Position: Supine, Prone, Lateral
Time: 2-4 hours (long)
Blood Loss: Moderate (50 – 200 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Generally not required

Approach – Typically general anesthesia with an ETT due to prone positioning, and duration of the surgery.

Risks – Fat embolism is a possibility, but extremely rare. The general concerns of the tumescent solution should be also considered (see below).

Prone Position (general considerations): Maintain cervical neutrality. Keep IV’s out of the antecubital space. The patients arms are typically flexed, which will kink the IV. Eye protection should be used as the prone position heightens the risk of corneal abrasion and/or traction on the globe (which can result in blindness). Check the patients eyes/ears/nose regularly throughout the case to ensure they are free of pressure. Positioning of the leads is typically high on the posterior and posterolateral back (somewhere free of pressure and out of surgical borders). Keep your connections and tubing where you’ll have fast access.

Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape.  Unhook anesthesia circuit while turning lateral and be especially careful to keep patient’s head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient’s head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn’t being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

Tumescent (general considerations): Maximum safe dosages of tumescent lidocaine are 28 mg/kg without liposuction and 45 mg/kg with liposuction. Peak serum concentrations typically occur 13–14 hours. This long peak implies that Local Anesthetic Toxicity (LAST), which is the primary concern of tumescent, could occur well after the procedure. Lipid emulsion therapy should be readily available. Tumescent solution also contains epinephrine and sodium bicarbonate. Epinephrine is a vasoconstrictor and delays the systemic absorption of the lidocaine. Epinephrine in high doses can cause hypertension, tachycardia, and arrhythmias. Sodium bicarbonate serves a few purposes: It buffers the solution, reducing the level of pain on injection, and also reduces the onset time of lidocaine.

This surgery is purely cosmetic. It is performed to augment the shape and size of the buttocks without implants.

The surgeon will begin with liposuction of the abdomen, flank, thighs, or back. The fat will be removed from these areas and then injected into the hips and buttocks.

Fat is injected only into the subcutaneous layer and not the muscle or fascia. Injections into the muscle increase the risk of a fat embolism.