There are very few forms of surgery
that are truly and completely painless. Discomfort is a euphemism (synonym)
for pain, and many doctors use these terms interchangeably. The pain
and discomfort associated with liposuction may best be divided according
to the time that the sensation happens and the type of liposuction performed.
The most common times for pain to occur during liposuction vary with
the method of liposuction (please refer to the Table
of Comparisons). The tumescent
technique, when purely practiced (without "twilight"
or general anesthesia or intramuscular injection) by most dermatologic
surgeons, unfortunately carries pain during
the injection of the tumescent
solution. Unfortunately, the minimal sedation
medications used by surgeons without board-certified anesthesiologists
usually cannot completely relieve the pain of tumescent fluid instillation.
Fortunately, once the tumescent solution is inside the body, the rest
of the procedure is usually not as uncomfortable. Most importantly,
the tumescent solution usually provides about a day of continuing numbness
in the suctioned areas so that patients can move, do chores, etc. Movement
and activity help to avoid blood clot formation in the legs. All in
all, the safety provided by the tumescent method usually justifies most
of the discomfort. However, just a little modification of the overall
procedure can significantly reduce the unwanted pain of the injection
of the tumescent solution (see below under "The author believes . .
.").
As an aside, the author is especially
concerned about solo surgeons (those who are acting without the help
of an anesthesiologist
or certified
registered nurse anesthetist) who perform liposuctions
while they alone give the patient anything more than "light" sedation.
The use of heavier sedation, provided by the solo surgeon who is also
performing the liposuction, could be of concern, since there is a risk
that the solo surgeon cannot manage a "three-ring circus" (patient's
consciousness, vital functions, and the liposuction surgery) all at
once. It is to be noted that there are many excellent nurse anesthetists;
however, on average, most have less experience than do board-certified
anesthesiologists. This experience difference might be found in the
numbers of patients treated, emergencies managed, and in the severity
of the cases treated. It is usually best to seek an overtrained person
(board-certified anesthesiologist) whenever you are treated or anesthetized.
It usually best not to be a "challenge" to the doctor or nurse who is
treating you. By the way, not all is etched in stone; it could easily
be that 80% of nurse anesthetists are safer and better for your care
than the bottom 10% of board-certified anesthesiologists (these numbers
are crude estimates and only provided to illustrate the point...there
is no published basis for the percentages).
The wet
technique and traditional liposuction rely
heavily on the use of an anesthesiologist and/or nurse anesthetist (or
the doctor performing the liposuction, if he is working solo). The wet
technique and traditional liposuction, when performed with general
anesthesia (gas and tube in throat) or with
heavy sedation, hurt very little during the procedure. However, some
critical parts of the tumescent solution are usually not used with the
"wet technique." With the wet technique and original liposuction,
pain, tenderness, and soreness usually are noted within hours of the
procedure and may be somewhat incapacitating during the following days.
Unfortunately, lack of movement for any reason (e.g., pain) may cause
problems during the recovery phase for liposuction patients. In summary,
there is usually less pain DURING the wet and traditional "dry"
liposuction procedures, as they are usually
performed under general anesthesia, rather than with the straight tumescent
technique. This is because general anesthesia stops pain (or because
patients cannot remember the pain) while fluids are injected into the
patient's body. There is, however, greater pain AFTER wet and traditional
liposuction procedures, because they do not use the true Klein
tumescent solution. The author dislikes using
general anesthesia because it carries a potential serious risk by altering
how the human body tolerates and metabolizes lidocaine.
The author believes that it is
in the best interests of the patients to offer each patient the choice
of tumescent liposuction with or without the presence of a board-certified
anesthesiologist or certified registered nurse anesthetist. The patient
is made aware that the instillation of the tumescent fluid would otherwise
be felt to a varying degree. What are some of the benefits of an in-office
procedure with the assistance of such personnel? First, the patient
is able to have a similar level of quality pain control as if the procedure
were performed in the hospital. Second, the patient is able to reduce
exposure to hospital infections and antibiotic-resistant germs, which
could cause serious complications. Third, cost for an operating room
is greatly reduced or removed. Fourth, in-office procedures tend to
place fewer time constraints on the surgeon, and the surgeon is less
likely to "rush" the liposuction procedure. Fifth, the procedure is
probably more likely to start on time (less hours on an empty stomach...imagine
not eating since midnight for a liposuction scheduled at 1pm the next
day which is then delayed 3 hours). There are many other potential benefits
that vary with the hospital, surgicenter, or office setting. Patients
may wish to visit and scout the possibilities. The above thoughts have
to be tempered with the fact that there are some great hospitals and
surgicenters and with the fact that a patient's current health status
and state laws may necessitate the use of certain different facilities.
PAIN AND PAIN CONTROL
The principle determining factors
in planning the type of liposuction and type of anesthesia patients
should have (for example, straight tumescent method or sedation standby
or sedation or general anesthesia) are the patient's pain tolerance,
the amount of fat to be removed, and the patient's past and current
medical health conditions. These factors must be considered in combination
as well. For example, if just a small area of the body needs liposuction
and the patient is in good medical condition, and even if the patient
does have a great sensitivity to pain, the "straight" (no
sedation, no general anesthesia) tumescent method will usually suffice.
The most important word in the last sentence is "usually.'' To prepare
for anything "unusual," it is always prudent to have an anesthetist
standing by or the capability to deliver light sedation. A very important
question then arises: Who will administer the anesthesia?
Many surgeons prefer to administer
the anesthesia "solo" (by calling out orders to a floating nurse who
injects medicines into the patient or the IV) while they are performing
the liposuction. Although this is frequently done, it may not be the
most desirable situation. (Incidentally, the Web site author has written,
in the last decade, a major chapter in a published surgical textbook
regarding anesthesia and sedation for cosmetic surgery.) Any surgeon
trying to perform liposuction or eye surgery or a face-lift who is also
running the anesthesia is acting as if he/she is the master of a three-ring
circus. Being a "jack of all trades and master of none" may not be helpful
to the patient in this situation. In order to perform the surgery accurately,
to watch all the instruments that are recording the patient's most important
vital statistics, to request the proper amount of drugs and watch that
the floating nurse draws up the proper dosage, and to watch as the nurse
pushes the drugs into the IV line at the proper speed and dilution is
like a juggling act. Even the most normal of patients can have something
shift out of balance in each or any of the three rings of the circus
just described. If the surgeon has to devote his attention to one of
the rings more than the other two, then the best outcome may not result.
The website author spoke these same points at special formal hearings
held by the Florida Board of Medicine on cosmetic surgery safety issues
in 1999 and 2000.
Many patients have flown from virtually
all of the continents except Antarctica to see the Web site author. The Web
site author prefers to offer the option of having a board-certified
anesthesiologist to sedate patients who have been not operated on before
for other cosmetic conditions in order to increase the certainty that the
patient will be kept restful and comfortable during the liposuction. Why
is the option of an anesthetist beneficial? Because if a patient does not
have this option available and the patient starts to experience pain, either
during the injection of the tumescent solution (possibly the most painful
period of the liposuction) or during the fat removal itself, then the surgeon
alone may have to operate a "three-ring circus."
Unfortunately, many surgeons have
claimed that ALL patients can safely have liposuction performed under
"straight" tumescent anesthesia. These are either false claims
or these doctors are misinformed or simply have not completed enough
liposuction cases to see a good statistical representation of patient
numbers.
Deciding whether or not you want
to have an anesthesiologist that is board certified or a nurse anesthetist
Certified
Registered Nurse Anesthetist (CRNA) present during your
surgical procedure is a decision that is usually not able to be undone
after the beginning of surgery. Again, If you do not have an anesthetist
present to allow pain control during the liposuction or if you develop
pain or an unusual problem, you may face the risk of either having your
surgeon run a three-ring circus or of having to suffer various levels
of discomfort during the procedure. Either risk may have an adverse
outcome on you and/or the surgeon. To be on the safe side, requesting
that an anesthesiologist or at least a nurse anesthetist be present
during your procedure will still allow you to have the option of declining
anesthesia if you don't think you need it and can tolerate the discomfort.
However, if you do feel that you need some pain control or relaxation
during the procedure, just ask for it when you feel the need. An intravenous
injection of a very rapid-acting pain-relieving or relaxing medication
can be given, so as to make the procedure go more smoothly for you and
your surgeon.
Again, when a patient's blood pressure
increases because of stress related to pain or anxiety, the substances in
the tumescent solution tend to fade or "wash out" a bit more quickly. When
the blood pressure increases, pain may also increase, sometimes creating
a vicious cycle. The elements of irritation and fear may add to the cycle.
"Fright" hormones may be released by glands in the bloodstream at the blink
of an eye. This can make the heart beat faster. In older patients or in those
with weak hearts, the hormone adrenaline is released from the adrenal glands
during situations involving fright or pain. Too much circulating adrenaline
can cause the blood vessels of the rest of the body to "clamp down," thereby
increasing the blood pressure and making it more difficult for an already
compromised heart to pump blood. A heart attack could possibly result.
Even "normal" appearing patients can have
unforeseen problems during straight tumescent liposuction. Something may
be wrong with these patients, something that has not been detected during
their lives thus far and that can only be brought out by stress. Liposuction
(even straight tumescent) is surgery, and it does cause stress to your body.
Say, for example, that a 45-year-old businessman is having his "love handles"
treated with straight tumescent liposuction. If he experiences pain in the
highly fibrous areas of the love handles, the pain causes a rise in adrenaline
and, therefore, a rise in blood pressure. The patient may have a heart attack
if he has an unknown clogged coronary (heart) artery. As of 1999, poor coronary
arteries usually cannot be detected or seen or listened to by a regular doctor
performing a routine physical exam before the liposuction. Having a good
board-certified anesthesiologist or nurse anesthetist who is trained in advance
cardiac life support (ACLS) standing by and working with the surgeon and
office staff (who may also be trained in ACLS), as well as the presence of
a defibrillating device (chest shocking device, which would be mandatory
in all offices performing liposuction), may save a life. The more skilled
people who are working together, the better it is for the patient. Unfortunately,
one single person (for example, the surgeon) who is skilled and trained in
cardiac life support will find it extremely difficult to run a three-ring
circus in a pinch if there is a problem.
Board-certified anesthesiologists
and certified registered nurse anesthetists who charge very reasonable
prices (without having the surgeon tack on extra fees) provide a solution
to the aforementioned concerns. The Web site author prefers to prearrange
yet let the patients directly pay board-certified anesthesiologists
or nurse anesthetists (this is easily done even on the day of surgery).
This way, patients know there is no fee or "cut" being taken out by
the surgeon and that all the money they expect is going to the particular
anesthesia specialist involved in the liposuction.
