In the May 2013 issue of Plastic and Reconstructive Surgery, Pace et al. presented an article that discussed local anesthetic use in liposuction.1 The article reviewed much of the existing literature and recommended modifying the current American Society of Plastic Surgeons Practice Advisory. In particular, the authors recommended restricting the use of bupivacaine in infiltrative solution because of its pharmacologic properties and higher propensity for cardiotoxicity when compared with lidocaine. However, none of the evidence presented by the authors included any clinical data on the patient safety impact of bupivacaine use in tumescent solution, and we believe that this issue deserves further discussion and study before such changes are made to the Practice Advisory.
The authors justify their recommendation by citing studies involving modalities where bupivacaine is injected directly and where toxicity resulting from accidental intravascular injection is more likely.2,3 In contrast, we believe that using bupivacaine in tumescent solution is more comparable to its use in pain infusion pumps, where it has an established track record of safety and efficacy. Pain infusion pumps have gained popularity in surgical practice as a means of limiting postoperative narcotic use, decreasing length of stay, and improving patient satisfaction.4 There have been no reports in the literature of cardiac adverse events related to this modality.
Furthermore, newer bupivacaine equivalents, such as ropivacaine, are now available to reduce the likelihood of cardiotoxicity while maintaining the advantages of bupivacaine’s longer duration of action. Given preliminary results suggesting that bupivacaine may offer superior postoperative pain control where liposuction was combined with abdominoplasty,5 we believe that proper clinical studies should be performed evaluating bupivacaine and its equivalents in tumescent solutions before rendering judgment about their role in liposuction.
Practice guidelines should be made based on the best possible evidence. We agree with the authors on the necessity for caution when using bupivacaine in tumescent liposuction; however, we respectfully submit that the evidence currently does not conclusively support their recommendation to restrict its use.
The authors have no financial interest in any of the products, devices, or drugs mentioned in this communication.
Angie M. Paik, B.A.
Lily N. Daniali, M.D.
Edward S. Lee, M.D.
Rutgers New Jersey Medical School
Henry C. Hsia, M.D.
Rutgers Robert Wood Johnson Medical School
New Brunswick, N.J.
1. Pace MM, Chatterjee A, Merrill DG, Stotland MA, Ridgway EB. Local anesthetics in liposuction: Considerations for new practice advisory guidelines to improve patient safety. Plast Reconstr Surg. 2013;131:820e–826e
2. Howe NR, Williams JM. Pain of injection and duration of anesthesia for intradermal infiltration of lidocaine, bupivacaine, and etidocaine. J Dermatol Surg Oncol. 1994;20:459–464
3. Neal JM, Bernards CM, Butterworth JF IV, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35:152–161
4. Hernandez JL, Savetamal A, Crombie RE, et al. Use of continuous local anesthetic infusion in the management of postoperative split-thickness skin graft donor site pain. J Burn Care Res. 2013;34:e257–e262
5. Failey CL, Vemula R, Borah GL, Hsia HC. Intraoperative use of bupivacaine for tumescent liposuction: The Robert Wood Johnson experience. Plast Reconstr Surg. 2009;124:1304–1311
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