Four types of anesthetic approaches are commonly used on patients undergoing liposuction. The local only, or tumescent approach, pioneered by dermatologist Jeffrey A. Klein, MD, is a time consuming approach that is favored by the dermatologic surgical community (www.aad.org). This entails keeping the patient entirely awake or minimally sedated with oral medication. The tumescent solution works to swell the fat tissues. This approach may hurt the patient if not administered slowly, and is therefore a very time consuming task.

More efficient use of the patients' surgery time can be achieved with either intravenous (IV) sedation, major conduction (spinal or epidural) or general inhalational anesthesia (GIA). All three of these approaches are combined with a "superwet" technique, which uses lesser amounts of tumescent fluid. This anesthetic mixture contains both lidocaine, a pain reliever, and epinephrine, which acts as a blood vessel constrictor. The lidocaine provides non-opioid, preemptive pain relief, while the epinephrine greatly reduces the amount of blood lost during this surgery. Plastic surgeons and cosmetic surgeons tend to favor one of these three techniques. For more information, please see plastic surgeons (www.plasticsurgery.org or www.surgery.org), and cosmetic surgeons (www.aafprs.org or www.cosmeticsurgery.org).

Major conduction blocks, spinal or epidural, sometimes result in patients' complaints of soreness at the injection site in the back, delayed ability to urinate without assistance, and delayed discharge as the patient waits for the block to wear off. For the preceding reasons, Dr. Friedberg does not offer this alternative to his patients.

Drugs like desflurane, sevoflurane, and isoflurane for general inhalation anesthesia (GIA) are triggering agents for the very rare, often fatal syndrome of malignant hyperthermia (www.mhaus.org). Although the risk is low, Dr. Friedberg feels it is unacceptable when the PK technique is a proven alternative.

Since most patients prefer some alteration in their awake level of consciousness for the procedure and it is impractical to bring an anesthesia machine to many office-based practices, it is common to have intravenous (IV) sedation for liposuction. Many anesthesiologists favor the combination of propofol and alfentanil (a short acting, synthetic opioid) for IV sedation. A growing number of anesthesiologists in the US, UK, Canada, Australia, and Japan have become convinced that better results, medically referred to as outcomes, can be achieved using Dr. Friedberg's PK technique.

PK technique has been greatly simplified by the addition of the Bispectral Index® (BIS®) monitor (Aspect Medical System, Inc., Newton, MA - www.aspectms.com). With the monitor's measurement aid, the anesthesiologist knows just the right amount of anesthetic needed by the patient so that the patient receives no more anesthetic than absolutely necessary. In more medical terms, the monitor permits quantification of the safe range of propofol. This is important in helping to prevent rare occurrence of hallucinations from ketamine; arguably, this is the safest anesthetic drug in the anesthesiologist's toolbox. The dissociative state ketamine produces allows the injection of the local anesthetic into a motionless patient. In this way, the injection and the surgery provide no perceived pain stimulus to the patient. When the propofol infusion is turned off, patients awaken quickly with little discomfort and no PONV. With a rapid return to their pre-anesthetic mental state, patients are able to return home soon after their surgery is completed, with their surgeon's approval.

Bispectral Index® (BIS®) monitor   www.aspectms.com

Details of Dr. Friedberg's innovative PK technique, which provides narcotic-free pain relief, were published in Aesthetic Plastic Surgery 1993; 17:297-300. (No patient's identities were revealed.) The technique is designed to maximize patient safety while creating the illusion of general inhalation anesthesia, i.e. "no hear, no feel." The article has been subsequently cited in twelve peer-reviewed journal articles, and one surgery and four anesthesia textbooks. This is noteworthy because half of all journal articles in print are never referred to in subsequent articles. Several subsequent articles by Dr. Friedberg have also been published.

In the past decade, Dr. Friedberg has successfully performed his PK technique on more than 600 liposuction patients, with more than 25 different surgeons. Many of these procedures were documented (without revealing the patients' identities) in his five-year review article published in Aesthetic Plastic Surgery 1999; 23:70-75. No patients were admitted to the hospital for uncontrolled pain or PONV, the two most common causes of post-operative hospital admission following a day surgery.