Liposuction and Anesthesia

Patients are usually aware of the importance of the anesthetic. Liposuction is unlikely to be a life-threatening procedure in itself. However, anesthetic factors such as airway management, fluid administration, and medication effects can be life-threatening. When I discuss complications, it is not unusual for me to discuss many of the details of how the anesthesia works, modifications that make it safer, and how patients are monitored during surgery.

Types of Anesthetic

Local anesthetic: The area is numbed with anesthetic.

Many practitioners, particularly dermatologists, use local anesthesia exclusively. "Local" anesthetic is anesthetic medication that is injected directly into the tissues to numb them. The patient is awake during liposuction under local anesthetic.

After allowing some time for the anesthetic to take effect, liposuction is performed. Advantages to the patient include the avoidance of a deeper level of anesthesia, less cost, and virtually no recovery time. A disadvantage is patient discomfort during longer procedures in which multiple areas are treated. There was one memorable television report showing a patient casually talking on the telephone while having liposuction, but this is not the typical experience! Patients who have had previous liposuction elsewhere under local anesthetic typically tell me it was not a day at the beach and they welcome the recommendation of a short I.V. anesthetic.

Many surgeons, including myself, use local anesthesia alone only for small liposuction cases, such as a touch-up liposuction to limited areas. Patients tolerate this well and have minimal discomfort, like a trip to the dentist. The cost is minimal.

This represents the spectrum of anesthesia from lighter to heavier.

Local anesthetic: The area is numbed with anesthetic ("lidocaine").

Most plastic surgeons frown on nonsurgeons doing any substantial amount of liposuction as an office procedure under local anesthetic alone. This is a serious surgical procedure that should be done by a qualified surgeon in an operating room in an outpatient surgery center or hospital. Ideally, this is done by a plastic surgeon who has the capability to perform other cosmetic procedures if they are indicated, such as an abdominoplasty.

Furthermore, a local anesthetic is not necessarily the safest type of anesthesia. The patient may not have an intravenous access or be properly monitored with an oxygen monitor, EKG, and an attending anesthetist present monitoring the patient. If a patient is uncomfortable or in pain, this can cause variations in respiratory rate, pulse and blood pressure, including hypertension which is undesirable during surgery.

Intravenous Sedation

Many physicians consider any anesthetic that renders a patient unconscious a "general anesthetic." However, there are some important technical points that distinguish a "deep" or unconscious sedation from a traditional general anesthetic. The anesthetist administers the medication through the I.V. tubing, and uses an infusion pump to provide a continuous delivery of a short-acting anesthetic called Diprivan^® (propofol). This "wonder drug" has made traditional general anesthesia unnecessary for many types of surgery, particularly out-patient surgery such as liposuction. Many patients are already familiar with this type of anesthetic, which has been used for years for G.I. procedures, knee arthroscopies and dental procedures.

If Diprivan^® is a "wonder drug," the LMA^TM (short for "laryngeal mask airway") is a "wonder airway." Designed by a British anesthesiologist just 20 years ago, it provides a reliable airway without the need for intubation. This ingenious but weird-looking device lodges in the back of the throat and protects the airway, without going between the vocal cords. It is unnecessary for the anesthetist to intubate the patient, which involves hyper-extending the neck. The LMA eliminates the need to pass a tube between the vocal cords, which can be difficult to do in some patients and occasionally traumatic to the vocal cords. Some patients still need to be intubated, such as those with esophageal regurgitation, but the majority may be safely treated with an LMA^TM.

Intravenous Sedation

Once the patient is asleep, I inject dilute local anesthetic solution into all the areas that I plan to treat with liposuction. Why use local anesthetic if the patient is asleep already?

There are two reasons:

An unconscious intravenous sedation, with the addition of local anesthetic injected into the tissues once the patient is asleep, is the preferred type of anesthetic used in our facility for almost all plastic surgical procedures.

General Anesthesia

The classical general anesthetic calls for a muscle relaxant, intubation, a breathing machine ("ventilator"), and an inhalational anesthetic agent ("gas"). Patients are paralyzed to allow mechanical ventilation, which necessitates an endotracheal tube to secure the airway.

This type of anesthesia certainly provides deep sedation, controlled ventilation, and a motionless patient for the surgeon. This level of anesthesia is necessary for major surgical procedures that require mechanical ventilation such as intra-abdominal surgery or open heart surgery. But, it is a deeper level of anesthesia than is necessary for plastic surgical procedures, even for an abdominoplasty (tummy tuck).

General Anesthesia - Risks

There are additional risks related to the use of an endotracheal tube, such as:

This is just a partial list of possible problems.

As a general principle, any opportunity to eliminate a risk factor is worthwhile to keep the odds in favor of patient safety and comfort. This is part of the well-known KISS principle (Keep it simple, stupid). The incorporation of a technique that has a risk without a necessary benefit should be questioned. Rituals need to be examined. This is not easy for any surgeon who has developed habits, including myself.

Positioning in Surgery

Prolonged motionlessness can cause problems. Nerves can be damaged by unrelieved pressure. Skin breakdown can occur at pressure points. It is advantageous to move patients during surgery. Our patients start supine on the operating table, but are then moved to one side and then the other when the anesthetic solution is injected. This turning routine is repeated when liposuction is performed. The patient is treated for about 30 minutes in a supine position, followed by 30 minutes on one side, and then 30 minutes on the other side. This ensures that there is no prolonged pressure while the patient is in one position. The intraoperative movement of the lower extremities may also be helpful to avoid blood pooling in the calves ("venous stasis") which can cause dreaded deep vein blood clots.

Some surgeons place the patient prone on the operating table. This is the anesthetist's least favorite position for some very good reasons. The airway is more difficult to manage and endotracheal intubation is needed. If the tube comes out, it's a big problem because the patient is face-down. Pressure on the face is not ideal and can potentially cause problems. Pressure at the hips caused by rolls used to bolster the hips may interfere with venous return from the legs. There is often a period of inactivity, about 20 minutes, in the operating room while the patient is turned from face-up to face-down on the operating table. Often the patient needs to be re-prepped and draped because of loss of sterility.

Prone positioning is unnecessary. Moving the patient from side to side allows full-body access, avoids problems related to prone positioning, avoids intubation, and improves operating time and efficiency by eliminating unnecessary interruptions.

Blood Clots

The development of blood clots in the legs is a major concern. These clots can develop even without surgery. This is why flight attendants have passengers get up and move around on long flights. Inactivity raises the risk of blood pooling in the legs, called "stasis." If a piece of this blood clot breaks off, it travels to the heart and then to the lungs, where it becomes a pulmonary embolus. This can be a fatal complication. Accordingly, it is important to steps to prevent this complication.

Preventive measures include reducing periods of immobilization, such as very long surgery times or bed rest after surgery. It makes sense to avoid muscle relaxation, including the use of paralytic agents that are part of a traditional general anesthetic. Movement of the patient's legs, position changes during surgery, and the use of sequential compression devices also make sense. Early ambulation is important. Getting up to go to the bathroom after surgery get the legs moving. Out-patient surgery forces the patient to ambulate during the first 24 hours. I usually see patients the day after surgery, so that I am assured they are up and moving. The trip to the doctor's office helps.

Blood Thinners

Some surgeons have recommended the use of blood thinners such as Heparin^® or Lovenox^®, but these may increase the risk of bleeding. The objective is to reduce the risk of blood clots to a level as close as possible to the baseline risk that we have without surgery.

Outpatient Surgery

Improvements in anesthesia have shortened patient recovery times, allowing surgery to be performed safely in an outpatient setting. Benefits include greater convenience, easier scheduling, greater consistency in medical personnel, better cost-containment, and avoidance of hospital-acquired ("nosocomial") infections. As a safety measure, the American Society of Plastic Surgeons mandates that its members use only accredited outpatient facilities or licensed ambulatory surgery centers.

Skin Tone

The most important advantage of ultrasonic liposuction may be improved skin contraction. Every woman I see wishes to preserve her skin tone as much as possible, so any advantage the surgeon can provide in this regard is very much appreciated.

In the early days of liposuction (circa 1983, which is when I graduated from medical school) surgeons would advise their patients, yes, I can reduce your bulges, but at the expense of loose skin. You may well need additional surgery afterward to tighten loose skin, and these procedures leave long scars. So, it was with understandable apprehension that women chose liposuction. That they chose it at all is testimony to how unhappy they were with their body shape! In fact, early on, surgeons recommended not performing liposuction on patients over fifty!

Certainly, if secondary skin excision procedures can be avoided, so much the better. With tumescent (more precisely "superwet") and ultrasonic techniques, I find that in the majority of cases skin tone is no worse after surgery than it was before, and often better. Some patients that I was quite sure would need a tummy tuck later on seemed to do remarkably well with liposuction, the skin showing much better ability to contract than expected (See patient T.M.).

However, skin which has already been very stretched by pregnancy or weight loss is still best treated with a tummy tuck in most patients if loose skin is a problem for them. Liposuction alone will not suffice.

When endoscopic procedures were introduced in the 1990's, plastic surgeons tried this approach for the abdomen, to see if an effective abdominoplasty could be performed used a smaller incision, with endoscopic tightening of the muscles. However, this did not prove practical because the skin remained stretched out. The skin did not contract sufficiently. It was clear that removal of excess skin was needed. As it turned out, this was not a good place for minimally invasive technique.

Liposuction of the Arms

The arms are a favorable area for liposuction. It is very common for me to treat the arms and armpits ("axillae") at the same time as liposuction of the lower body. Women often complain about extra "flub" in their arms and will shake this area to demonstrate. They may be embarrassed about it and will avoid wearing sleeveless tops, even during the summer.

Most women are understandably concerned about what will happen to the skin after the fat is suctioned. They don't want to end up with a lot of loose skin hanging down. Often, the skin responds better than expected, even in older patients. The skin tone may be no better, but it is unlikely to be made worse and the removal of the extra fat improves the contour. It is always possible to come back and remove the extra skin ("brachioplasties") if necessary.

However, I have had plenty of women over 50 with compromised skin tone who have had liposuction, and surprisingly few return for brachioplasties. It is always a plus to avoid a brachioplasty scar because this scar, which goes down the back border of the arm, cannot be completely hidden.

In patients who have lost a great deal of weight and have loose skin hanging to start with, it is better to proceed directly to brachioplasties, which are usually done in combination with liposuction. There is a limit after all to skin contraction. The brachioplasty scar is always preferable to loose skin that is sometimes called a "bat wing."

"Bra Fat" (Axilla) Liposuction

Women often reach around and grab a roll of fat just lateral to their breasts. This is commonly called the "bra fat." It can bulge around the bra strap, which is not very attractive. Even though this area is actually below the axilla, we refer to it as the "axilla" or sometimes the "scapular" area.

The same armpit incision used to treat the arms may be used for access to the axillary area. There is often a crease between this fat roll and the love handle. By treating the extra fat in the roll above and below this crease, the crease may be softened or sometimes eliminated.

Liposuction of the Arms: How It Is Done

An incision is made in the armpit. The area is first injected with anesthetic solution, the same way that liposuction is performed in other areas, using the "super wet" technique. The second step is the introduction of the ultrasonic probe to dissolve fat cells. The third step is removal of the fat using liposuction.

Some surgeons have been reluctant to treat the arms or calves because of concerns about complications. However, if the super wet technique is used, ultrasonic times are kept to a few minutes at the most, incisions are limited, and overtreatment avoided, these become very favorable areas to treat with minimal risk.

It is unusual for me to treat just the arms and axillae. Most women also have areas of the lower body to treat, so these areas are treated at the same time as liposuction of the lower body. The exception is the patient who has liposuction of the lower body and then returns to have the arms done. Of course, ideally these areas are treated in one operation. Because of the difference in fat distribution in men, very few men require liposuction of the arms, although I frequently treat the axillary areas when I perform liposuction on male breasts.