Plastic & Reconstructive Surgery

Date Published: 
June 2005

Plastic and Reconstructive Surgery


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 “[d]uring 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 “[g]eneral anesthesia also decreases the risk of intraoperative airway obstruction, aspiration, and intraoperative laryngospasm” are contentions supported by a single reference with general anesthesia only2 and ignore other recent, pertinent sedation references 3,4.

Also, the liposuction practice advisory was submitted for publication on May 15, 2003, while an article by White, et al.5 was submitted on May 12, 2003. The article by White, et al. concludes that using either a bispectral or auditory evoked potential index monitor expedited discharge from recovery by an hour. Although Wender, a co-author of the White et al. article, was part of the advisory panel and was well aware of the role of level of consciousness monitoring, nowhere in the liposuction practice advisory is there 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.

The discussion about the signs and symptions 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. In my one case of lidocaine toxicity, while the propofol was progressively titrated to zero, the bispectral monitor tended down toward zero. Only after the airway was intubated did the electrocardiogram complex widen and the blood pressure begin to fall. In this case, the bispectral monitor was the canary in the coal mine, warning of impending disaster in time to avert it.

The price of patient may pay for the complete immobility of general of epidural anesthesia is the pooling of blood in both the leg and pelvic veins, which predisposes the patient to pulmonary embolic phenomena. Sequential compression stockings will deal only with the leg veins, leaving the pelvic veins as a possible source of emboli. Conversely, minimally invasive anesthesia6,7 preserves the normal functioning of the leg muscles, thereby reducing the likelihood of embolic phenomena. The fact that liposuction is performed extraperitoneally, extrathoracicly, and extracranially defines it as a minimally invasive surgery. It is disingenouous to suggest that liposuction is not for the treatment of obesity while describing the means to safely extract more than 5000 cc per operative visit.

As to the many omissions, it was unfaithful to the history of the literature to merely cite Klien’s 1993 article published in this Journal while failing to cite his 1990 article (in the dematologic literature) when giving the 35-mg/kg lidocaine dose as a safe dose,8 in addition to the omission of Ostad’s reference (again in the derrmatologic literature) for the 55-mg/kg lidocaine dose.9 Also omitted was proper credit the Klein for the wetting solution formula of 1000 cc of lactated ringers (or normal saline solution) plus 500 mg of lidocaine proach and 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 American Association for Accreditation of Ambulatory Plastic Surgery Facilities (now the America Association for Accreditation of Ambulatory Surgery Facilities) 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 anesthesists under physician supervision, and “another qualified health care provider (presumable 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 nonplastic surgeons. Continuing to imply that only plastic surgeon can safely perform liposuction and to disregard the liposuction practices of ear, nose, and throat and dematologic surgeons does not enchance the credibility of the plastic surgical community.

Last is the suggestions that patient safety will be improved or at least protected by having liposuction performed in an accredited facility, According to a recent editorial,12 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 accredited ones, 937 are accredited by the American Association for Accreditation of Ambulatory Surgery Facilities, 300 by the Accreditation Association for Ambulatory Health Care, and 103 by the Joint Commission on Accreditation of Healthcare Organizations. If accreditation were the answer to patient safety, why have we not seen an epidemic of liposuction deaths in the newspapers and televisions? Perhaps because liposuction may be safer when less than 5000 cc is aspirated. DOI:10.1097/01.PRS0000165165.19093.96

Regarding Aspect Medical Systems, Inc., the manufacturer of the bispectral index monitor, I have no financial interest in the company. I am neither a paid consultant nor a member of their board of trustees, nor do I receive any monies from the company for services provided. My opinions are based solely on my professional, published experience of nearly 7 years with this product.



1. Iverson, R. E., Lynch, D. J., and the ASPS Committee on Patient Safety. Practice advisory on liposuction. Plast. Reconstr. Surg. 113: 1478, 2004.
2. Hoefflin, S. M., Bornstein, J. B., and 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 Reconst. Surg. 107:243, 2001.
3. Friedberg, B. I., The effect of a dissociative dose of ktamine on the bispectral (BIS) index during propofol hypnosis. J. Clin. Anesth. 11:4, 1999
4. Friedberg, B. I.,and 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.Ma. H. Tang, J., Wender, R. H., Sloninsky, A., and Kariger, R. Does the use of electroencephalographic bispectral index or auditory evoked potential index monitoring facilitate recovery after desflurane anesthesia in the ambulatory setting? Anesthesiology 100:811, 2004
6. Aspect Medical Systems. Bibliographies 1991 – 2004 Available at http://www.aspectms.com/resources/bibliographies/default.mspx.
7. Friedberg, B. L. Minimally invasive anesthesia® for minimally invasive surgery. Outpatient Surgery Magazine February 2004, p. 57
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., and 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. Reconst. Surg. 67: 1999, 1981
11. Vinnik, C. A. Dissociative anesthesia in ambulatory plastic surgery: A ten year experience, Aesthetic Plast. Surg. 9: 255, 1985
12. O' Connor, D. The trouble with office surgery. Outpatient Surgery Magazine, March 2006, p. 6

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