Plastic & Reconstructive Surgery

Date Published: 
June 2004

Plastic and Reconstructive Surgery®

Note: unedited version of the letter accepted for publication June 21, 2004.

Inaccuracies and Omissions with the Report of the ASPS Committee on Patient Safety Practice Advisory on Liposuction.

While one must congratulate the authors’ recent publication of the practice advisory on liposuction (1), their assertion that "this practice advisory reflects the state of knowledge current at the time of publication" cannot go unchallenged.

"General anesthesia (without level of consciousness monitoring, my italics) is particularly suitable for complex or long operations and may provide a greater margin of safety than other routes of anesthesia because the anesthetic dose is more precise” and “During general anesthesia, the patient is comfortably asleep, allowing the surgeon to focus full attention on the procedure without the distraction of inadvertent patient movement” and “General anesthesia also decreases the risk of intra-operative airway obstruction, aspiration and intra-operative laryngospasm" are contentions supported by a single reference with general anesthesia only (2) and ignores other recent pertinent sedation references (3,4).

Also, the liposuction practice advisory was submitted for publication on May 15, 2003 while an article by Wender (5) was submitted May 21, 2003. Wender's article concluded that using either a bispectral (BIS) or auditory evoked potential index monitor expedited discharge from recovery by an hour. Although Wender was part of the advisory panel and well aware of the role of level of consciousness monitoring, nowhere in the liposuction practice advisory is a single suggestion that level of consciousness monitoring might play a significant role in improving the accuracy and safety of anesthesia administration for liposuction patients. A possible explanation for this inaccuracy may lie in the admitted bias of another panel member (Apfelbaum), who, despite more than a decade and over 1,300 papers and abstracts (6) attesting to the validity and utility of the BIS, dismisses level of consciousness monitoring as "technology in evolution" because the algorithm is different in the Baxter Physiometrix A4000 from the Aspect BIS.

The discussion about the signs and symptoms of lidocaine toxicity fails to note that these will only be observed when the patient is minimally sedated and totally obscured by general anesthesia, apparently favored by the panel. On my one case of lidocaine toxicity, while the propofol was progressively titrated to zero, the BIS monitor tended down toward zero. Only after intubating the airway, did the EKG complex widen and the blood pressure begin to fall. In this case, the BIS was 'the canary in the coal mine,' warning of impending disaster in time to avert it.

The price the patient may pay for the complete immobility of general or epidural anesthesia is the pooling of blood in both the leg and pelvic veins, predisposing to pulmonary embolic phenomena. Sequential compression stockings will only deal with the leg veins, leaving the pelvic veins as a possible source of emboli. Conversely, a minimally invasive anesthesia®(7) preserves the normal functioning of the leg muscles, reducing the likelihood of embolic phenomena. The fact that liposuction is performed extra-peritoneally, extra-thoracicly and extra-cranially defines it as a minimally invasive surgery. It is disingenuous to suggest that liposuction is not for the treatment of obesity while describing the means to safely extract more than 5,000 ccs per operative visit.

As to the many omissions, it was unfaithful to the history of the literature to merely cite Klein's 1993 paper published in this journal while failing to cite his 1990 paper (in the dermatologic literature) when giving the 35 mg/kg lidocaine as a safe dose (8) in addition to the omission of Ostad's reference (again in the dermatologic literature) for the 55 mg/kg lidocaine dose (9). Also omitted was proper credit to Klein for the wetting solution formula of 1000 cc Lactated Ringers (or NSS) + 500 mg lidocaine + 1 mg epinephrine, used in both his tumescent approach as well as the super wet technique. Another egregious omission was the failure to include the contribution to patient anesthesia safety advanced by Vinnik (10, 11), a founding member of the AAAAPSF (now AAAASF) and a regular biannual lecturer at both the plastic and aesthetic meetings for more than two decades.

I found it uncomfortable that the panel had no difficulty including anesthesiologists, nurse anesthetists under physician supervision or "another qualified health care provider (presumably any R.N., my italics) under the supervision of a qualified physician (presumably the plastic surgeon, again my italics) as required by law" as acceptable anesthesia providers while totally excluding any mention of the safe liposuction experience of many ENT and dermatologic surgeons. I vividly recall, on more than one
occasion, the words of the late Frederick Martel Grazer, M.D., when asked what he thought of Klein's solution for liposuction, as "what could a dermatologist possibly know
about surgery?" (12) The 'turf' war over who 'owns' the right to perform liposuction surgery was lost over a decade ago. Continuing to deny (or at least insinuate that only plastic surgeons can safely perform liposuction) the ENT and dermatologic surgeons' liposuction practice does not enhance the credibility of the plastic surgical community.

Lastly is the suggestion that patient safety will be improved or at least protected by having liposuction performed in an accredited facility. According to a recent editorial (13), there are an estimated 50,000 office-based surgery practices (where the majority of liposuction is presumedly being performed) in the United States. Of the 1,337 accredited ones, 937 are accredited by the AAAASF, 300 by AAAHC and 103 by JCAHO. If accreditation were the answer to patient safety, why have we not seen an epidemic of liposuction deaths in the newspapers and television? Perhaps because liposuction may be safer when less than 5,000 cc are aspirated. Ever fearful of criticism, the ENT and dermatologic surgeons with whom I have worked seem less often inclined to surpass this limit than the plastic surgery community.

Yours for better ( & reproducible) outcomes,

Barry L. Friedberg, MD
3535 E. Coast Hwy., PMB 103
Corona del Mar, CA 92625

Volunteer Instructor in Clinical Anesthesia
University of Southern California
Los Angeles, CA

Tel. 949-233-8845
FAX 949-760-9444
email drfriedberg@drfriedberg.com


1. Iverson, R.E., Lynch, D.J., and the ASPS Committee on Patient Safety. Practice advisory on liposuction. Plast Reconstr Surg 100:1478, 2004.

2. Hoefflin, S.M., Bornstein, J.B., Gordon, M. General anesthesia in an office-based plastic surgical facility: a report on more than 23,000 consecutive office-based procedures under general anesthesia with no significant anesthesia complications. Plast Reconstr Surg 107: 243, 2001

3. Friedberg, B.L. The Effect of a Dissociative Dose of Ketamine on the Bispectral (BIS) Index during Propofol Hypnosis. J Clin Anesth 11: 4, 1999.

4. Friedberg, B.L., Sigl, J.C. Clonidine premedication decreases propofol consumption during bispectral (BIS)index monitored propofol-ketamine technique for office based surgery. Dermatol Surg 26:848, 2000.

5. White, P.F., Hong, M., Tang, J., Wender, R.H., et. al. Does the use of electroencephalographic bispectral index or auditory evoked potential index monitoring facilitate recovery after desflurane anesthesia in the ambulatory setting? Anesthesiol 100: 811, 2004.

6.www.aspectms.com'education & resources' page, bibliographies 1991-2004.

7. Friedberg, B.L. Minimally invasive anesthesia® for minimally invasive surgery. Outpatient Surgery Magazine. Herrin Publishing Partners LP, Paoli, PA. 2:57, 2004

8. Klein, J.A. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Oncol 16: 248, 1990.

9. Ostad, A., Kageyama, N., Moy, R. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol Surg 22:921, 1996.

10. Vinnik, C.A. An intravenous dissociation technique for outpatient plastic surgery: tranquility in the office surgical facility. Plast Reconstr Surg 67: 199, 1981.

11. Vinnik C.A. Dissociative anesthesia in ambulatory plastic surgery: a ten year experience. Aesth Plast Surg 9: 255, 1985.

12. Grazer, F. M. Personal communication 1985.

13. O’Connor, D. The trouble with office surgery. Outpatient Surgery Magazine. Herrin Publishing Partners LP, Paoli, PA. 3: 6, 2004.

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