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DEFINING WETTING SOLUTIONS IN LIPOPLASTY

by Peter Bela Fodor, M.D.

The volume and composition of wetting solutions administered in lipoplasty varies among practitioners. While debate for the best approach continues, the terms describing the wetting solutions are often used incorrectly and interchangeably in our literature. The aim of this editorial is to clarify the issue.

Blunt-tipped cannula lipoplasty introduced in this country in the early 1980s gained popularity rapidly. Volumes of aspirate were modest, complications were rare, and satisfaction rates were high. The traditional procedure produced predictably good results. A sense of complacency developed, and research was not thought necessary.

During the last few years, the standard procedure has been challenged by the introduction of numerous "revolutionary innovations," often without any research preceding their acceptance. The rate of significant or lethal complications, however, has risen dramatically, starting in 1995. The thoughtless use of very large volumes of wetting solutions, especially in large-volume removals, has played a significant role in this scenario.

In an ideal patient, small volumes of removal (arbitrarily defined as less than 1500 cc of decanted fat) can usually be carried out safely, relatively speaking, using any approach. This is not the case when dealing with larger volumes. The physiological events triggered by subcutaneous administration of massive amounts of fluids has not been subject to study since the use of hypodermoclysis, which was replaced many years ago by intravenous fluid administration. Similarly, insufficient data exists on the effects of subcutaneous administration of large amounts of local anesthetics, including lidocaine. A conservative approach, in the absence of good data, is the only logical course to follow.

Accurate usage of the terms describing different wetting solution techniques is essential for proper communication among surgeons:

In the "dry" technique, abandoned by most, suction is carried out without any fluid whatsoever infused into the area being treated.

In the "wet" approach, still used by many surgeons, anywhere from a few to at most 200 to 300 cc of isotonic solution, usually containing epinephrine in low doses, is introduced into each surgery site regardless of the volume of aspirate.

In the "super wet" technique, the volume of wetting solution equals the estimated volume of aspirate. The isotonic infusate, preferably Ringer's lactate, contains low doses of epinephrine in concentration of 1:1,000,000 to 1:2,000,000, depending on the volume of infusate. General or epidural anesthesia is used routinely for anything but small extractions, and local anesthetics can be avoided entirely from the infusate. In the super wet technique, the wetting solution is not used as the primary anesthetic.*

The "tumescent technique" uses tissue turgor as the endpoint of infusion. This may lead to volumes of infusate far in excess of the volume of aspirate. Especially when used in large-volume removals (arbitrarily defined as in excess of 4000 cc of decanted fat), the fluid load may be very dangerously large. Furthermore, the tumescent technique, by its strict definition, employs the wetting solutions as the primary mode of anesthesia ( by adding large amounts of lidocaine to the infusate).

Many individual variations exist but often are not precisely thought out. Therefore, the different wetting solution techniques can be defined only in general terms, but the amounts of ingredients should all be known beforehand and considered carefully. Sound clinical judgement based on clear understanding of physiological events surrounding subcutaneous administration of fluids and local anesthetics is essential for patient safety in lipoplasty.

The primary intent of this editorial is not to dwell on the advantages or lack thereof of any one approach, but rather to alert the surgeon to use the proper nomenclature when presenting clinical data. This will assist all of us in our efforts to seek the best and safest approaches for our patients.

*Note: Small amounts of lidocaine (Xylocaine)., 10 to 20 cc of 1% to each 1000 cc, or bupivicaine (Marcaine), 10 to 20 cc of .25% to each 1000 cc, can be added for the benefits of preemptive and postoperative analgesia. Similarly, prophylactic antibiotics {e.g., garamycin (Gentamicin) 40 mg to each 1000 cc} may be added according to the surgeon's preference. The infusion is carried out segmentally or sequentially ass the procedure progresses to treat the different body regions. The total volume of infusate seldom exceeds 5000 cc.

Peter Bela Fodor, M.D.
2080 Century Park East, Suite 710
Los Angeles, California 90067

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