SCIENTIFIC
FORUM
Superwet Anesthesia Redefines
Large-Volume Liposuction
Alan Matarasso, MD
Superwet anesthesia is a method of regional anesthesia for liposuction surgery that uses
an evenly distributed, rapidly infused solution under pressure, until tissue blanching and
moderate tension are achieved, in a ratio of 0.5 to 1.5 ml per milliliter of injectate to
lipoaspirate. It is accompanied by systemic anesthesia and supplemented with intravenous hydration. The efficacy of superwet formulation for regional anesthesia was evaluated in a consecutive series of 20 patients who underwent large-volume (>1500 ml)
liposuction. The average volume of injectate was 2285 ml and fat aspirate was 2437.5
mI. The average fluid volume fractionated from the aspirate infranatant was 507.5 ml,
and the amount of injectate absorbed was 1775.5 mi. The mean "pure fat" fractionation
was 1930 mI. Approximately 21 % to 22 % of injected fluid is not absorbed, so the ratio
of fat removed to fluid absorbed by hypodermoclysis is in the range of 1:1.
Consequently, this requires an alteration in traditional fluid replacement levels. This also
alters the threshold of what has been traditionally considered "large" -volume liposuction so that the traditional 1500 ml defining large-volume aspirate may no longer be
applicable. To achieve consistency in reporting, all liposuction data should be standardized to routinely include the volumes of injectate, aspirate, and infranatant fluid fractionation.
U
se of large volumes of dilute local anesthetic with epinephrine has proven an effective
method for reducing blood loss and increasing the volume of fat aspirates in liposuction surgery.1-7 The concept is based on the principle that larger volumes of wetting
solutions injected slowly are less toxic in the same milliliter dosage than in more concentrated
form. Popular formulas call for the infusion of approximately 3 ml of solution per 1 ml of
estimated lipoaspirate until tissue turgor and blanching are achieved. Concentrations of 35
mllkg and up to 55 ml/kg or more of lidocaine have been tolerated, corresponding to (plasma)
serum levels of 0.9 to 3.6 Ilg/ml, peaking 8 to 14 hours after surgery.8-10 This is in contrast to
lidocaine 1 % 5 to 7 mg/kg (1 ml = 10 mg) that have been the "standard," (the Physicians
Desk Reference recommendation is based on procaine). In this technique no systemic anesthetic is administered. Furthermore, as a result of hypodermoclysis, it provides adequate
hydration.
The toxic dose of local anesthetic depends on such factors as the total milligram dosage, the
concentration, and the type of local anesthetic. l l There is a linear correlation between the
injected dose and the plasma concentration of lidocaine. 12 The systemic absorption and serum
358
AESTHETIC
SURGERY
JOURNAL
-
NOVEMBER/DECEMBER
1997
Alan Matarasso is assistant
attending surgeon at Manhattan
Eye, Ear, & Throat Hospital, and
clinical associate professor of
Plastic Surgery at Albert Einstein
College of Medicine, New York, NY.
Accepted for publication Nov. 5,
1997.
Data from this article were presented at the 13th Annual Meeting of
the International Society of
Aesthetic Plastic Surgery, the 29th
Annual Meeting of the American
Society for Aesthetic Plastic
Surgery and the Horizons in
Cosmetic Plastic Surgery
Symposium, La Jolla, CA, January
1997.
Reprint requests: Alan Matarasso,
MD, 1009 Park Ave., New York, NY
10028.
Copyright © 1997 by the American
Society for Aesthetic Plastic
Surgery, Inc.
190-820X/97/$5.00 + 0
70/1/87204
SCIENTIFIC
FORUM
I
SYMPTOMS
Subjective
PLASMA LIDOCAINE LEVELS
• circumoral numbness, tinnitus, drowsiness,
ligbt beadedne.., difficulty focusing
• 3-6!,g1ml
Objective (tremors, twitching, shivering)
• seizures, cardiac depression
• 5-9 !,g/ml
• unconscious, coma
·8-\2 !,g1ml
• respiratory arrest
• 12 - 14 !,g/ml
• cardiac arrest
• 20 !,g1ml
• 26 !,g1ml
Figure 1. Plasma lidocaine levels, correlated with symptoms.
levels of lidocaine are affected by the presence of vasoconstrictors, the site of injection (e.g., vascularity, scarring), the
pH of the solution, possibly the speed of injection, hepatic
function, age of the patient, and the body surface area of the
patient. Factors that have been proposed for the delayed
absorption of lidocaine include the fact that it is relatively
lipid soluble and that fat is known to bind local anesthetic;
the poor vascularity of adipose tissue; the low concentration
of lidocaine in the solution used; the tension created by the
fluid (which increases interstitial pressure and diminishes its
uptake); and alkalization of the solution, which increases the
amount of nonionized lipid-soluble base, causing a more
rapid inflow into the nerve cell and leaving less ionized lidocaine outside available for systemic uptake. 13 -14 In addition,
it has been stated that 10% to 30% of the injected fluid is
removed during liposuction 6 and, hence, is not absorbed.
However, plasma lidocaine levels at less than 11lg/ml can
result in subjective symptoms of toxicity, and excessive levels
can result in cardiac arrest and death (Figure 1).
The advantages of this technique for regional anesthesia during liposuction have been well documented (Figure 2).
Others have suggested disadvantages that include the possibility that toxic levels of lidocaine will be reached after the
patient has left the surgical facility; the potential for fluid
overload causing pulmonary or cardiac decompensation; the
time-consuming nature of the injection (which can leak out
during infiltration); an adjustment in the preoperative estimate of fat volume removal; an alteration in the tactile or
visual end point of liposuction; and inadvertent emptying of
the superficial fat compartment, leading to long-term tissue
laxity. Moreover, remaining fluid can result in persistent
drainage requiring multiple, open-wound sites, the need for
drains, prolonged edema, or repeated seroma formation
Tumescent Anesthesia
Potential Disadvantages
hjgh plasma levels of lidocaine reached after
Tumescent Anesthesia
Potential Advantages
discbarge
high fluid volumes, poteotial pulmonary Icardiac
problems
• . blood Joss
+ injection time
• - bruising
adjuslmenl in SAL endpoint
• + vol. rat removal
? drains
• ? faster recovery
potential seroma formation
• ? less pain
? prolonged edema
• ? no sedation or anesthesiologist
open wounds
• ? immediate discbarge
? prolonged drainage
Figure 2. Reported advantages and disadvantages of tumescent technique.
Superwet Anesthesia Redefines Large· Volume
Liposuction
AESTHETIC
SURGERY
JOURNAL
-
NOVEMBER / DECEMBER
1997
359
SCIENTIFIC
FORUM
Table
Series of 20 consecutive patients
Sites
Case
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Abdomen, inner thighs, neck
Arms, abdomen, circumferential thighs, KCA
Bll
BLl, knees, calves
2" abdomen, 2" chest, flanks
Bll, arms
Bll, knees
Bll, knees, calves, neck
Bll, knees
Neck, arms, abdomen, Bll, knees
Bll
Abdomen
Abdomen
Bll
Anterior thighs, knees, Bll
Abdomen
Arms, axilla, abdomen, knees, Bll
Bll
Abdomen
Abdomen, flanks
Injeetate (ee)
Aspirate (ee)
Fractionation (ce)
2700
3000
1500
2000
2500
2500
2000
2000
1700
3800
2000
2000
1800
1800
1700
1900
3800
2000
3000
2000
5000
4400
1700
1500
3000
2600
1500
1600
1650
3500
1950
1900
1600
2425
1525
1650
3150
2300
3600
2200
800
800
300
300
500
550
400
400
250
650
400
550
400
375
600
600
650
325
800
500
KCA, knees, calves, ankles; BL T, buttocks, love handles, thighs; 2 ", secondary.
The fractionation represents the fluid that settled in the infranatant over the first hour.
(Figure 2).15,16 Some may consider the absence of an anesthesiologist or early discharge of patients to be imprudent.
calves, and ankles, with several patients having multiple
treatment sites.
The purpose of this study was to review my experience
with superwet 17,18 anesthesia in patients exceeding the traditionallarge-volume (>1500 ml) suction-assisted lipectomy
(SAL) level and to determine the change in typicalliposuction volumes as a consequence of these methods.
Patients were prepared for surgery by use of reported protocols, including appropriate laboratory data, adequate
hydration, and antimicrobial washing. When possible they
were marked in a standing position, before being medicated, in front of a three-way mirror to verify the treatment
sites. Intravenous hydration and sedation (by use of
Propofol®, Fentanyl®, and Versed®) was monitored by an
anesthesiologist. All patients received antibiotics and
steroids. The site for introducing the superwet solution
(and later the cannula) was injected with lidocaine 1 % and
epinephrine 1:1000. "Stab-wound" incisions were well-hidden and were subsequently closed with sutures.
Patients and Methods
A consecutive series of 25 patients undergoing liposuction,
treated by the author, were selected for review. Twenty of
those with volumes exceeding 1500 ml were included in this
series (Table). To determine the merits of the anesthetic
method alone, variables such as superficial suction lipectomy, syringe liposuction, ultrasound-assisted liposuction, or
combined SAL and open procedures were not included in
this series. Sixteen patients were women, four were men,
with an age range of 19 to 66 years of age. Most procedures
were performed on an ambulatory basis. Various sites were
treated, including neck, arms, abdomen, back, thighs, knees,
360
AESTHETIC
SURGERY
JOURNAL
-
A wetting solution of local anesthesia fluid (Figure 3) containing injectate 0.5 to 1.5 ml per estimated milliliter of aspirate was infused . The injection consisted of Ringer's lactate
solution 1 L, lidocaine 1 % 25 to 50 ml (depending on systemic anesthesia and total volume required) and epinephrine
1:10001 m!. Injection was done with a 14 to 16 gauge mul-
NOVEMBER/DECEMBER
1997
Volume 17, Number 6
SCIENTIFIC
FORUM
Superwet Anesthesia
Superwet Anesthesia
R.L.
IL
Lidocaine (1%)
25-50cc
Epinephrine (1:1000)
Icc
=
.05% Lidocaine
IDigIrt
Volume of l.ocal Anestbesia (35 mg/kg)
35 L
50 kg
1:1,000,000 Epinephrine
70 kg
5 L
100 kg
7 L
B
A
Figure 3. A, The superwet fo rmula for regional anesthesia in suction·assisted lipectomy. B, With the above formula, the volume of injectate fluid (in
liters) and milliliters of lidocaine (50 milL) that can be used without exceeding 35 mg/kg of lidocaine.
tiport, reusable injection needle under high pressure (300
mm Hg) at a rapid infusion rate of 200 to 300 mVmin.
sage and ultrasound treatments were recommended,
although their efficacy has not been clearly established.
After infiltration of local anesthesia, a sufficient time interval
was allowed for diffusion of the anesthetic. In circumstances
necessitating alterations in position, the anesthetic was
injected with the patient in the supine position; the patient
was then turned to the prone position and injected, and suction was commenced. Before the patient was returned to the
supine position, intravenous sedation was diminished, the
patient was assisted in repositioning when possible, and sucrioning was continued. A variety of multilumen cannulae
and a vacuum machine were used.
ResuHs
After surgery patients were placed in snug-fitting elastic compression binders. In patients with poor skin tone, the skin
was taped, and Reston® foam was occasionally used. 20
Patients were observed in the recovery room until their conditions were stable for discharge. All patients but one were
in American Society of Anesthesiologists Physical Status I.
They telephoned on reaching their discharge destination; the
staff called them that night and the next day; and they were
seen at 48 hours by the staff. Postoperative lymphatic mas-
The average volume of fluid injected was 2285 ml (range
1500 to 3800 ml), and the average volume of fat aspirated
was 2437.5 ml (range 1500 to 5000 ml). The average fluid
volume fractionated from the aspirate infranatant was 507.5
ml (range 250 to 800 ml), and the amount of injectate
absorbed was 1775.5 ml (2285 - 507.5 ml). The "pure fat"
fractionation was 1930 ml (2437.5 - 507.5 ml).
Approximately 21 % to 22 % of injected fluid is not absorbed
(507.5 ml, although a portion of the infranatant is blood).
Consequently, the ratio of fat removed to fluid absorbed by
hypodermoclysis approached 1; 1. The aspirate was fractionated by allowing it to settle undisturbed for a minimum of
15 minutes (Figure 4).
All patients reported being definitely satisfied or satisfied
with the results of surgery. One patient had mild, persistent
edema in the inner thi~hs that responded to lymphatic massage, diuretics, elevation, and time. One patient requested a
revision of the inner thigh-knee area.
SUPER WET ANESTHESIA
SUPERWET ANESTHESIA
2285 cc
Fat-aspirate
Fluid Fraction
2437.5 cc
507.5 cc
Fluid Absorbed
"Puce" - Fat
% FlujdNo\
Ahs.orllliI
1775 .5cc
1930 cc
n = 20
21-22%
n = 20
B
A
Figure 4. A, Average injectate, aspirate, altd fluid fractionates. B, Th e net (pure) fat and amount of in;ectate not absorbed. This is useful for deter·
mining additional patient fluid requirements.
Superwet Anesthesia Redefines Large· Volume
Liposuction
AESTHETIC
SURGERY
JOURNAL
-
NOYEMBER/DECEMBER
1997
361
SCIENTIFIC
FORUM
Discussion
Superwet anesthesia seems to have many of the same advantages that have been reported with tumescent anesthesia,
that is, less blood loss and bruising, the possibility of larger
volumes of fat removal, analgesia, hydration, and patient
cooperation, although a lower total milligram dosage of
lidocaine and volume of fluid are used. Drains or extra
drainage incisions are not required, and persistent edema
and seromas seem less common. The amount of injectate
was based on an estimate of fat aspiration, body surface
area, number and vascularity of sites being injected (or presence of scars), and the achievement of skin blanching and
moderate tension.
With these methods and waiting for tissue blanching and
moderate tension after injection, the traditional tactile and
visual end points of liposuction evaluation are maintained,
potentially avoiding subsequent contour problems.
Furthermore, the subcutaneous fat compartment is less likely
to be inadvertently overemptied (Figure 5).
Lidocaine
Because lidocaine toxicity can mimic certain postoperative
signs and symptoms (e.g., light-headedness, shivering,
euphoria, drowsiness), achieving similar aesthetic results
with lower doses is advantageous. Repeated experience with
lidocaine doses of 35 mg/kg have proven that it is safe and
efficacious, in spite of correspondence to plasma lidocaine
levels of 0.9 Ilg/ml. However, exceeding these levels clearly
places a patient in the plasma range where objective lidocaine toxicity is possible. Furthermore, it has not been
shown to be of any additional benefit,21 and rapid infusion
of the solution can be expected to be safer at lower doses.
Figure 5. A and B, Front preoperative and postoperative views of a
21-year-old woman who had liposuction of the arms, anterior thighs,
lateral and medial thighs, and calves. C and D, Posterior preoperative
and postoperative view of the same patient. The fractionals are: 4000
ml were infused, 4350 ml were aspirated. The infranatant contained
800 ml fluid.
No cases of systemic fluid, lidocaine, or anesthetic complications were reported. Aspirates tended to accumulate more
blood as surgery reached its end point. Blood hemoglobin
and lipocrit levels were not measured. Patients were not
typed and cross-matched for blood, and no patients required
blood transfusions.
362
A EST H E TIC
5 U R G E R Y
J
0 URN A L
-
Nov E M B E
RID
Lidocaine concentrations varied from 25 to 50 milL injectate. Even with general anesthesia, lidocaine is added
because it has been postulated that with it there is a faster
sensory return and some postoperative analgesia may occur
with its use.
Fat Removal
With this technique a larger amount of fat can theoretically
be removed with similar doses of local anesthetic than are
recommended with tumescent anesthesia, without altering
injectatelaspirate ratios, as would be required with increasing volumes of fat removal in the tumescent procedure. For
example, use of tumescence in a 70 kg person to suction 5 L
of fat, 15 L of injectate are recommended, which far exceeds
35 mg/kg of lidocaine. Looking at this another way, to continue to follow the 3:1 tumescent rule, 5 L would be injected
and 1666 ml of fat could be suctioned. With the superwet
method, 5 L would be injected and removed. Thus an alter-
E C E M B E R
1 9 9 7
Volume 17, Number 6
SCIENTIFIC
ation in injectate volumes with increasing fat volumes is not
required, as with tumescent anesthesia.
In accumulating this series of patients (n = 20) with more
than 1500 ml of suction lipectomy, 25 patients were treated;
five patients from the consecutive group were excluded
because they did not meet study criteria. This implies that
the average volumes that are being suctioned tend to be larger than in previous reports and that the traditional level of
1500 ml no longer defines large-volume aspirate. Common
liposuction volumes may exceed this.
Fluids
The combination of fluid absorption resulting from hypodermoclysis and aspirates that are less bloody necessitates an
adjustment in hydration levels. Our results indicate that
patients absorb approximately 1 ml of the injectate fluid per
milliliter of fat aspirate. Twenty percent of the injectate is
not absorbed, because it is removed by SAL. Therefore fluid
replacement is necessary to supplement the injectate, so that
the total intake of injected, intravenous, and postoperative
fluid is 2 to 3 ml/ml of aspirate over the course of the first
day of surgery. This is adjusted according to clinical parameters. If objective data are necessary, a urine output of 1 to 2
mllkg/hr would be the goal. Anesthesiologists familiar with
the old "rule" of replacing 3:1 intravenously should be alerted to this alteration in fluid requirements. A small portion of
the infranatant typically represents blood. For example, in
1000 ml of aspirate, 200 ml of injectate might be suctioned
out, and 10 to 100 ml or less (1 % to 10%) of the total
(1000 ml) might be blood.
Solution of the total (1000 ml)
Normal saline solution (sodium = 154 mEq, pH 5) or
Ringer's lactate solution (sodium = 130 mEq, pH 6.5) can be
used. The addition of bicarbonate (10 ml of 8.4%) to alkalinize the fluid is advised when normal saline solution is used. 22
This is advantageous in diminishing the pain of injection and
also because it leaves less ionized lidocaine outside the cell for
uptake. 23 However, altering the pH of the solution has the
potential for changing the effectiveness of the epinephrine.
Warmed and room-temperature injectate have been used.
Epinephrine
Not exceeding epinephrine doses of 0.07 mg/kg is recommended, although doses as high as 10 mg (of 1:1000) have
been safely used. With the superwet formula, 0.07 is approximately the dose patients will receive (e.g., a 70 kg person
receiving 5 L of superwet injectate with 1 ml of epinephrine
per liter will receive 4.9 ml of epinephrine.)
In spite of the fact that the minimal effective concentration
Superwet Anesthesia Redefines Large· Volume
Liposuction
AESTHETiC
FORUM
of epinephrine is reported to be 1:800,000, the less concentrated doses that are being used (1:1,000,000) are still effective as evidenced by blanching and reduced blood loss-this
is due to a longer waiting period and possibly an increased
interstitial compressive effect of the fluid. With this technique, the onset of action (normally approximately 8 minutes with peak serum concentrations at 30 to 60 minutes) is
delayed to 15 to 20 minutes, with peak serum levels occurring 8 to 14 hours after infusion. 24 Consequently, the beginning of surgery is delayed waiting for the epinephrine to take
effect.
In this study lipocrit and hematocrit levels were not
obtained. Previous reports confirm aspirates with levels in a
1 % to 10% range and hematocrit drops in the range of 2%
t04%.
Local/Systemic Anesthesia
It should be emphasized that comparing different wetting
techniques is not a comparison of "general" anesthesia with
"local" anesthesia. Systemic anesthesia is not necessarily the
germane issue; however, the combination of superwet local
anesthesia and intravenous sedation can be expected to
reduce the requirements of either alone. Furthermore, in
spite of the development of rapid injection systems, the discomfort encountered with the injection of local anesthesia
often limits the speed of injection. Systemic anesthesia is useful in countering this and in maintaining comfort in areas
such as the upper abdomen, costal margins, medial thighs,
mons pubis, or scarred areas, which have a tendency to be
more difficult to anesthetize and require higher concentrations of local anesthetic for adequate analgesia. An essential
component to the instillation of the local anesthetic solution
is its even distribution in the adipose tissue.
Before using any large volume local anesthesia technique, the
surgeon should be thoroughly familiar with the pharmacokinetics of lidocaine and epinephrine used in this fashion.
Continual awareness of the injection volume/patient weight
correlation and its relation to plasma lidocaine levels must
be noted.
other Areas
Superwet anesthesia has been used to perform surgery in
other areas where hydro dissection, hypodermoclysis, and
reduced blood loss would also be advantageous. In spite of
the obvious advantages, I would caution the routine extrapolation of any high-volume local anesthetic techniques to
other areas. The safety and efficacy of high-volume wetting
techniques is dependent on the poor vascularity and binding
of lidocaine by adipose tissue, and the spongelike uptake of
the fluid by adipocytes. (Other tissues may not do this and
SURGERY
JOURNAL
-
NOVEMBER/DECEMBER
1997
363
SCIENTIFIC
indeed may be more vascular.) These factors result in
delayed absorption of the fluid. Indeed, pathologic examination of fat cells containing increasing amounts of injectate
reveal a proportionate expansion in cell size. Also, with liposuction surgery, unlike other procedures, a portion of the
injectate will be removed. Moreover, patients generally
require more fluid replenishment after liposuction than after
other procedures.
Conclusion
The introduction of wetting solutions with high volumes of
fluid and pH-adjusted lidocaine and epinephrine has been
suggested by a number of surgeons and is a concept based on
a spectrum of formulas (AA Mottura, in conversation,
1995).25.33 Superwet anesthesia uses an evenly distributed,
rapidly infused, anesthetic fluid, under pressure, in a consistent ratio of 0.5 to 1.5 ml per milliliter of aspirate, until tissue blanching and moderate tension are achieved. It is used
in conjunction with systemic anesthesia. The ratio of subcutaneous fluid replacement to fat aspirate is in the order of
1:1 and is therefore supplemented with intravenous and oral
hydration to achieve 2 to 3 ml of fluid per milliliter of aspirate during the first 24 hours.
FORUM
9. Samdal F, Amland PF, Bugge JF. Plasma lidocaine levels during suctionassisted lipectomy using large doses of dilute lidocaine with epinephrine. Plast Reconstr Surg 1994;93:1217-23.
10. Samdal F, Amland PF, Bugge JF. Blood loss during liposuction using the
tumescent technique. AesthetiC Plast Surg 1994;18:157.
11. Scott DB, Jebson P Jr, Braid DP, Ortengren B. Factors affecting plasma
lidocaine levels of lignocaine and prilocaine . Br J Anesth
1972;44:1040.
12. Nattel S, Rinkenberger RL, Lehrman LL, Zipes DP . Therapeutic blood
lidocaine concentrations after local anesthesia for cardiac electrophysi·
ologic studies. N Engl J Med 1979;301:418.
13. Di Falco CA, Carron H, Grosslight KR, Moscicki JC, Bolding WR, Johns
RA. Comparison of pH-adjusted lidoc ai ne solutions for epidural anesthesia. Anesth Anal 1986;65:760.
14. Ritchie JM, Ritchie B, Greengard P. The effect of the nerve sheath on
the action of local anesthetics. J Pharmacol Exp Ther 1965;150:160.
15. Gilliland M. liposuction using the tumescent technique. Aesth Surg
News 1994;24:424.
16. Pitman GH. Tumescent technique for local anesthesia improves safety
in large-volume liposuction. J Plast Reconstr Surg 1993;92 :109.
17. Pitman GH, Grazer FM , Lockwood , TE, et al. Liposuction: problems and
techniques. Perspect Plast Surg 1993;7:73-119.
18. Hunstad JP. The tumescent technique: an evolution. Lipo News
.1994;11:1.
19. Hunstad JP. Tumescent and syringe liposculpture: a logical partnership.
Aesthet Plast Surg 1995;19:321.
20. Matarasso A. Superficial suction lipectomy: something old, something
new, something borrowed ... Ann Plast Surg 1995;34:268.
This report documents typical liposuction aspirates with a
standardized superwet solution. A new threshold of "large"
volume liposuction is also defined. This technique requires
an alteration in our reporting methods. I believe that all Ii posuction reports should be standardized to routinely include
the volume of injectate and aspirate and the fractionation of
aspirate (fluid vs fat). _
21. Knize 0 , Pepper G. Does the tumescent technique require tumescence?
Aesthet Surg Q 1996;16:1:59.
References
25. Matthews WA, Grazer FM. Lipoplasty (panel). Presented at the annual
meeting ofthe American Society of Plastic and Reconstructive
Surgeons. October 30-November 4,1983; Dallas, TX.
1. Coleman WP , Klein JA. Use ofthe tumescent technique for scalp
surgery , dermabrasion, and soft tissue reconstruction. J Dermatol Surg
OncoI1992 ;18:130.
22. McKay W, Morris R, Mushleina P. Sodium bicarbonate attenuates pain
on skin infiltration with lidocaine, with or without epinephrine. Anesth
Anal 1987;66:572.
23. Stewart JH, Cole GW, Klein lA. Neutralized lidocaine with epinephrine
for local anesthesia. J Dermatol Surg Oncol 1989;15:1081.
24. Burk RW III. Large doses of lidocaine, epinephrine and fluids in abdomi·
nal liposuction. Oper Tech Plast Surg 1996;3:35.
26. Lewis eM , Hepper T. The use of high·dose lidocaine in wetting solutions
for lipoplasty. Ann Plast Surg 1989;22:307 .
2. Klein JA . The tumescent technique for liposuction surgery. Am J Cosmet
Surg 1987;4:263.
27 . Mottura AA. Cirugia estetica ambulatoria: drogas usadas en anestesia
local. Cir Plast Iber Lat in 1992;46:224.
3. Lillis PJ. liposuction surgery under local anesthesia, limited blood loss,
28. Replogle SL. Experience with tumescent technique in lipoplasty. Aesth
Plast Surg 1993;17:205.
and minimal lidocaine absorption . J Dermatol Surg Oncol
1988;14:1145.
4. Klein JA. Anesthesia for liposuction in dermatologic surgery. J Dermatol
Surg Oncol 1988;14:1124.
5. Klein lA. The tumescent technique: anesthesia and modified liposuction
technique. Dermatol Clin 1990;8:425.
6. Klein JA . Tumescent technique for regional anesthesia permits lidocaine doses of 35mg/ kg for liposuct ion. J Dermatol Surg Oncol
1990;16:248.
29. Mottura AA. Tumescent techniques for liposuction [Letter]. Plast
Reconstr Surg 1994;94:1096.
30. Ersek R. Liposuction using the "super·wet" technique. Aesthet Surg
News 1994;25:166.
31. Fodor PB. Wetting solutions in aspirative lipoplasty: a plea for safety in
liposuction (editorial) . Aesth Plast Surg 1995;19:379.
7. Klein JA. Ethics of promoting patient safety and comity among surgical
specialties. Plast Reconstr Surg 1995;95:603.
32. Fodor PB , DiSpaltro F, Rohrich RJ , Welch JD, Hunstad JP, Matarasso A,
Samdal F. Lipoplasty update (panel) . Presented at the 29th Annual
Meeting of the American Society for AesthetiC Plastic Surgery; May 2,
1996; Orlando, FL.
8. Klein JA. Tumescent technique for local anesthesia improves safety in
large-volume liposuction. Plast Reconstr Surg 1994;92:1085-98.
33. Fodor PB, Rohrich RJ. The role of subcutaneous infiltration in suctionassisted lipoplasty: a review. Plast Reconstruct Surg 1997;99:514.
364
AESTHETIC
SURGERY
JOURNAL
-
NOVEMBERIDECEMBER
1997
Volume 17, Number 6