What is your opinion on using a tumescent anesthesia technique during BBL surgery?

Question

I’ve come across some doctors that do the surgery while the patient is awake. Is this safe? I’ve also read that recovery is quicker with this technique. Is that true?

Dallas Buchanan, MD · Answer

Thank you for your questions. I think you have some confusion here. The term "tumescent" has nothing to do with your state of alertness during the procedure. Tumescent is the term that is used for the infiltration of the fluid used in liposuction and is done whether the patient is awake or asleep. You are referring to the type of anesthesia for the procedure. In my practice, all BBL surgery is done in a real hospital with real anesthesia doctors under a general anesthetic. It is more comfortable for the patients and leads to a better and safer outcome in my opinion. There are some procedures that can be done under sedation safely, but be very careful when getting "sold" this bill of goods. There are some physicians out there who are unable to get privileges to do plastic surgery procedures at a real surgery facility because they do not have the training or experience to achieve that, so they put up shop in their own facility (where they are not allowed to do general anesthesia) and sell all the patients that doing it awake is better. Now this does not apply to all people out there, but make very sure that your surgeon is board certified by the American Board of Plastic Surgery and ask them if you wanted to, could you do the procedure under general anesthesia. If the answer to those questions is no, then you probably are not sitting in the right office, look elsewhere.Hope this helps!Dallas R. Buchanan, MD, FACSOwner & Board-Certified Plastic SurgeonVIVIFY plastic surgery

Nicholas A. Flugstad, MD · Answer

Thanks for posting. Tumescent solution is usually a fluid that is mixed with lidocaine (numbing medicine), and epinephrine (for bleeding control). It is commonly used in most types of liposuction. Depending on the area being treated, it can be adequate enough to give you numbness in the area. There are safety limits to how much lidocaine and how much fluid can be given in this way. Also, I have found that many patients do not get enough long lasting numbness with tumescent solution alone, especially for a good sized BBL. I typically recommend anesthesia for the majority of these cases for maximum safety and comfort. Make sure you are seeing an American Board of Plastic Surgery certified /ASAPs member surgeon.

Mats Hagstrom, MD (license on probation) · Answer

I am one of those few plastic surgeons( board-certified with hospital privileges ) who perform liposuction with or without feta transfer using local anesthesia without general anesthesia.
 Let's first get some terminology out-of-the-way  Tumescent solution is a dilute numbing solution consisting generally have lidocaine IV solution and a drug called epinephrine. This is basically a dilute version of what a dentist would inject to make you numb for a dental procedure.
 If patients are awake it is mandatory to use tumescent solution. If not the procedure would be excruciatingly painful.
 Tumescent solution is generally also used even when general anesthesia is used.
 So referring to a procedure as tumescent anesthesia is not sufficient since this is used whether general anesthesia is used or not.
Tumescent solution minimizes blood loss during the procedure and keep his patients comfortable during the early recovery phase.
 To get the full effect of tumescent solution  The surgeon needs to wait at least 15 minutes after injecting it. It also needs to be injected in a meticulous manner so all areas that are going to be treated are soaked in tumescent solution.
 Any area that is not treated with tumescent solution has the propensity to bleed more during liposuction and fat grafting.
 My experience has been that too many providers do not spend unnecessary amount of time both injecting and waiting for the tumescent solution's affect.
 Operating room time is expensive and keeping patients exposed under General Anastasia longer than necessary is not a good idea.
 I simply don't see my colleagues opening a book and reading for 15 minutes while it's a mess and solution is starting to activate.
 When the proper amount of tumescent solution is injected and it's given enough time to be fully effective  blood loss is kept to an absolute minimum during even high-volume liposuction cases like when 5 L of fat is removed.
 The decrease in bleeding makes for a better recovery, patients have more energy complications are lowered and patients experience less bruising.
 When patients are awake during the procedure they have the ability to communicate with the surgeon during the entire procedure. If an area does not have a proper amount of tumescent solution The patient will tell the provider because they will feel discomfort. This confirms that all areas being treated have an appropriate amounts of tumescent solution.
 Should the surgeon also make a mistake and push the cannula into an area where it does not belong like the chest or abdomen the patient has the ability to tell the doctor  something does not feel right or will show signs of abnormal discomfort.
 This is one more way that keeping the patients awake adds a level of safety to the procedure.
 This same concept of making sure tumescent solution is added properly to all areas being treated on is also true of the buttocks during the fat grafting part of the procedure.
 One of the most serious complications described for a BBL as a fat embolism. It has been described as happening in as many as one and 3000 surgeries.  A fat embolism is often fatal and if not can lead to severe pulmonary problems for long periods of time.
 We don't have science to prove this but I believe the vasoconstrictive properties of tumescent solution dramatically decrease the chance of developing fat embolism's.
 It should be pointed out that full body liposuction with feta transfer procedures like a BBL or substantial procedures that can be uncomfortable if not done correctly.
 Patients will generally need some form of sedation above with the local anesthesia can deliver.
 As well, injecting the tumescent solution even when done with very small cannula's can be uncomfortable to some.
 During my training all liposuction and feta transfer procedures were done using General Anastasia. 
 I had colleagues who were doing these procedures with their patients awake and mentored me in the proper ways of administrating tumescent solution.
 There is a very real learning curve to keeping patients comfortable during these procedures when general anesthesia is not used. 
 It takes several hundred cases of experience before the surgeon gets competent at properly injecting tumescent solution.

As well, the procedures take much longer than when general anesthesia is used.
 Luckily complications like hypothermia and blood clots are significantly decreased when patients are awake.

From my experience and in my hands I believe keeping patients awake for these procedures has advantages that override the disadvantages. For me having the patient  be able to move and hold different anatomic positions multiple times throughout the case gives me access to areas and allows me to truly sculpt during the liposuction part of the procedure. 
 Moving the patients especially moving them several times while under General Anastasia is tedious and has safety implications. It is not particularly popular with the anesthesiologist or the nursing staff.
 This is not to say that this is the best or the right way to perform either liposuction or fat transfer procedures but it is a way that I believe has numerous advantages. For patients who are very sensitive or have high anxiety levels general anesthesia may be a better option.
 I currently perform approximately 400 major liposuction cases per year about 1/3 include fat transfer. The great majority of these cases are done without general anesthesia. 
 Best, 
Mats Hagstrom M.D.

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