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Liposuction Related Deaths

INTERNATIONAL JOURNAL OF COSMETIC SURGERY
Vol. 7, No. 1, 1999

Letter to the Editor: The following comments are regarding the recent article in the New England Journal of Medicine (NEJM) on liposuction-related deaths.

We have heard almost everyone expound on the merits, toxicity, lack of toxicity, and other qualities of lidocaine. The recent report1 is no exception. But nowhere in the article is there a comment about the common feature of these cases, the epinephrine concentration in the tumescent solution, which was documented to be 1:2,000,000 (this apparently was considered of such little importance by the authors that it was not even calculated). In the fourth case, there was no epinephrine in the solution (the epinephrine dose column showed "NA"). I have heard that for one of the fairly recent and widely publicized liposuction deaths in Los Angeles, the epinephrine in the tumescent solution was 0.5 mL of 1:1,000, or a concentration of 1:2,000,000 (Chavez personal communication).

Recommendations for recommended epinephrine doses are all over the map, and even the well-known authorities on lidocaine dosages are somewhat unclear on the epinephrine. 2,3

Note also that the fatalities reported in the NEJM were relatively conventional by modern standards in terms of subcutaneous volume, sedation, and dose of lidocaine. In two of these cases the volume of intravenous fluid quantity was very high, and in another it was not reported. I would submit that based on these few case reports, the toxicity of the liposuction process, and perhaps of lidocaine, may be more likely if epinephrine doses are less than the conventional dose of 1:1,000,000 (1 mL of 1:1,000 epinephrine in each 1,000 mL of tumescent fluid). Toxic lidocaine doses or fluid quantities are absorbed from the tumescent fluid in the absence of proper adequate epinephrine concentration.

Robert Yoho, M.D.

Dr. Robert Yoho
Pasadena, California

References

  1. Rao RB, Ely SF, Hoffman RS. Deaths related to liposuction, N Engl J Med 1999;340:1471-1475.
  2. Klein JA. Tumescent technique chronicles: local anesthesia, liposuction and beyond. Dermatol Surg 1995;21:449-457.
  3. Pitman GH, Aker JS Tripp ZD. Tumescent liposuction: a surgeon's perspective. Clin Plastic Surg 1996;23:663-641.