Dangers Poorly Appreciated
Tumescent liposuction is now the most frequently performed cosmetic surgical procedure in the United States. Plastic surgeons as well as physicians from several other surgical disciplines report dramatic increases of 200% to 300% in the number of liposuction procedures between 1990 and 1997 1. Many of these surgeries are done in private offices, hence there is no mandatory reporting of deaths or adverse events. Therefore, comparatively little is known about the morbidity or mortality related to this very commonly performed operation. Factors related to liposuction patient safety are briefly reviewed here.
Liposuction is a frequent procedure that is rapidly growing in popularity and is most often done in a private physician office setting. Depending on the practitioner, it may be performed using monitored anesthesia care or conscious sedation, epidural anesthesia, or general anesthesia. It is believed about 50% of such procedures involve general anesthesia. The most common surgical technique today is called "tumescent" liposuction 2 in which large volumes of saline with epinephrine and lidocaine are infused into the subcutaneous fat. The infusion of this solution facilitates subsequent aspiration via the operative microcannulae. While the content of the infusate varies, it typically contains 500-1,000 mg of lidocaine, and 0.25-1.0 mg epinephrine, per liter of saline. These drugs are also utilized in an effort to minimize pain and blood loss both during and after the procedure. Lidocaine doses as large as 55 mg/kg have been touted in the cosmetic surgery literature as "safe".3 "Large-volume" liposuction, defined as aspiration of more than 1,500 mL of fat, typically requires the infusion of several liters of the infusate solution, and may take several hours to perform.
In the May 13, 1999 issue of the New England Journal of Medicine, five deaths related to liposuction were reported by the Office of the Chief Medical Examiner of the City of New York. 4 These deaths occurred between 1993 and 1998. Three of these five patients died as the result of unheralded, and precipitous intraoperative hypotension and bradycardia. At the time of these arrests, arterial hemoglobin oxygen saturations were between 100% and 97% (one medical record and the details of the third intraoperative death were not available). These two patients who arrested intraoperatively had received total lidocaine doses of 10 and 14.3 mg/kg, with blood lidocaine concentrations of 5.2 and 2.0 mg/L (determined at autopsy).4 Other causes of serious morbidity or death associated with tumescent liposuction are reviewed in Table 1.
Local Anesthetic Toxicity
Toxicity induced by local anesthetic (LA) is an uncommon, but often catastrophic, complication. The first sign of systemic toxicity with potent drugs such as bupivacaine typically results from LA binding to the cardiac Na+ channel, producing early electrophysiologic disturbances and serious (or lethal) arrhythmias at relatively low plasma concentrations. A different picture of LA toxicity is usually seen with a less potent LA such as lidocaine. Lidocaine will generally manifest initial CNS toxicity (such as tinnitus, somnolence, confusion, and seizures) well before overt cardiac toxicity occurs. Animal studies have shown the fatal dose of IV lidocaine is 9-fold greater than that of bupivacaine. 5 However, all LA also depress cardiac contractility at the cellular level, via inhibition of ß-adrenergic receptors.6 We and others have reported that the rank order of this form of cardiac toxicity mirrors LA potency and lipid solubility as well (i.e., bupivacaine >> mepivacaine). Thus, sheep receiving iv bupivacaine died of sudden onset ventricular tachycardia/fibrillation. However, all animals infused with lidocaine died secondary to marked hypotension and bradycardia, without arrhythmias.5
It appears that the lidocaine blood concentrations determined in two patients (postmortem) were not in the grossly toxic range. However, this single value has several limitations. No data is available regarding the stability of lidocaine in postmortem blood and tissues.4 The site of postmortem blood samples may not accurately reflect the myocardial concentration of local anesthetic at the time of arrest. In addition, the effect of the resuscitative medications and interventions on lidocaine levels is unknown. It is known, however, that concentrations of 4-6 mg/liter have been found in deaths due to lidocaine toxicity.7,8
Other Complications Related to Tumescent Liposuction
Between October 1996 and March 1998 nine patients in the city of Caracas, Venezuela were reported to have developed rapidly growing mycobacteria infections.9 Alterations in instrument cleaning and sterilization procedures appeared to remedy this outbreak. Fluid overload, pulmonary edema,10 significant blood loss, nerve compression,11,12 necrotizing fasciitis,13 and fat embolism14 have all been reported after liposuction. These complications are often difficult to manage in the hospital setting, and would be even more problematic if they were to occur in the office setting or after the patient returns home.
Table 1. Complications Associated with Tumescent Liposuction
Peripheral nerve injury
Local infection; sepsis
Overhydration, leading to:
- pulmonary edema and respiratory distress
- congestive heart failure
- extreme hemodilution
Pulmonary embolism, as a consequence of:
- immobilization (secondary to overhydration and pain)
- venous stasis
- tissue factor activation and thrombogenesis
- fat embolization
Hemorrhage, leading to:
- need for blood transfusion
Intraoperative hypotension, bradycardia, and cardiac arrest *
* "Unexplained" but likely related to local anesthetic cardiotoxicity
As part of our efforts to ensure patient safety, anesthesia personnel must be aware of the potential complications which may accompany tumescent liposuction. More research should be performed to better assess the relationship between large volumes of local anesthetic infusate and local anesthetic toxicity. Care must be exercised when making clinical decisions regarding: the extent of liposuction to be attempted, maximum amounts of local anesthetic permitted, monitoring of fluid requirements and blood loss, and postoperative care. Issues pertaining uniquely to office-based anesthesia must also be addressed, since many of these procedures are performed in an office setting, where monitoring and personnel qualifications are highly variable. We must strive to prevent iatrogenic illness and injury. Prevention begins with awareness.
Dr. Prielipp and Dr. Morell, APSF Newsletter Associate Editor, are from the Department of Anesthesiology, Section on Critical Care, The Wake Forest University School of Medicine, Winston-Salem, North Carolina.
- 1996 National cosmetic surgery statistics. Chicago: American Academy of Cosmetic Surgery, 1997:1-8.
- Dolsky RL. State of the art in liposuction. Dermatol Surg 1997;23:1192-1193.
- Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol Surg 1996;22:921-927.
- Rao RB, Ely SF, Hoffman RS. Deaths related to liposuction. N Engl J Med 1999;340:1471-1475.
- Nancarrow C, Rutten AJ, Runciman WB, et al. Myocardial and cerebral drug concentrations and the mechanisms of death after fatal intravenous doses of lidocaine, bupivacaine, and ropivacaine in the sheep. Anesth Analg 1989;69:276-283.
- Butterworth JF, Brownlow RC, Leith JP, et al. Bupivacaine inhibits cyclic-3’,5’-adenosine monophosphate production. A possible contributing factor to cardiovascular toxicity. Anesthesiology 1993;79:88-95.
- Peat MA, Deyman ME, Crouch DJ, et al. Concentrations of lidocaine and monoethylglycylxylidide (MEGX) in lidocaine associated deaths. J Forensic Sci 1985;30:1048-1057.
- Christie JL. Fatal consequences of local anesthesia: report of 5 cases and a review of the literature. J Forensic Sci 1976;21:671-679.
- Anonymous. From the Centers for Disease Control and Prevention. Rapidly growing mycobacterial infection following liposuction and liposculpture—Caracas, Venezuela, 1996-1998. JAMA 1999;281:504-505.
- Gilliland MD, Coates N. Tumescent liposuction complicated by pulmonary edema. Plast Reconstr Surg 1997;99:215-219.
- Lombardi AS, Quirke TE, Rauscher G. Acute median nerve compression associated with tumescent fluid administration. Plast Reconstr Surg 1998;102:235-237
- Young KB, Commons G, Halperin B. Tumescent liposuction and median nerve compression. Plast Reconstr Surg 1999;103:1533.
- Barillo DJ, Cancio LC, Kim SH, et al. Fatal and near-fatal complications of liposuction. South Med J 1998;91:487-492.
- Fourme T, Vieillard-Baron A, Loubières Y, et al. Anesthesiology 1998;89:782-784.