provide a degree of local analgesia was known as “massive infiltration” in the early part of the 20th century.²⁷ The addition of small amounts of analgesics, known as “massive infiltration analgesia with weak analgesic solutions,” was being used in the United States by 1915.²⁷ Meanwhile in Russia, a surgeon named Aleksandr Vasilyevich Vishevsky was developing a similar technique that he published in 1932, which he called “Local Anesthesia by Creeping Infiltration Method,” later known as the “Vishnevsky anesthetic technique.”²⁸ However, these techniques were largely ignored in the surgical literature from the 1930’s until the latter part of the 1970’s, when they were first applied to liposuction. Since that time, the solutions used for infiltrating tissue have evolved considerably. In fact, from the late 1970’s onward, it is difficult to document all of the significant changes and improvements that have occurred. In this brief history, we will attempt to highlight and discuss the major events, giving credit as appropriate, in the evolution of the tumescent solution. And it all started with liposuction.

Liposuction with hollow bore needles, under general anesthesia, was first reported by Giorgio Fischer in 1976.³ This was performed without local infiltration of fluids or analgesics. It was Yves-Gerard llouz (Figure 1) who pioneered the “wet technique” in 1977, which involved the injection of small amounts of hypotonic saline, hyaluronidase and epinephrine into the subcutaneous fat.³ According to a recent conversation with Dr. Richard Glogau, who learned liposuction from Illouz in Paris in 1981, Illouz began using lidocaine with epinephrine in his solution at some point between 1977–1981. He was not, initially, using this for anesthesia, but for the vasoconstrictive effect of the epinephrine. His procedures during this period were all performed under general anesthesia. A significant benefit of the wet technique is improved hemostasis, leading to a relatively bloodless surgical site, thus decreasing the potential risk of hematoma, seroma and ecchymosis.³⁵ Also, the hypotonic solution leads to swelling of tissue and lipolysis of adipocytes, facilitating easy removal of fatty tissue with less tissue damage.³⁵ Later, in 1984, Stegman and Tromovitch documented a method for small areas of liposuction to be performed using local anesthesia only (no general anesthesia and/or systemic analgesia) in their textbook, “Cosmetic Dermatologic Surgery.”³⁰ The combination of these two concepts, the wet technique and local-only anesthesia for liposuction, collided with Dr. Saul Asken’s work (Figure 2) in the early-to-mid 1980’s.³⁵ Asken was on the verge of performing