Problem or panacea: “awake” cosmetic surgery

More and more, I see ads by non-plastic surgeons touting the alleged advantages of having major elective procedures, such as a tummy tuck or a breast augmentation, done “awake” – under local anesthesia. Invariably, these ads tout “avoid risky general anesthesia”, or “quick recovery”.

While liposuction under tumescent (local) anesthesia is an accepted and validated technique, performing breast augmentation or tummy tucks while awake is very controversial, to say the least. The New York Times recently did an investigation on this issue – their article is here (link)

Typically, these procedures are heavily advertised by cosmetic surgeons who are not board-certified in plastic surgery, and who do not have hospital privileges to work in the operating room. Their offices are usually not accredited, inspected surgical facilities. And they don’t typically have an anesthesiologist monitoring the patient.

Really, I feel that the “local anesthesia” angle is a bit of a dodge. It’s a clever bit of marketing spin. The reason most of these “wanna-be’s” promote this is because it’s their only option for anesthesia….they usually can’t get the hospital privileges or work in accredited surgery centers, due to lack of credentials.

There are also real disadvantages to the “local only” technique:
– It can be hard to numb large areas completely, even with the tumescent technique. Remember, just like when you visit the dentist, it can take a few painful shots before the injected area is numb.
– If the local isn’t working 100%, the patients may be fully aware and in pain, as the procedure goes on. I wouldn’t wish that on my worst enemy, thank you.
– You can’t get satisfactory muscle relaxation with just local anesthesia, either – which is important for procedures like tummy tucks, or sub-pectoral breast augmentation.
– it isn’t good for patients who are nervous, or who are resistant to lidocaine.
– lidocaine, the most commonly used numbing agent, isn’t risk free. Toxic doses can occur, resulting in seizures and cardiac arrhythmias.

If you want a rapid recovery from anesthesia, use an expert anesthesiologist, who can monitor the patient, and give them exactly the right doses of medication, keeping them comfortable, but not over-sedated.

Modern anesthesia, administered by an anesthesiologist in an accredited facility, is actually very safe. The risk of something bad happening under anesthesia is less than 1 in 57,000, according to recent studies. Essentially, you are far safer under anesthesia than you are driving your car to work every day.

As for the claims of “quicker recovery”, the recovery from the surgery depends more on the nature of the surgery, on delicate handling of the tissues by the surgeon, good hemostasis, and avoidance of tension on the tissues, all of which are skills that are stressed in Plastic Surgery school.

If I were to have a surgery done, I don’t want to feel it, see it, or smell it, thank you very much. Wake me up when it’s all over. Most of my patients feel the very same way.