The tumescent technique: the effect of high tissue pressure and dilute epinephrine on absorption of lidocaine.

Injection of lidocaine into the subcutaneous tissues by the tumescent technique results in a delayed absorption of the local anesthetic and has allowed clinicians to exceed the maximum recommended dose of lidocaine without reported complications. However, little knowledge exists about the mechanisms that permit such high doses of lidocaine to be used safely with this technique. The presence of low concentration epinephrine and the increased tissue pressure resulting from the tumescent injection have both been implicated as important factors, but neither has been studied in patients whose results were not altered by the variability of the suction procedure. The purpose of this work was to determine the effect of tissue pressure during tumescent injection and presence of low concentration epinephrine on the absorption of lidocaine from subcutaneous tissues in human volunteers. Twenty healthy female human volunteers were randomized into four study groups. After body fat measurements, all subjects received an injection of 7 mg/kg of lidocaine into the subcutaneous tissues of both lateral thighs. The injected solution consisted of 0.1% lidocaine and 12.5 meq/liter sodium bicarbonate in normal saline with or without 1:1,000,000 epinephrine. Tissue pressure was recorded during injection using a specially designed double-barreled needle. The time required for injection was also recorded. Subjects in group 1 received lidocaine with epinephrine injected by a high-pressure technique. Group 2 subjects received lidocaine with epinephrine injected by a low-pressure technique. Group 3 subjects received lidocaine without epinephrine injected under high pressure. Group 4 subjects received lidocaine without epinephrine injected under low pressure. Following injection, sequential blood samples were drawn over a 14-hour period, and plasma lidocaine concentrations were determined by gas chromatography. No suction lipectomy was performed. Maximum tissue pressure during injection was 339 +/- 63 mmHg and 27 +/- 9 mmHg using high- and low-pressure techniques, respectively. Addition of 1:1,000,000 epinephrine, regardless of the pressure of injected fluid, significantly delayed the time to peak plasma concentration by over 7 hours. There was no significant difference in the peak plasma concentration of lidocaine among the four groups. Peak plasma concentrations greater than 1 mcg/ml were seen in 11 subjects. Epinephrine (1:1,000,000) significantly delays the absorption of lidocaine administered by the tumescent technique. High pressure generated in the subcutaneous tissues during injection of the solution does not affect lidocaine absorption. The delay in absorption may allow time for some lidocaine to be removed from the tissues by suction lipectomy. In addition, the slow rise to peak lidocaine concentration in the epinephrine groups may allow the development of systemic tolerance to high lidocaine plasma levels.

Compartment syndrome of the upper extremity following cutaneous laser surgery.

Cosmetic tattoo removal by laser is commonplace and is followed by recognized complications. We report a previously unrecognized complication: a case of forearm compartment syndrome following Q-switched Nd:YAG laser for treatment of a decorative tattoo.

The effects of hyaluronidase on local anesthesia: a prospective, randomized, controlled, double-blind study.

Hyaluronidase, an enzyme that breaks down intercellular cement, has been advocated as an additive to local anesthetics because it allows injected solutions to spread and penetrate tissues. Because epinephrine is commonly used in conjunction with local anesthetics, the combined effects of both hyaluronidase and epinephrine were studied in a prospective, controlled, double-blind manner. The forearms of volunteers ranging in number from 15 to 23 were injected with 0.5 ml of lidocaine to which graded doses of hyaluronidase and epinephrine had been added. At various intervals after injection, the areas of anesthesia were measured. From these data, the time to reach peak area of anesthesia (onset), the size of the peak area of anesthesia, and the time until disappearance of anesthesia (duration) were computed and analyzed. We found that epinephrine has a more profound effect on the onset, area, and duration of anesthesia than hyaluronidase. Epinephrine delayed the time to reach peak area of anesthesia (onset) relative to lidocaine alone more than hyaluronidase (0.28 h versus 0.04 h). When both agents were used together, the effect was subtractive (0.28-0.04 = 0.24 h, compared with 0.22 h observed). This suggests a negative interaction (inhibition) because hyaluronidase decreased the epinephrine effect by 21 percent. Concerning the size of peak area of anesthesia, epinephrine increased the area relative to lidocaine alone more than hyaluronidase (626 versus 221 mm2). When both agents were used together, the effect was additive (626 + 221 = 847 mm2, compared with 848 mm2 observed). This suggests that the two agents acted independently of each other in relation to area of anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthetic practices in ambulatory aesthetic surgery.

Although ambulatory aesthetic surgery is commonly practiced and information concerning methods of anesthesia is readily available, little is known about the prevalence of various anesthetic practices and whether such practices differ according to the location of surgery. To obtain this information, we sent a carefully structured, 16-page, 69-item questionnaire to the members of the American Society for Aesthetic Plastic Surgery. Six hundred four (76.6 percent) of the 789 actively practicing members returned questionnaires, an exceptionally high response rate. Of interest are the following findings. More than 50 percent of the respondents operate in their offices half or more of the time. About one-half never perform aesthetic surgery in the hospital. Free-standing ambulatory surgical facilities are used less frequently. A wide range of laboratory studies are ordered routinely, regardless of the location of surgery or age of the patient. Local anesthesia with intravenous sedation is widely used in all settings. When employed for office surgery, neither a nurse anesthetist nor an anesthesiologist is present about one-third of the time. General anesthesia is used in half of the office surgical units and is administered by dedicated anesthesia personnel. About half of the time it is administered by an anesthesiologist and about half of the time by a nurse anesthetist. The intensity and methods of patient monitoring are similar in the office, in the hospital, and in a free-standing ambulatory surgical facility. Preoperative laboratory evaluation, monitoring, and the use of anesthetic agents are similar regardless of the surgical setting.

Temporalis fascia grafts in open secondary rhinoplasty.

Parchment thin skin is a common problem associated with secondary rhinoplasty. When such skin is present, the underlying osseocartilaginous skeleton often becomes visible. Although many techniques have been used to treat the condition, we have found that an onlay graft of temporalis fascia is a most satisfactory method to cover the underlying osseocartilaginous framework or cartilage grafts. Temporalis fascia grafts have been advocated for this purpose in closed rhinoplasty; however, precise placement of the graft is difficult because the graft rolls. On the other hand, when used in open rhinoplasty, the graft may be placed accurately and secured under direct vision. This paper presents our experience with temporalis fascia grafts in open secondary rhinoplasties. Six female patients ages 31 to 57 underwent open secondary rhinoplasty. Five patients also had autologous cartilage grafts. Our average follow-up was 24 months; the minimum was 1 year, and the longest 7 years. All patients had excellent dorsal contours and osseocartilaginous irregularities were not observed. One patient developed a culture-proven nasal infection that responded successfully to antibiotics without removal of the fascia or cartilage graft, a result unlikely to occur when alloplastic materials are used. Biopsy of the temporalis fascia and cartilage grafts was obtained in one patient 12 months after placement. Microscopic examination confirms the long term viability of both grafted tissues, inasmuch as the temporalis fascia was vascularized and normal chondrocytes were present in the cartilage grafts. In summary, we have found that temporalis fascia grafts are a very satisfactory method for managing thin skin in open secondary rhinoplasty.

Experience with 326 inflatable breast implants.

Inflatable breast implants, which have been available for 27 years, have been accepted with varying enthusiasm. Advocates suggest that they result in breasts that look and feel natural because they have a low incidence of capsular contracture. Others note the obvious: Anything that is inflated may deflate. The purposes of this report are to present our experience with inflatable breast implants and to focus on deflation. We examined the records of all our patients who underwent breast augmentation or reconstruction. The 173 patients who had 326 inflatable breast implants form the basis of this report. Eighty-four percent of the patients were treated for aesthetic reasons; 16 percent were for reconstruction after mastectomy. The longest follow-up was 14.5 years, and the shortest was 3 months. Our findings indicate that inflatable breast implants remain soft. Overall, 256 implants (78.5 percent) were Baker I, 39 (12.0 percent) were Baker II, 28 (8.6 percent) were Baker III, and 3 (0.9 percent) were Baker IV. Twenty (6.1 percent) of the 326 implants deflated. No patient whose implant deflated had a closed capsulotomy nor gave a history of a proximate athletic endeavor. Most deflations were associated with pain, not previously present, and over the next few days the patient noted that her breast became smaller. All deflations were explored surgically, usually within 1 week. At surgery, a white fold was noted usually where the leak in the implant occurred. It was easy to slide out the old implant and insert a new one. The shortest interval between the surgery and deflation was 3 months; the longest was 9 years and 9 months.

Reduction mammaplasty by suction alone.

Because unsatisfactory scars often result when traditional methods of reduction mammaplasty are performed, techniques that leave less noticeable scars have been advocated recently. One such technique is suction lipectomy, which has been employed previously, but only for patients who have well-located, small nipple-areola complexes and whose hypertrophy is primarily fat. I have found that concern for the size and location of the nipple-areola complex and cause of hypertrophy are unfounded. Thus reduction mammaplasty by suction alone may be the technique of choice in certain patients. Eleven patients had reduction mammaplasty by suction alone and obtained aesthetically pleasing breasts that had good sensation and minimal scars. As a result, the method is suggested for selected patients: those with minimal to moderately large breasts.

Large-volume suction lipectomy: an analysis of 108 patients.

Suction lipectomy was initially advocated for the treatment of localized collections of fat and for the removal of less than 1500 ml of material. However, many patients wished to have multiple areas treated or had diffuse collections of fat. In such instances, the removal of over 1500 ml of material and circumferential lipectomy are necessary to provide optimal aesthetic results. However, when over 1500 ml of material is removed, anesthetic requirements, fluid replacement, and treatment of blood loss become important if the operation is to be performed safely. We have treated 108 patients who had over 1500 ml of material removed. Eight-eight percent of the patients were female; 12 percent were male. Using the body-mass index, 3 percent of patients were underweight, 70 percent were normal weight, and 27 percent were overweight. Fifty-five patients (51 percent) had 1500 to 2499 ml of material removed, 26 patients (24 percent) had 2500 to 3499 ml removed, 16 patients (15 percent) had 3500 to 4499 ml removed, and 11 patients (10 percent) had over 4500 ml removed. All patients were treated in the hospital; 44 percent were admitted after surgery. A total of 227 units of autologous and 2 units of homologous blood were transfused. As measured by a computerized monitor, the average amount of blood in the material removed from thighs was 30 percent; from abdomens, the blood loss was 45 percent. The aesthetic results were generally excellent. No complications were encountered. A few patients developed undesired sequelae, the most common of which was seroma formation, which occurred in 19 percent of those who had suction of abdominal-wall fat. We believe that large-volume suction lipectomy is safe and efficacious, provided attention is directed to such important aspects of patient care as anesthesia, fluid replacement, and blood loss.

The effect of epinephrine on blood loss during suction lipectomy.

In a prospective, double-blind, controlled study on 26 consecutive patients who underwent suction lipectomy, the injection of epinephrine (1:250,000, 1:500,000, or 1:1,000,000) was not found to decrease fluid/blood loss when compared with saline injection or no injection at all. Since our study fails to support the use of epinephrine to lessen fluid/blood loss during suction lipectomy, we have abandoned its use in that procedure.

Suction mammaplasty: the use of suction lipectomy to reduce large breasts.

The use of suction lipectomy to reduce breast volume is described. The technique applies only to a very limited group of patients whose nipple-areola complexes are normally located and whose enlargement is primarily fibrofatty in nature. Suction mammaplasty can be used as a sole technique in congenital asymmetry or in post-reduction enlargement or asymmetry.

The prevention and management of medical problems during office surgery.

Surgeons who perform office surgery without the presence of personnel trained in anesthesia are responsible for both the surgery and the general condition of the patient. Thus the prevention and management of medical problems that may occur during the operation or in the recovery room become their concerns. Fortunately, medical problems arise infrequently. However, the anxiety of the moment may cloud important details of treatment; as a result, having a preconsidered plan is advised. This paper presents step-by-step outlines that provide safe and effective treatment plans for guiding the surgical team during the management of medical problems during office surgery.

Skin sensation after suction lipectomy: a prospective study of 50 consecutive patients.

Using a reproducible pain stimulus, skin sensation was evaluated in a prospective study of 50 consecutive patients who underwent suction lipectomy. A total of 294 anatomic areas were evaluated and treated. Before operation, many patients were found to have patchy areas of decreased sensation, a condition that was unknown to them. Initially after surgery, all patients had decreased sensation in the treated areas. However, sensation usually returned to normal in 6 to 8 months. In some patients, sensory return to preoperative levels took as long as 1 year, and in a few, patchy areas of decreased sensation were present even longer. In general, the larger the treated area, the larger are the area and degree of sensory loss and the slower is the return of sensation.

Diagnosis and treatment of nasal airway obstruction due to inferior turbinate hypertrophy.

Bilateral inferior turbinate hypertrophy is the most common cause of nasal airway obstruction. Treatment by resection is advised. Following this, a significantly improved airway has been demonstrated and no adverse sequelae have been observed or reported.