Introduction

As a prerequisite of any pain-related medical treatment, the matter of anesthesia is of greatest importance. Usually the anesthesiological part of the whole medical treatment has a preparatory character, but is not an essential part of the actual therapy. When tumescent local anesthesia (TLA) was performed for the first time, the primary motivation for the invention was to be able to perform liposuction surgery on an outpatient basis, since most dermatologists in the United States at that time did not have hospital privileges to be able to perform liposuction.

It was a secondary observation to experience a dramatically reduced rate of complications in liposuction. For the first time in medical history the local anesthesia itself became an important active part of the surgical intervention. Comparable to the mobilization of a skin flap, the TLA fluid prepares the surgical site by hydrodissection for a more predictable treatment outcome. Today, understanding of TLA has reached an even more advanced state of importance. As more experience in liposuction surgery enables the surgeon to have a better and more refined imagination in debulking fat and mobilizing different tissue planes and at the same time where to avoid fat removal, we have learned how liposuction surgery should be performed.

Today we have explored the subcutaneous anatomy and have a clear comprehension of the interaction in the subcutaneous honeycomb-type structure of connective tissue in which the fat lobules are embedded. Depending on the body area we can find two, three or four planes of fat layers, each being separated by anatomically described fascias. For a predictable liposuction surgery today, extended knowledge about the subcutaneous anatomy is needed in order to achieve the potential esthetic results in body sculpturing. By conditioning the fat tissue with the TLA fluid, a hydrodissection process will expose the subcutaneous anatomy to the liposuction cannula and will enable the surgeon to orientate himself in the multiple fat tissue levels. Also, the extended amounts of fluid will lead to a homogenization of the fat tissue itself due to the high fluid volume and the resulting diffusion pressure.

Historical Background

When the first liposuction surgery was performed by Arpad and Georgio Fischer in Rome in 1975, a suction unit for abortion was used to curettage and remove fat from the human body through a hollow cannula.

Amongst others, the French surgeons Illouz and Fournier in 1978 started to inject saline solution in fairly minimal amounts (up to 300 ml per surgery) and this showed some improvement with regards to the ease of cannula penetration through the subcutaneous space and also a diminished amount of bleeding. In 1984, to my personal knowledge, Lawrence Field performed an abdominal liposuction on his own wife using a dilute formula of local anesthesia of 0.1%.

In 1985 Jeffrey Klein, a dermatologist from San Juan Capistrano, California, performed his first case using the original TLA formula (Table 45.1). Dr. Klein is trained also in internal medicine, pharmacology, biostatistics and mathematics.

TABLE 45.1 Klein Formula

At that time TLA was called the “tumescent technique for liposuction surgery” or “tumescent liposuction”.

Today¹ we use the term “tumescent local anesthesia” (TLA). The formula is composed of a combination of a local anesthetic drug (short acting), epinephrine, bicarbonate, and optional triamcinolone, diluted in physiologic saline solution. Today we use the so called “Hamburg Formula”, which has been described by Friedrich and Schneider-Affeld (Table 45.2).

TABLE 45.2 Hamburg Formula

The subcutaneous infiltration of large volumes of this formula causes the targeted tissue to become swollen and firm, or tumescent, and permits procedures to be performed on patients without general anesthesia while minimizing blood loss due to the vasoconstrictive effect of epinephrine² and also reduces the resorption of the local anesthesia drug in order to avoid lidocaine toxicity.

The major advantage of the Hamburg Formula is the use of two short-acting local anesthesia drugs, lidocaine and prilocaine, which are metabolized through different pathways. Lidocaine is mostly metabolized in the liver by cytochrome CYP 3A4 to monoethylglycinexylidide (MEGX) and then to glycine xylidide.

Prilocaine is metabolized in the liver but also in the kidneys and the lungs.

Usually the elimination half-life of lidocaine is about 90 to 120 minutes for most patients. This may be prolonged in patients with hepatic impairment or congestive heart failure.

Since patients today expect marked improvements after undergoing a liposuction procedure in terms of body sculpturing, in many cases four to five areas of the body need to be prepared and anesthetized by the TLA. This sets the need for high volumes of TLA fluid in one session for liposuction. Consequently the TLA formula we are using today is a modified Hamburg solution with an exact concentration of 0.038%.

When J. Klein performed his first case with TLA, he used 35 mg/kg bodyweight as a maximum amount of local anesthetic. In a patient of 70 kg the total amount of drug used would be 2450 mg. This is about 5 liters of the classical Klein formula.

Patrick Lillis published data explaining that 55 mg up to 90 mg/kg bodyweight would be safe. Today most of the dedicated uses of TLA use 55 mg/kg of bodyweight. In a 70 kg patient this allows us to use approximately 7.5 liters of the Klein formula. With our sure dilute formula we are able to use approximately 9.5 liters of TLA fluid, still taking into account that we use two different kinds of local anesthetic, which reduces the risk of toxicity to half.