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LIPOSUCTION ANESTHESIA Ó PJWMDPA Let us first review the terms related to the process helping achieve and maintain comfort in a liposuction patient. These terms may be found in the Glossary but are grouped together here for easy comparison and to make the topic more understandable. Anesthesia is the loss of feeling or sensation (numbness), with or without loss of consciousness (Webster's Collegiate Dictionary). The term usually indicates the loss of the sensation of pain. There are several types of anesthesia, including general anesthesia and local anesthesia. An anesthetic is a chemical that causes anesthesia (loss of sensation, numbness). An anesthetist is a person who administers an anesthetic. An anesthetist can be a nurse anesthetist (see CRNA) or a doctor anesthesiologist (M.D.). Although it is a less desirable option, the anesthetist may even be the surgeon or an operating room nurse. An anesthesiologist is a special doctor, one who has extensive medical school and hospital training in administering anesthesia. An anesthesiologist is usually a medical doctor (M.D.) who completed college, four years of medical school, and three years of anesthesia residency (formal on-the-job training). The best anesthesiologists are usually board-certified by the American Board of Anesthesiology. The CRNA (certified registered nurse anesthetist) is a registered nurse who is specially trained in anesthesia and who has been certified following the completion of special training (including hospital) and has passed an examination. CRNA's have not gone to medical school and do not have as much training as anesthesiologists do. However, there are some excellent CRNA's who are better than some anesthesiologists. Sometimes the experience of a well-trained and conscientious CRNA is more important than the credentials of a board-certified anesthesiologist who barely passed his boards and has been sued several times and has only been out of training for a few years. Some doctors are convinced that CRNA's may be best suited to a hospital-based setting where they can be monitored by board-certified anesthesiologists. Anesthisiologists have made a strange argument for the value of their services to the Florida Board of Medicine. The anesthesiologists say on one hand " that CRNA's may be unsafe especially if unmonitored by an anesthesiologist," and then on the other hand anesthesiologists insist on collecting the money for overseeing multiple CRNA's working on multiple patients at one time (too many in fact for one anesthesiologist to adequately handle more than one problem patient at one time). This is tantamount to anesthesiologists' admitting they rely heavily on the skill and expertise of a CRNA to allow them (the anesthesiologists) to do multitasking = multibilling = multirisking. The "dry method" of liposuction is the oldest and most antiquated type of liposuction technique. The dry method of liposuction was the first form of liposuction performed at the "birth" of the procedure, and it saw extensive use in the early years. "Dry" implies that NO fluids are first pumped into the tissues that are about to undergo the liposuction. The dry method was usually performed under general anesthesia, since there was little local (in the fat) pain control (as compared with the great local pain control of today's tumescent method). This is because no numbing fluids were pumped into the target fat. The dry method usually meant more bleeding into the suctioned areas and, therefore, more overall blood loss. Therefore, transfusions were common with this method. Patients could not move for many days after the "dry" liposuction because of pain, blood loss or unwanted blood collections. Immobility led to blood clots in the legs, which could break loose into the bloodstream and travel to the lungs (thereby causing pulmonary embolism, a life-threatening condition). Amazingly, some plastic surgeons still practice the "dry" method of liposuction. With the "dry method," the amount of non-fatty fluid (infranatant) removed in the aspirate (suctioned material) is usually much less than with the "wet method" and many times less than with the original "tumescent method." With the dry method, the relative amount of blood removed in the aspirate is usually greater than with the wet method and many times greater than the amount of blood removed with the tumescent method. With the dry method, the amount of harmless fluid leakage following surgery is usually much less than with the tumescent method and less than with the wet method. An epidural anesthetic is a form of spinal anesthesia in which an injection of anesthetic is placed by an anesthesiologist or anesthetist into the area just around the lower spinal cord. Epidural anesthetic is customarily used for deliveries of babies or surgery on the legs or lower abdomen. General anesthesia is a state of unconsciousness produced by anesthetic agents. It creates an absence of pain sensation over the entire body and a greater or lesser degree of muscular relaxation. The drugs that produce this state can be given by inhalation (through the lungs), intravenously (through the veins), intramuscularly (injected into the muscle), rectally, or through the gastrointestinal tract (through the intestines). With this type of anesthesia, the risks are small but the risks are still higher than that associated with sedation, which, in turn, are higher than that associated with local anesthesia (tumescent method numbing only). Overall, the risk of problems is not high, but a ranking of risk looks like this: general anesthesia > sedation > local anesthesia (straight tumescent method only). The Klein (tumescent) solution is a special formula of sterile dilute saltwater, adrenaline (natural simple human hormone that reduces bleeding), lidocaine (a numbing medicine that is also a heart medicine), and bicarbonate (to reduce the acidity of the IV, which, in turn, reduces discomfort). Not only is the formula special, but the formula was specially developed by Klein to balloon the target fat to a very large degree, thereby allowing easier penetration of the cannulae, which reduces overall trauma to the fat, vessels and other structures. Bleeding, pain, and complications are therefore reduced with the Klein solution. These factors make the tumescent approach different from the "wet method." The Klein method (as described in this Web site) is the use of the Klein solution together with tumescing (ballooning) of the target fatty tissues. Local anesthesia occurs when numbing is confined to one part of the body. Local anesthetics percolate into nerves and prevent them from sending or transmitting their usual signals of pain or of sensation, in the case of "sensing nerves." The nerve(s) that "serve" the injected area are numbed or "deadened." In the case of liposuction, local anesthesia (given by needle or probe) is used to numb the entrance wounds, since local anesthetic makes up a large part of the Klein tumescent solution. One might correctly say that having the "tumescent method" performed straight (without sedation or general anesthesia) is the same as having liposuction performed entirely under local anesthesia. In properly selected patients, the risk of a problem is extremely slight and is lower than that associated with sedation, which is in turn lower than that associated with general anesthesia. However, this may not be the case in many other patients, because before local anesthetics can numb an area, the nerves "fire off" one last time, an action that may be felt as pain or stinging. In patients with a low pain threshold, known or unknown heart disease, or nervousness (among many other common conditions), the use of straight tumescent or local anesthesia can cause problems that can lead to a less-than-optimum results. It is therefore usually advisable to offer patients the option of having an anesthesiologist or CRNA present for the liposuction. This does not mean that any drugs have to be given. Sedating drugs could then be given, if requested by the patient, to reduce the pain of the initial local anesthesia or Klein tumescent solution. The overall risk of problems is not high, but a ranking of risk (for the average patient) would look like this: general anesthesia > sedation > local anesthesia (straight tumescent method only). An outpatient may have surgery performed in a doctor's office or surgicenter with no intention of spending at least the night after surgery in the hospital. Sedation results from the production of a sedative (to reduce activity or excitement) effect: the act or process of calming. When referring to liposuction, the term sedation usually means the administration of a sedative/hypnotic drug; however, opiates and other medications may be thought of as well. Straight tumescent or straight local liposuction is the use and reliance upon only a local anesthetic for pain control during liposuction. Although this practice may seem safe, a significant percentage of the public may not benefit from losing the option of an available anesthetist, CRNA, or anesthesiologist. "Tumescent" means swollen or ballooned. In referring to liposuction, the term tumescent refers to the ballooned look of the tissues just after large volumes of Klein solution fluids have been pumped into the target fat and just before (and sometimes during) the liposuction. See tumescent liposuction. All surgical specialists (even plastic surgeons) now accept tumescent liposuction as the safest and most effective form of liposuction. It was invented and developed by dermatologic surgeons. Tumescent liposuction implies the use of the Klein tumescent solution in a fashion that greatly swells the target fat or tissues and thereby enables passage of the liposuction instruments with less pain, trauma, and bleeding. The "tumescent method" is also known as the Klein method. With the tumescent method, the amount of non-fatty fluid (infranatant) removed in the aspirate is usually greater than that removed with the "wet method" and is much greater than that removed with the "dry method." With the tumescent method, the relative amount of blood removed in the aspirate is usually less than that removed with wet method and much less than that removed with the dry method. With the tumescent method, the amount of fluid leakage following surgery is usually greater than that associated with the wet method and much, much greater than that associated with the dry method. The tumescent solution is also known as Klein solution and is designed to inflate the tissues, reduce bleeding, and provide targeted anesthesia. The "wet method" is the second oldest type of liposuction technique. The "dry method" of liposuction was the first type, performed at the "birth" of the procedure, and it saw use in the early years. The wet method eventually took the place of the dry method. The wet method implies that fluids are first pumped into the tissues that are about to undergo the liposuction. The wet method has been performed under both general and local anesthesia. There was some pain control (but it was less effective when compared with the great pain control of today's "tumescent method"), since the fluids pumped into the target fat contained some adrenaline (small blood vessel constrictor to restrict bleeding) and lidocaine (a numbing medicine). The wet method helped to reduce bleeding into the suctioned areas. It reduced blood loss when compared with the dry method. Transfusions were reduced with the wet method as compared with the dry method. Patients could move more easily after the liposuction with the wet method than they could after undergoing liposuction using the dry method. The wet method does not imply the use of the special Klein tumescent solution, and, therefore, the wet method is not as effective as the Klein tumescent solution method (when it is used properly). The wet method also differs from the tumescent method in that the target fat is not filled up with so much fluid that it becomes "tumesced" (ballooned, distorted with expansion). Plastic surgeons still widely practice the wet method. With the "wet method," the amount of non-fatty fluid (infranatant) removed in the aspirate is usually less than that removed with the "tumescent method" but greater than that removed with the "dry method." With the wet method, the relative amount of blood removed in the aspirate is usually less than with the dry method but greater than the amount of blood removed with the tumescent method. With the wet method, the amount of fluid leakage following surgery is usually less than that associated with the tumescent method but greater than that associated with the dry method. The above information is not meant to single out or criticize any particular anesthetic technique. The author would like to note that in each liposuction patient, appropriate anesthesia may take many forms including a combination of all of the aforementioned techniques. For example, in certain cases in the formal hospital operating room or in an accredited surgicenter, when the Web site author is performing liposuction, a combination of all of the aforementioned techniques may be used to maximize the benefits of each while minimizing the side-effects. The use of a laryngeal mask airway (LMA) takes the place of a windpipe irritating tooth fracturing endotracheal tube airway, general anesthesia in small amounts is passed down the LMA and reduces the amount of propofol needed to achieve sedation through the IV, each of which are in low enough doses not to compete significantly with the metabolism of the all-important lidocaine local anesthetic given as the original tumescent Klein solution.
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