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68
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M. Jugenburg and W. Jalil
Our modications: increased epinephrine content
(2g/L); we have not seen any deleterious effects on
intraoperative or postoperative vitals, or rebound
bleeding or ecchymoses
Addition of tranexamic acid (TXA): IV, PO, or in
tumescent solution
• Liposuction technique
– SAFELipo
Using one to three exploded baskets cannula
• 5mm for average patients
• 3mm for thinner patients (BMI under 23), with
thin layer of subcutaneous fat
– VASER
Using 80% continuous setting with 3.7 mm tworing probe
Using 80% continuous setting with 3mm three- to
ve-ring probe in thinner patients
Following 1m per 100cc of tumescent rule or until
area shows minimal resistance
– Separation
Initial fat pretreatment with basket cannula PAL or
VASER
– Aspiration
40mm Hg setting
Handling of tissue
• Pinch versus at surface pressure
Always be aware of the tip
Always be aware of the underlying anatomy
Goal is to leave a good amount of fat behind to minimize contour deformities
– Equalization.
After liposuction we go through all areas with the
same basket cannula used for separation to help
break up any residual fat collections, followed by
manual massage
• Manual massage gives tactile feedback on the
presence, size, and consistency of the residual
fat collections and guides the massage to break
up these collections
• Pinching and stretching, and milking the fat collections are effective in producing smoother
results
– Drains
We have started to use drains when liposuction is
more aggressive (when more than 50% of fat
removed from the target area)
Drains last until <20cc/day is produced, which usually represents 10–14days
• When energy devices used, this timeline is
prolonged
One drain in the lower abdominal areas is used
We nd that when patients are able to start their
massage earlier, they seem to produce more serous
discharge
• Theory is that while massage is great for fat
equalization and thus to minimize brosis, it disrupts interstitial healing thus enhancing serous
uid collection
– Postoperative care
Immediate
• Compression garments
• Silicone sheaths for padding
• Focused pressure points for HiDef
First week.
• Patient instructed to remove garment several
times a day, massage out any contour issues, and
ensure the garment itself is not deformed
• Patient instructed to gently touch/massage liposuction areas, and perform sensitization
exercises
– Some surgeons get their patients to massage
from Day 1; in our practice, we found it difcult for patients to cooperate.
• At the end of the rst week, patient returns for
follow-up.
– Incision site sutures removed except the one
by the drain.
– Introductory liposuction massage session
takes place.
After rst week.
• Patient instructed to self-massage several times a
day for the rst 2–4 months.
• Weekly massage sessions with our registered
massage therapist (RMT) for the rst 1–2 months
or as needed.
Compression garment.
• The use of the garment varies.
– In patients unable to follow garment care
instructions, the garment is removed; the benet of compression is outweighed by the risk
of contour deformities from inappropriate
garment wear and positioning.
– Some patients chose to get a Faja.
Patients who take great care of their body through
regular massages, or proper Faja garment wear tend
to have better results—less brosis, better shape.
4 Liposuction: Principles andTechniques
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69
• Our hypothesis is that after the liposuction, after
the fat equalization step, the subcutaneous fat is
malleable and can be distorted.
– Inappropriate use of compression garments.
Folds create indents.
Not rotating it can create pressure points.
– Poor posture can result in abdominal folds—
we recommend the use of abdominal board to
prevent the patient from slouching.
Technologies to help address skin laxity.
• Helium plasma.
– New technology with promising results but
unknown long-term benet.
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4 Liposuction: Principles andTechniques
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Upper Limb
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GregoryAlouf
5
5.1 Upper Arm Adiposity
Adiposity resides in all areas of the body habitus including
the upper arms. Several factors inuence the amount and distribution of this fat layer. Genetics seem to play a large part
in determining the amount of localized adiposity that occupies the upper arm region. Additionally, overall health,
comorbidities, body mass index (BMI), exercise, and activity
level can inuence upper arm fat deposition and skin laxity
in the upper arm anatomy [1].
Excess adiposity and/or skin laxity within the upper arm
region seldom creates functional problems; thus the primary
focus on correcting these conditions relates to cosmetic or
aesthetic enhancement.
5.2 History
Liposuction is a treatment modality that has been used for
decades to remove unwanted adiposity. The evolution of
liposuction started with the rst reported case in 1921, by
Charles Dujarrier where he used a curette to remove fat from
a patient’s legs [2]. In the 1960s, liposuction was attempted
by Schrudde resulting in compound complications [2]. Then,
in 1974 blunt-tipped liposuction as we know today was
developed by Italian doctors Arpad and Georgio Fischer. The
father and son obstetrics and gynecology (OB/GYN) surgeons are considered the pioneers of liposuction [2].
In the mid-1970s, liposuction was performed without
infusing uid or epinephrine into the tissues to be treated.
This technique is termed dry technique and was preferred
because the surgeons felt the uid distorted the tissues [2].
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_5].
G. Alouf (*)
Cosmetic Surgery, Salem, VA, USA
e-mail: drgreg@aacosmed.com
Doctors Arpad and Georgio Fischer performed dry technique
liposuction using a hollow cannula that housed a motorized
blade to remove fat within the adipose layer [3]. Despite
efforts to reduce the fat layer, the trauma produced from the
motorized cannula and dry technique caused large amounts
of blood loss. High rates of hematomas, infection, and blood
transfusions encouraged innovation. A few years later, a
French general surgeon, Illouz, developed the wet technique.
The wet technique utilized a small volume of normal saline,
a small amount of epinephrine, and hyaluronidase [3]. This
solution was inltrated into the adipose tissue prior to aspiration with the cannulas [3]. Additionally, Illouz developed
and used blunt-tipped cannulas instead of motorized cannulas that housed a sharp blade. This advancement reduced the
amount of bleeding during the lipo-aspiration while yielding
more fat within the aspirate.
Despite the work by many surgeons in the rst decades of
liposuction, the procedure still had drawbacks and the complications were high. As time progressed, minor improvements such as smaller cannulas were introduced to reduce
complications [4].
In 1987, Dr. Jeffrey Klein presented his research and ndings on the tumescent technique. His extensive research and
clinical trials created a gateway into local anesthesia. This
technique reduced the number of complications and allowed
liposuction to be performed in an outpatient setting without
general anesthesia being required [3]. The tumescent technique involves a mixture of normal saline, lidocaine, epinephrine, and sodium bicarbonate for injection within the fat
layer and tissues prior to liposuction. The volume of inltration of this solution compared to the volume aspirated is
closer to a 2:1 ratio [3].
The tumescent technique continues to be the standard of
care worldwide for liposuction and many other cosmetic procedures and surgeries and its advantages are mentioned in
Table5.1 [3].
Training in medical school and in residency for cosmetic
surgical procedures including liposuction for primary purpose of aesthetics is limited. Graduates interested in cosmetic
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_5
73
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G. Alouf
Table 5.1 Advantages of using the tumescent technique
• Minimal blood loss.
• No need for general anesthesia.
• Decreased postoperative pain.
• Decreased bruising.
• Less trauma to non-fatty tissues.
• Quicker recovery.
• Decreased infection.
surgery do not have the knowledge, skill, and experience to
immediately begin practicing in the eld. Therefore, after
residency, young doctors seek additional fellowships, preceptorships, workshops, conferences, or attempt to obtain
employment within an already established practice where
they can gain experience while working along seasoned doctors. For many years, cosmetic/aesthetic surgery was not a
primary focus during residency education. A survey of plastic surgery residents in 2008, published in the platic and
reconstructive surgery journal (PRSJ), revealed an overwhelming consensus of inadequate cosmetic surgery training
within their respective programs [5].
The demand and growing social acceptance of cosmetic
procedures worldwide have put more focus on the amount of
cosmetic training during residency. Still, there are no current
residency programs in the United States that are solely dedicated to cosmetic and aesthetic surgery. However, there is only
one fellowship for cosmetic surgery that is available through
the American Academy of Cosmetic Surgery (AACS) [6].
5.3 Anatomy oftheUpper Arms
The posterior upper arm consists of adipose tissue that is
globular and contains little connective tissue. In the upper
anterior portion of the arm more connective tissue can be
found [1]. The upper arms have less contractility of the skin
compared to other parts of the body after liposuction [1]. This
consideration is important to avoid excess skin laxity from
over-aspiration of adipose tissue in the upper arm. These anatomical differences inuence the approach to liposuction.
Unfortunately, there is not an exact amount of fat aspiration
for optimal aesthetic results. It is important to obtain adequate
training and form mentorships with experienced surgeons.
Upper arm liposuction is not for the novice surgeon.
There are salient anatomical points that make upper arm
liposuction more complicated. The upper arm is not a at
compartment of fat, but instead is cylindrical and varies in
size from the top of the arm near the deltoid and axilla down
to the elbow, antecubital fossa, and olecranon process, then
transitions to the forearm. Caution areas in the upper arm
include the brachial plexus that lies deep in the axilla and on
the medial side of the arm. Avoiding this area during liposuction is imperative. Multiple large vessels and nerves make up
the plexus causing profound bleeding, and sensory nerve
and/or motor nerve dysfunction to the limb if injured. Within
the antecubital fossa, there are several large supercial veins,
and the arteries are just below these veins [7].
The ulnar nerve runs between the trochlea and the medial
epicondyle of the humerus [7]. Deep along the bicipital
grove houses the brachial artery, basilic vein, as well as
median nerve [7]. These structures are more supercial and
are more at risk of injury during deeper liposuction [3, 7].
Again, placement of adits in the area should be avoided, as
well as passing a liposuction cannula in this area. The surgeon must understand the anatomy of these structures to perform liposuction in the safest manner.
5.4 Examination andClinical Features
It is important to perform a clinical examination when considering liposuction of the upper arms. This is a focused
exam conducted during the interview and initial consultation
of the patient. A more thorough exam should take place during the preoperative visit. The primary purpose of this limited exam is for the surgeon to assess the area and give the
patient input about treatment options or whether no surgery
is indicated at all. Pictures alone will not sufce or replace a
hands-on approach. It is necessary to palpate the fat layer
and to manipulate the arm at the shoulder joint in exion,
extension, abduction, and adduction to evaluate both the fat
layer and the amount of skin laxity within. Liposuction alone
will reduce fat content but will do little to address skin laxity
that is commonly found in conjunction with excess fat.
Improper patient selection for liposuction in this area can
leave a patient with a worse aesthetic outcome than before
surgery. This point cannot be overstated.
During the physical exam it is important to not only
examine the fatty layer, but also other structures that play a
part in the treatment as a whole. The skin should be evaluated to assess a few important concerns. Skin laxity should
be a concern to the cosmetic surgeon when considering liposuction alone. The amount of loose skin appreciated on
examination should direct an experienced surgeon toward
the correct treatment plan for the patient. As one can imagine, there are quite a vast array of patients and their respective anatomical presentations. Some present with large
amounts of adipose tissue and very tight healthy skin, while
others have a small fat layer and much more skin laxity.
Furthermore, there are a multitude of varying degrees of skin
laxity and localized adiposity. To obtain an acceptable aesthetic outcome, the correct treatment choice is paramount.
The choices of treatment can include liposuction alone in a
patient that has tight, healthy skin with a considerate layer of
fat, conservative liposuction in a patient with mild–moderate
skin laxity, conservative liposuction and also a skin-
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Table 5.2 Absolute exclusion criteria for liposuction
• Active cancer.
• On immunosuppressive therapy.
• Smoker.
• Active skin lesions (infection, psoriasis, tinea, eczema).
• Uncontrolled diabetes (HbA1c >7 mg%).
• Any abnormal laboratory data.
• Hemoglobin less than 12.
• Psychologically unstable.
• Unrealistic expectations.
• Bleeding disorder.
• Any uncontrolled medical condition (i.e., hypertension, etc.).
tightening modality in a patient with moderate skin laxity,
and liposuction combined with skin excision (Brachioplasty)
in a patient with both adipose tissue and a marked amount of
skin laxity.
Patient evaluation and selection is of the upmost importance to avoid complications or unwanted outcomes. Typical
liposuction exclusion criteria apply to arm liposuction, as it
does to other areas of the body (Table5.2).
Liposuction in all areas of the body decreases the amount
of fat within the treatment area, but does not affect the
amount of skin. The result of fat removal by liposuction also
creates a form of injury within the subdermal layer.
Depending on the level that the fat was removed, it can have
a varying effect on skin contraction. Although liposuction
uses blunt-tipped cannulas that remove unwanted fat, it still
creates injury within. During a liposuction treatment, the
cannula can pass in and out of a treatment area between 100
and 1000 times. As a result, there is an inammatory
response that comprises the treatment area. Inammation
normally peaks at about 1week postoperatively from liposuction and can be appreciated on examination. Induration
comprises the entire treatment site and when specic to
liposuction this phenomenon is called woody induration [8].
Upon palpation, it can be described as rm and hard, like a
piece of wood under the skin, hence the descriptive terminology. This inammatory response starts to resolve at oneto two-week time frame and can take up to a full year to
completely heal. During the healing process there is a
remodeling effect in the treated area and commonly the area
will undergo tissue contraction. The inammatory response
can also affect the overlying skin, especially if more supercial liposuction is performed. However, this author cautions on the use of supercial liposculpture for a beginning
or novice surgeon. Trying to determine which patient will or
will not get adequate skin contraction after liposuction can
be a frustrating task.
A proper skin evaluation is important in assessing the
ability to attain skin contraction. The age of the patient, the
amount of photodamage (cumulative sun exposure), and
evaluating if a patient has undergone massive weight loss are
important points of information to ascertain during the
examination. Younger skin contains more viable elastic
bers. This can allow a younger patient to achieve more skin
contraction after liposuction than an older individual with
the same presentation during examination. Sun damage or
long-standing sun exposure is a very important factor when
determining the ability of the skin to not only stretch, but
also contract after injury as in liposuction. Years of sun exposure creates solar elastosis within the skin [9]. During this
process, elastic bers are slowly replaced with scar formation on a microscopic level. This creates much less expansion of skin under pressure and also decreases the ability to
contract after liposuction [9]. This phenomenon is much
more common in the lighter skin types such as Fitzpatrick
1–3 [10]. Also, in these patients, it is important to evaluate
the skin for any skin changes such as dysplasia, neoplasia, or
any skin infections. All of these require treatment prior to
proceeding with liposuction.
Individuals who have experienced massive weight loss
need to be evaluated. The majority of these patients will have
more skin laxity than localized adiposity alone. The chronic
stretch on the skin over the years decreases the elasticity of
the skin. There is a decrease in the distension and contractile
properties of the skin of these patients. Liposuction alone
can leave a much worse cosmetic outcome than before surgery. These patients almost always are better suited for a brachioplasty or a lipo-brachioplasty.
5.5 Investigations
A preoperative visit is needed. During this visit, the surgeon
and his staff will evaluate the patient and review the treatment plan that was formulated during the initial consultation.
This is an important time to further educate the patient about
what can and cannot be done, including the benets of the
procedure as well as the limitations. Also, the consent form
should be reviewed, and signed during this visit. Time must
be given to the patient to ask any questions about the consent
form, and also if they understand what they are signing as
well as accepting the risks of surgery. It is also important for
the patient to retain a copy of the consent form to take home
and review over the next 2weeks. A phone call is made the
day before surgery from the staff asking if they have further
reviewed and read the consent form and if they have any further questions. A further discussion of the consent and medical legal issues that exist goes beyond the scope of this
chapter.
Pictures and preoperative markings can be done during
the preoperative visit. Often, patients will go home with the
markings in place as it can help them further understand the
area to be treated. During this visit, the surgeon should
perform a more complete examination of the treatment area
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G. Alouf
prior to the surgery. This will include a second look at the
treatment area and to note or discover any ndings on examination that were not elucidated during the initial consultation. Additionally, a full physical examination should take
place as well. Evaluation of the patient’s cardiovascular,
respiratory, gastrointestinal, nervous, psychological, and
integument systems are important.
Additionally, vital signs, measurements of the treatment
area, and the patient’s weight are important to obtain before
surgery. In this author’s opinion, obtaining these prior to surgery is vital for a successful outcome. These parameters
document a “starting point” and record the foundation from
which you start. Countless times in this author’s experience,
patients have returned to the clinic months after their respective surgery and complained that the results were less than
they expected. Many times patients will gain 20–30 lbs. and
having a presurgical weight can quickly pacify and educate
an unhappy patient. Additionally, the patient commonly does
not see any improvement until preoperative photos are placed
alongside postoperative photos. This phenomenon is all too
common within the cosmetic surgery arena. Hence, having a
sound system to document a patient’s “starting point” is
essential.
During the preoperative visit, laboratory data are obtained.
In our surgical practice, a complete blood count and an overview of chemistry panel is obtained. Additionally, other labs
can be checked depending on a person’s health issues. Those
patients who are diagnosed with diabetes will have an HbA1c
checked to assess their diabetic control. Those with thyroid
issues will have a thyroid stimulating hormone (TSH) and
thyroid peroxidase (TPO—for autoimmune diseases of thyroid) levels checked, and so on.
Depending on the patient and their respective health
issues, the type of surgery being performed, the type of anesthesia used, and the subjective opinion from the surgeon (this
author) may require medical/surgical clearance from the
patient’s primary care physician prior to getting a “green
light” for surgery. Despite the diverse protocols instituted by
different surgeons, the health and safety of all patients needs
to come rst before any type of treatment or surgery. The
preoperative examination should take place at least 2 weeks
prior to any surgery. This time frame allows for a patient to
have ample time to review consent forms and ask any further
questions about their planned surgery. Also, it allows a surgeon to review the patient’s case as well as any laboratory
data that were obtained.
5.5.1 Treatment Modalities
Within the aesthetic arena there are several energy-based
devices that are intended to supplement liposuction.
Ultrasonic, laser, water assisted, radiofrequency, and newer
plasma type devices are available to surgeons to use alongside liposuction. It is my opinion that these can have some
benets with regard to skin tightening; however, the results
of each are marginal at best and cannot replace surgical intervention to remove excess skin. These devices can cost a surgeon thousands of dollars and can also have disposables that
add additional cost per procedure. There are many variables
that ultimately dictate how a surgeon may or may want to
add an energy device to supplement their surgical armamentarium. Further exploration and details of each device go
beyond the focus of this chapter. Furthermore, this author
does not advocate for or against any of the devices
aforementioned.
The aspiration of fat from a treatment area can be performed with different techniques. Syringe liposuction or the
syringe technique (Fig.5.1) involves using a syringe attached
to a blunt-tipped cannula [11, 12]. The size of the syringe
and cannula can vary depending on the purpose of the fat
extraction. All of the air needs to be removed from the
syringe with the plunger pressed all the way in. The tip of the
cannula is then placed through an adit site within the adipose
layer. Next, the surgeon pulls back on the plunger creating
negative pressure within the syringe and extending to the
opening of the cannula. The plunger can be maintained with
either a syringe locking device or with hand holding the
syringe. Forward and backward strokes will allow fat aspiration to ensue, and fat will ll the syringe.
Suction-assisted liposuction involves the use of cannula
that is attached to a piece of aspiration tubing [3]. The other
end of the tubing is connected to a motorized suction
machine. Additionally, there is a collection container that is
placed inline on the aspiration tubing. This container is usually placed close to the aspiration pump. Mechanical strokes
moving in and out of the treatment area along with suction
will procure fat that will ultimately end up in the collection
container.
Power-assisted liposuction uses a motorized handpiece
that increases disruption of the fat cells combined with hand
strokes [13]. This technique is meant to decrease the work/
effort required by suction-assisted liposuction as well as
increasing the rate of fat aspiration.
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Fig. 5.1 Components of a
syringe liposuction
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Cannula
Syringe
Liposuction
with Fat
Aspirate in
Syringe
Gregory ALouf.MD
5.6 Treatment Modality ofChoice
As mentioned previously, liposuction of the upper arm region
requires proper planning and preparation. Ultimately, the
goal of the surgeon should be to safely perform the procedure, while achieving the best possible results for patients.
Safety for the patient, above all, is the rst and most important mission for the surgeon. Liposuction of the arms is generally not the rst area for the novice surgeon to begin.
Liposuction teaching commonly begins on the abdomen or
other atter surfaces on the body. In this author’s experience,
it is recommended that the surgeon undertaking liposuction
of the arms has at least 50–100 cases of liposuction experience on other parts of the body prior to attempting solo arm
liposuction. This author also encourages proctorship with an
experienced surgeon while performing their rst three to ve
cases of arm liposuction. This will enhance and excel the
learning curve, while avoiding unwanted complications.
From my personal experience, during the examination
and consultation with the patient, it is paramount that the
surgeon not only performs a thorough examination, but also
learns about the patient and their expectations. Considering
these limited access points, it makes navigating the cannula/s
within the entire cylinder of fat in the upper arm more difcult. Also, one must use longer aspiration cannulas that
Leurlok
Union
Syringe
Courtesy of
should not exceed 3mm in diameter. Limiting the diameter
of the cannulas decreases the unintended incidence of contour irregularities.
5.6.1 The Day ofSurgery
The patient should arrive at the stated time to allow an efcient and timely surgery. The patient needs to have a responsible adult there to pick them up from the surgical procedure
and also needs to be available for postoperative instructions
given by the staff upon discharge. The nursing staff will help
with intake of the patient. This involves changing the patient,
and reviewing and updating any health-related changes that
may have occurred within the two-week interval since the
preoperative visit. Preoperative instructions and medications
that needed to be stopped as well as medications that needed
to be started prior to the surgery day are reviewed.
Medications that are commonly stopped 10 days prior to surgery include aspirin, all non-stimulating anti-inammatory
drugs (NSAIDs), vitamins, and herbal medicines that affect
platelet or the blood clotting cascade, and any medications
that can affect the normal metabolism of lidocaine within the
liver. Vital signs and the patient weight are obtained. The
patient is changed into the proper surgical gown. A saline
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lock is placed in the patient’s hand. It is important the intravenous (IV) site is placed in the distal forearm or down on
the hand. An IV placed in the antecubital fossa would interfere with the treatment site of the upper arms.
Both a urine pregnancy test (for those menstruating
females) and a urine nicotine test are performed. If either of
these is positive, the planned surgery for the day is canceled.
Additionally, if the patient’s vital signs are not within normal
or acceptable limits, or if the patient has not followed preoperative directions, the surgery may be canceled as well.
Canceling surgeries is an inconvenience and can be costly to
both the patient and the practice; however, patient safety and
avoiding unwanted complications cannot be overlooked.
Once the patient has been cleared, the surgeon comes in to
review the treatment area for a third time and discusses this
with the patient and the nursing staff in the room. It is important that all parties are in agreement to the planned treatment.
Often times, patients will try to add an area not previously
discussed during this time frame. It can be done, but this
author urges not to attempt more than was previously outlined, discussed, agreed upon, and consented for in the initial
consultation and preoperative visit. This can be troublesome
to collect extra money during this, already rushed, time
frame. Also, patients will most likely be premedicated and at
this point cannot legally consent.
The surgeon will take standard photographs and will
make presurgical markings (Fig.5.2). During the marking
period, the surgeon will also evaluate the treatment area and
determine the volume of tumescent solution that needs to be
prepared. Commonly, 1.5–2 liters of normal saline will sufce per upper arm area. Once the markings have been placed,
the surgeon will again take photographs of the markings.
During this time, the surgeon should also inspect the overall
health of the skin in the treatment area. Rashes, skin infections, or other types of edema need to be looked for. If something has developed within the past 2weeks, the surgery may
have to be canceled.
The patient is then taken to the operating room or suite for
sterile skin preparation and draping. At this time, general
anesthesia can be administered if required by the proper
anesthesia provider. The surgeon will then go to the mixing
station and prepare the tumescent solution for the case.
Properly preparing this solution is vital to the safety of the
patient. In fact, this author calls this stage in liposuction surgery, the “Rate Limiting Step of Safety.” With this in mind, it
is strongly urged that the surgeon performing the liposuction
actually calculates and mixes this preparation him/herself.
While performing liposuction of an area/s, there has to be
two factors considered in case of awake or mildly sedated
patient. One, there has to be adequate volume of tumescent
solution delivered in the treatment area. Two, there has to be
adequate concentration of lidocaine within each liter of solution to properly achieve anesthesia during the lipo- aspiration.
G. Alouf
Fig. 5.2 Right lateral, left lateral, anterior, and posterior views of
patient’s arms marked preoperatively for liposuction
These are critical factors for success. Too little volume or too
little lidocaine concentration in the treatment area will result
in pain, as well as unwanted bleeding during liposuction. A
successful outcome cannot be achieved in this setting.
Furthermore, there is a maximum safe amount of lidocaine
that can be used in a patient per surgery. In the awake patient,
there are several accepted standards for lidocaine concentration. This can vary between 35 and 50 mg/kg of lidocaine per
patient per surgery in a 24-h period. As patients’ weights
vary, so does the maximum allowable lidocaine dosage for a
procedure. For instance, a patient that weighs 100 kg can
have a maximum dose of 50 mg/kg of lidocaine: 100 × 50 =
5000mg of lidocaine. This maximum amount can be mixed
in different concentrations of lidocaine in each liter of normal saline. Dr. Jeffrey Klein commonly uses 500 mg/liter of
normal saline. Therefore, this patient could have 10 liters of
tumescent solution mixed with 500 mg/liter. It is commonly
agreed upon among cosmetic surgeons that 500 mg/liter of
lidocaine is the minimum amount that can be used and still
achieve dense enough anesthesia to properly perform lipo-
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