Optimizing Gynecomastia Correction Surgery: Efficacy and Safety of Tumescent Local Anesthesia Approach.

BACKGROUND: Tumescent local anesthesia (TLA) involves infusing a saline solution containing lidocaine and epinephrine into tissues to achieve localized anesthesia and vasoconstriction. While liposuction under general anesthesia remains the most used treatment, we introduce a novel TLA approach for gynecomastia surgery, drawing from our extensive experience in recent years. METHODS: Between the years 2010 and 2023, we performed gynecomastia surgery on 60 male patients under TLA. The gynecomastia was treated by liposuction plus periareolar excision technique. Liposuction was carried out on both breasts in every case, regardless of whether the gynecomastia was bilateral or unilateral. The tumescent solution consisted of 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. The solution was infiltrated between the pectoral fascia and the mammary gland, and then the surgery was carried out. RESULTS: The average volume of tumescent solution infiltrated during TLA was 300 mL per breast. There were no reports of adrenaline or lidocaine toxicity, and no cases required a conversion to general anesthesia. Patients experienced no pain or discomfort during the preoperative infiltration or surgical procedure. We observed a major postoperative complications rate of 6.7%, represented by three incident of hematoma and one case of seroma. A minor complication rate of 5% was observed: two cases of retraction of the NAC and one case of gynecomastia recurrence, the latter undergoing an additional combination procedure with liposuction and subcutaneous mastectomy. Follow-up time ranged from 30 days to 1 year. CONCLUSIONS: We developed a new outpatient surgical method for gynecomastia using liposuction and periareolar excision under tumescent local anesthesia. This technique, supported by a comprehensive rehabilitation plan, proved a successful and quick recovery, and high patient satisfaction. Our results suggest it is a feasible and effective option, warranting further consideration in gynecomastia treatment strategies. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Minimal Pain Tumescent Local Anesthesia Injection for Wide Awake Modified Radical Mastectomy.

The advent of minimal pain tumescent local anesthesia injection has improved patient safety by eliminating the need for sedation for many wide awake operations, especially in patients with significant medical comorbidities. Modified radical mastectomy (MRM) for breast cancer is commonly performed under general anesthesia as it requires the dissection of the entire breast and an ipsilateral axillary lymph node dissection (ALND). General anesthesia has been shown to have a high risk in patients with severe medical comorbidities. We present a case of a 78-year-old male patient who was diagnosed with invasive ductal breast carcinoma, cardiac failure, and other metabolic abnormalities. Taking his comorbidities into account, we performed a wide awake MRM and ALND after tumescent minimal pain local anesthesia injection. The patient experienced the successful procedure safely with minimal discomfort.

L'anesthésie locale par tumescence associée à une douleur minimale a amélioré la sécurité des patients en éliminant la sédation lors de nombreuses opérations éveillées, particulièrement chez les patients qui ont des affections concomitantes importantes. La mastectomie radicale modifiée (MRM) du cancer du sein est souvent effectuée sous anesthésie générale, car elle exige la dissection du sein entier et la dissection des ganglions lymphatiques axillaires (DGLA) ipsilatéraux. Il a été démontré que l'anesthésie générale comporte un risque élevé chez les patients atteints d'affections connexes graves. Les auteurs présentent le cas d'un patient de 78 ans qui a reçu un diagnostic de carcinome canalaire invasif, d'insuffisance cardiaque et d'autres anomalies métaboliques. Compte tenu de ses affections connexes, les médecins ont effectué une MRM et une DGLA après une anesthésie locale par tumescence associée à une douleur minimale. Le patient a subi avec accès une intervention sécuritaire et a éprouvé très peu d'inconfort.

Retrospective Study on Optimizing Breast Augmentation Outcomes in Transgender Patients: A Comprehensive Analysis of Tumescent Local Anesthesia Technique.

BACKGROUND: Tumescent local anesthesia (TLA) involves the infusion of a saline solution containing lidocaine and epinephrine into tissues to achieve localized anesthesia and vasoconstriction. While the use of TLA in sub-glandular augmentation mammoplasty has been documented, we present a modified TLA approach for primary sub-muscular breast augmentation in transgender patients based on our experience over the past years. METHODS: Between the years 2014 and 2021, we performed primary sub-muscular breast augmentation on 20 transgender patients under TLA and conscious sedation. The tumescent solution consisted of 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. Initially, the solution was infiltrated between the pectoral fascia and the mammary gland, and subsequently, during the surgery, under the pectoralis major muscle. RESULTS: The average volume of tumescent solution infiltrated during TLA was 740 mL per breast. There were no reports of adrenaline or lidocaine toxicity, and no cases required a conversion to general anesthesia. Patients experienced no pain or discomfort during the preoperative infiltration or surgical procedure. Reoperations due to short-term complications never occurred. We observed a major complication rate of 5%, represented by 1 hematoma. Long-term complications comprised one case of implant dislocation and one occurrence of dystrophic scar formation. No cases of capsular contracture needing reoperation, asymmetry, and implant rupture occurred. In total, one individual (5%) requested larger implants. Follow-up time ranged from 30 days to 1 years. CONCLUSIONS: Overall, augmentation mammaplasty is a valuable choice for transgender women aiming to enhance their feminine characteristics and alleviate gender dysphoria. It is imperative for patients to conduct thorough research, grasp the potential pros and cons, and consult experienced healthcare professionals in transgender care. Additionally, tumescent local anesthesia (TLA) has proven to be a safe and efficient method for sub-muscular breast augmentation, providing effective pain control with minimal postoperative complications, resulting in high patient satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Tumescent local anesthesia in geriatric patients with head and neck skin cancer - a retrospective study of 782 patients.

BACKGROUND AND OBJECTIVES: Due to frailty, dermatosurgery in the elderly is preferably performed under tumescent local anesthesia, but data is limited. The aim was to evaluate tumescent local anesthesia for skin cancer surgery in the elderly with focus on clinical benefits (treatment processes, pain management) and local postoperative complication risk. PATIENTS AND METHODS: Investigation of patients ≥ 75 years with inpatient head and neck skin cancer surgery under tumescent local anesthesia. RESULTS: 2,940 procedures in 782 patients (mean age 83.3 years) were performed with the aim of complete tumor resection during the inpatient stay. 3.8 (range: 1-20) interventions were done over an average of 4.9 days (range: 1-28). 43.2% did not require any postoperative analgesia. 53.5% received NSAIDs, 3.3% opioids. Infection (13.6%) was the most common local postoperative complication. Surgical intervention due to bleeding was required in 2.8%. None was hemoglobin relevant or life-threatening. Suture dehiscence and necrosis were rare (0.6%). CONCLUSIONS: Tumescent local anesthesia is an effective method for skin cancer surgery in the elderly. By avoiding general anesthesia, treatment processes can be optimized and anesthesiologic risks minimized. Local postoperative complications are still low and well treatable. The long-lasting analgesia results in a reduced need for analgesics and drug interactions.

Outcomes of Abdominoplasty in Tumescent Local Anesthesia Combined with Subdural Anesthesia.

BACKGROUND: Abdominoplasty is a common surgical procedure performed under general anesthesia, and although the use of TLA combined with subdural anesthesia has never been reported in abdominoplasty, it offers several benefits such as safe and effective local anesthesia and vasoconstriction. We outline our experience with the TLA technique for primary abdominoplasty over the last 7 years. METHODS: From 2014 to 2021, TLA and subdural anesthesia have been used in primary abdominoplasty surgeries for 106 patients. The TLA solution consisted of 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) diluted in 1000 mL of 0.9% saline solution. The solution was then injected with a 2-mm cannula into the subcutaneous adipose tissue in the suprafascial plane. The subdural anesthesia was performed at intervertebral level L1-L2 using Ropivacaine 15/18 mg in 4 ml. RESULTS: Patients aged from 32 to 75 years. The amount of tumescent solution infiltrated ranged between 500 and 1000 mL. Mean surgery time was 70 minutes, and recovery room time averaged at 240 minutes. Major complications related to the surgery were observed in 12.26% of patients, including eight hematomas and five seromas. Two patients experienced wound dehiscence, and no dystrophic scar formation was observed. Eventually, there was no need for a conversion to general anesthesia. CONCLUSIONS: Tumescent local anesthesia combined with subdural anesthesia is a highly effective and safe method for performing abdominoplasty. This technique has proven to be an excellent choice for primary abdominoplasty, providing significant benefits to patients and surgeons alike due to its safe administration, precise pain management during and after surgery, and minimal postoperative side effects. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Use of Radiofrequency-Assisted Liposuction (BodyTite) for Upper Arms Lifting.

BACKGROUND: Body contouring surgery is increasingly requested by patients, both for aesthetic and post-bariatric purposes. There has also been a rapid increase in demand for noninvasive aesthetic treatments. While brachioplasty is burdened by numerous complications and unsatisfactory scars, and conventional liposuction is unsuitable for all patients, nonsurgical arm remodeling performed with radiofrequency-assisted liposuction (RFAL) allows to effectively treat most of patients, regardless of the amount of fat and ptosis of the skin and avoiding surgical excision. METHODS: A prospective study was conducted on 120 consecutive patients who presented to the author's private clinic and required upper arm remodeling surgery for aesthetic purposes or after weight loss. Patients were classified according to the modified classification of El Khatib and Teimourian. Pre- and posttreatment upper arm circumferences were taken after 6 months of follow-up to assess the degree of skin retraction obtained by treating the arm with RFAL. A satisfaction questionnaire regarding the appearance of the arms (Body-Q upper arm satisfaction) was administered to all patients before surgery and after 6 months of follow-up. RESULTS: All patients were effectively treated with RFAL, and no cases required conversion to brachioplasty. The average reduction in arm circumference was 3.75 cm at 6 months follow-up, and patients' satisfaction increased from 35 to 87% posttreatment. CONCLUSIONS: Radio frequency is a valid tool to treat most patients with upper limbs skin laxity, with significant aesthetic results and a high degree of patient satisfaction, regardless of the degree of skin ptosis and lipodystrophy of the arm. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Back to the future: breast surgery with tumescent local anesthesia (TLA)?

PURPOSE: Breast surgery is usually performed under general anesthesia. Tumescent local anesthesia (TLA) offers the possibility to anesthetize large areas with highly diluted local anesthetic. METHODS: In this paper, the implementation, and experiences with TLA in the field of breast surgery are discussed. CONCLUSION: For carefully selected indications, breast surgery in TLA represents an alternative to ITN.

Tumescent local anesthesia versus general anesthesia for subcutaneous implantable cardioverter-defibrillator implantation: A cost-effectiveness analysis.

BACKGROUND: General anesthesia (GA) is the standard anesthetic approach for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation. Nonetheless, GA is expensive and can be associated with adverse events. Tumescent local anesthesia (TLA) has been shown to reduce in-room and procedural times and to decrease post-procedural pain, all of which could result in a reduction in procedure-related costs. OBJECTIVE: The purpose of this study is to compare the cost-effectiveness of GA and TLA in patients undergoing S-ICD implantation. METHODS: The present study is a prospective, nonrandomized, controlled study of patients who underwent S-ICD implantation between 2019 and 2022. Patients were allocated to either the TLA or the GA group. We performed a cost analysis for each intervention. As an effectiveness measure, the 0-10 point Numeric Pain Rating Scale at 1, 12, and 24 hours post-implantation was analyzed and compared between the groups. A score of 0 was considered no pain; 1-5, mild pain; 6-7, moderate pain; and 8-10, severe pain. Cost-effectiveness was calculated using incremental cost-effectiveness ratios. RESULTS: Seventy patients underwent successful S-ICD implantation. The total cost of the electrophysiology laboratory was higher in the GA group than in the TLA group (median ± interquartile range US$55,824 ± US$29,411 vs US$37,222 ± US$24,293; P < .001), with a net saving of $20,821 when compared with GA for each S-ICD implantation. There was a significant decrease in post-procedural pain scores in the TLA group when compared with the GA group (repeated measures analysis of variance, P = .009; median ± interquartile range 0 ± 3 vs 0 ± 5 at 1 hour, P = .058; 3 ± 4 vs 6 ± 8 at 12 hours, P = .030; 0 ± 4 vs 2 ± 6 at 24 hours, P = .040). CONCLUSION: TLA is a more cost-effective alternative to GA for S-ICD implantation, with both direct and indirect cost reductions. Importantly, these reduced costs are associated with reduced postprocedural pain.

Application of ultrasound-guided tumescent local anesthesia in prepectoral pacemaker implantation: A detailed procedural report.

Ultrasound image-guided tumescent local analgesia (TLA) is an effective technique in prepectoral pacemaker implantation surgery. The technique provides enough analgesic effect, at the same time, the pocket creation procedures become easy because of the hydrodissection effect of TLA solution. This technique relieves patients from intra-operative pain and relieves physicians from stresses during pocket creation.

Tumescent local anesthesia versus general anesthesia for subcutaneous implantable cardioverter-defibrillator implantation.

BACKGROUND: Subcutaneous implantable cardioverter-defibrillator (S-ICD) is an effective alternative to transvenous implantable cardioverter-defibrillator. General anesthesia (GA) is considered the standard sedation approach because of the pain caused by the manipulation of subcutaneous tissue with S-ICD implantation. However, GA carries several limitations, including additional risk of adverse events, prolonged in-room times, and increased costs. OBJECTIVE: The purpose of this study was to define the effectiveness and safety of tumescent local anesthesia (TLA) in comparison to GA in patients undergoing S-ICD implantation. METHODS: We performed a prospective, nonrandomized, controlled, multicenter study of patients referred for S-ICD implantation between 2019 and 2020. Patients were allocated to either TLA or GA on the basis of patient's preferences and/or anesthesia service availability. TLA was prepared using lidocaine, epinephrine, sodium bicarbonate, and sodium chloride. All patients provided written informed consent, and the institutional review board at each site provided approval for the study. RESULTS: Sixty patients underwent successful S-ICD implantation from July 2019 to November 2020. Thirty patients (50%) received TLA, and the rest GA. There were no differences between groups with regard to baseline characteristics. In-room and procedural times were significantly shorter with TLA (107.6 minutes vs 186 minutes; P < .0001 and 53.2 minutes vs 153.7 minutes; P < .0001, respectively). Pain was reported less frequently by patients who received TLA. The use of opioids was significantly reduced in patients who received TLA (23% vs 62%; P = .002). CONCLUSION: TLA is an effective and safe alternative to GA in S-ICD implantation. The use of TLA is associated with shorter in-room and procedural times, less postprocedural pain, and reduced usage of opioids and acetaminophen for analgesia.

Three-step tumescent local anesthesia technique for inguinal hernia repair.

The optimal method of anesthesia for inguinal hernia repair is still controversial. We have developed "three-step tumescent local anesthesia (TLA) technique" for inguinal hernia repair, and recently showed that this technique is acceptable in view of short- and long-term clinical outcomes. Our study included 273 consecutive cases (290 sides) of elective inguinal hernia repair performed under the newly developed technique between September 2003 and May 2019, and overall clinical outcomes were considered to be safe and feasible. Herein, we report the surgical procedure of "three-step TLA technique." Briefly, we rapidly inject the diluted solution of local anesthetic and epinephrine step-by-step into the three following closed tissue space. Initially, 80 mL injection into the subcutaneous tissue before skin incision (Step 1). After the external oblique fascia is exposed, injection of 20 mL into the inguinal canal before the external oblique fascia is incised and opened (Step 2). The hernia sac and spermatic cord are then dissected, and the blunt dissection of the preperitoneal space is made by injecting 20 mL under the internal inguinal ring (Step 3), followed by placing a gauze into the preperitoneal space, creating the space for mesh placement. We consider that the most important point of this technique is achieved through the rapid injection of TLA solution into each closed tissue space, which makes for easier dissection, hemostasis, and good pain control.

Single-incision laparoscopic totally extraperitoneal inguinal hernia repair with tumescent local anesthesia: report of more than 2000 procedures at a day-surgery clinic.

PURPOSE: The purpose of this study was to evaluate the feasibility and safety of single-incision laparoscopic surgery for totally extraperitoneal inguinal hernia repair (SILS-TEP) with tumescent local anesthesia (TLA) at a day-surgery clinic. METHODS: We analyzed, retrospectively, 2148 patients who underwent SILS-TEP under general anesthesia with TLA between April, 2015 and March, 2020 at Gi surgical clinic, to evaluate their operative outcomes. The TLA agent, consisting of normal saline and lidocaine with epinephrine and ropivacaine, was injected during surgery. RESULTS: The median operative times for unilateral and bilateral hernia were 50 min and 75 min, respectively. Blood loss was minimal in all patients. Conversion to the Lichtenstein method was required in 4% (91/2148) of patients. The median recovery room stay was 125 min and no analgesics were required in the recovery room by 75% (1613/2148) of the patients. All the patients left the clinic on the day of surgery. Complications developed in 6.5% (139/2148) of the patients, as seromas in 6% (125/2148), wound infections in 0.4% (8/2148), and hematomas in 0.2% (4/2148), respectively. Bowel injury and obstruction each occurred in 0.05% (1/2148) of the patients. There were no hernia recurrences. CONCLUSION: SILS-TEP with TLA can be performed safely at a day-surgery clinic.

Evaluation of tumescent local anesthesia in cats undergoing unilateral mastectomy.

OBJECTIVE: To evaluate the analgesic efficacy and safety of tumescent local anesthesia (TLA) in cats undergoing unilateral mastectomy. STUDY DESIGN: Prospective clinical trial. ANIMALS: A total of 12 ovariohysterectomized female cats. METHODS: All animals were premedicated with pethidine (4 mg kg-1) intramuscularly (IM), followed by induction of anesthesia with propofol (5 mg kg-1) intravenously and maintenance with isoflurane in oxygen. A refrigerated TLA solution (15 mL kg-1, 8 °C) was injected using a Klein cannula. The solution was composed of 0.5 mL of epinephrine (1 mg mL-1) and 40 mL of 2% lidocaine added to 210 mL lactated Ringer's solution (final lidocaine concentration 0.32%). Heart and respiratory rates, systolic arterial blood pressure, temperature and oxygen saturation were measured during anesthesia. Blood samples were collected from the jugular vein for measurement of plasma lidocaine concentration using high performance liquid chromatography. Postoperative pain scores were evaluated hourly for 6 hours. Analgesic rescue was performed with tramadol (2 mg kg-1) IM and meloxicam (0.15 mg kg-1) subcutaneously. RESULTS: Plasma lidocaine concentration peaked at 90 minutes after injection of TLA, but no concentration considered toxic for the species was measured. The median postoperative analgesia time was 6 hours after injection of TLA. CONCLUSIONS: This study found that TLA prevented sympathetic response to noxious stimuli during anesthesia and provided satisfactory postoperative analgesia in cats submitted to total unilateral mastectomy, with no apparent signs of toxicity. CLINICAL RELEVANCE: TLA can prevent sympathetic stimulation resulting from noxious stimuli during anesthesia, promoting good intraoperative conditions, proving to be a viable addition to analgesia in cats submitted to a total unilateral mastectomy.

Comparison of tumescent local anesthesia vs normal anesthesia technology in upper blepharoplasty in Asian women.

BACKGROUND: Blepharoplasty is the most common type of plastic surgery, used to improve most of the eyelid skin sag caused by aging. In the past, local infiltration anesthesia was widely used in blepharoplasty. Tumescent local analgesia (TLA) is safe and reliable method for anesthesia, even children can use this method. AIMS: This research aimed to systematically compare the differences between conventional local infiltration anesthesia and TLA in blepharoplasty. PATIENTS/METHODS: One hundred and seventy-eight bilateral upper blepharoplasty patients participated in this research. Visual analog scale (VAS) was employed to evaluate the postoperative pain in the patients. Periorbital appearances are based on light photography and judged by both medical and nonmedical panel. RESULTS: The use of TLA decreased the surgery duration but had no influence on the other surgery characteristics of upper blepharoplasty. Using TLA for anesthesia in bilateral upper blepharoplasty generated less pain than using local infiltration anesthesia. At day 7 after upper blepharoplasty, the rate of generation of both ecchymosis and erythema in normal anesthesia (NA) side were higher than in TLA side. The satisfaction of patients after upper blepharoplasty was not influenced by the use of different anesthesia methods. CONCLUSION: Compared with the normal anesthesia technology, the use of TLA in the upper blepharoplasty shortened the surgery duration, alleviated the postoperative pain, and mitigated the generation of ecchymosis and erythema. So, TLA is suitable for the performance of anesthesia in blepharoplasty.

Latest Advances in Wide Awake Hand Surgery.

Injection of tumescent local anesthesia should no longer be painful. WALANT anesthesia, strong sutures, a slightly bulky repair, intraoperative testing of active movement, and judicious venting of the A2 and A4 pulleys improve results in flexor tendon repair. WALANT K wire finger fracture reduction permits intraoperative testing of K wire stability with active movement to facilitate early protected movement at 3 to 5 days after surgery. WALANT can decrease costs and garbage production while increasing accessibility and affordability. Several surgeons have found no infection difference when the K wires are inserted with full operating room sterility versus field sterility.