13 Anesthetics

What Kind of Anesthetic is Recommended for Cosmetic Surgery?

There are three levels of anesthesia, although in practical terms they blend into one another:

• Local "tumescent" (usually lidocaine with epinephrine) possibly with some intramuscular or oral medications. This is often a dermatologist's method.
• "Monitored anesthetic care" or "twilight sleep," combined with local anesthetic. Our “diluted propofol only technique” (see below) used in our office is in this category.
• General anesthesia. No local anesthetic is needed, but physicians currently often combine this with the local anesthetic to reduce blood loss. The local also has some effect on post-operative pain.

Bear in mind that the first option is statistically less risky than the second, and general anesthesia is most risky. Exact risks of general anesthesia are difficult to establish. Suffice it to say that the risks of general anesthesia should never be minimized, that it should not be used casually, and that its use might represent a significantly increased risk of death. Several medical journal articles, including my own, suggest that it's use may be more hazardous with liposuction.

Using local anesthetic techniques certainly is possible, but after years of experience with this, we found that too many patients were having bad memories and pain. It's easier for surgeon and patient to combine this with twilight sleep, which is well tolerated and also very safe. We use “diluted propofol only technique,” combined with the tumescent anesthetic (an anesthesiologist, Dr. Barry Friedberg, described the PK or propofol-ketamine technique, but we quit using ketamine because we feel it's just an extra risk with little benefit). This results in virtually no nausea and rarely any memories after the procedure. In other words, people have the perception that they have been under general anesthesia with minimal side effects and risk. And the patients are so lightly sedated that after the drip is turned off, they wake up in just a few minutes. More information regarding this can be found in my academic paper, published in the American Journal of Cosmetic Surgery. It describes how we mix or dilute the propofol 10:1 in normal saline (sterile salt water) and drip it in through a micro-dripper so only a little can go into the body per minute. Extensive information and many academic papers about related anesthesia techniques can also be found at www.DoctorFriedberg.com. A detailed explanation of the tumescent local anesthetic is found in the next section.

It is my belief that most surgeons need a nurse anesthetist or anesthesiologist to safely administer "twilight sleep" anesthesia, and certainly for general anesthesia. In poorly trained hands, the drugs are more dangerous than the surgery. This is supported by a report of Los Angeles area fatalities caused by surgeon-administered anesthesia. However, as a board certified emergency physician (American Board of Emergency Medicine) and with the experience of many thousands of cosmetic surgery cases I have anesthetized, I feel confident with the single, diluted anesthetic agent I use. I do not use anesthesia professionals unless the patient requests one. We virtually never use any opiates (such as Demerol® or morphine) or Valium-class drugs (Versed® for example) intravenously. These medications, especially in larger doses, make the anesthetic and recovery process more unpredictable and dangerous.

Intravenous medications have much higher risk than those that are oral or intra-muscular. The most dangerous factor is that when more drugs that are added together, the risks go much, much higher. The American Society of Anesthesiologists recommends, at the minimum, that an individual trained in basic life support should be in the room to monitor the patient when anesthesia is administered by a non-anesthesiologist surgeon. A higher standard is to have licensed personnel - registered nurses or physician assistants — performing this duty. The modern machines constantly check the patients' blood oxygen, blood pressure, heart rate, and electrocardiogram during the procedure. There are beeper alarms if the readings are not right. This other person uses the equipment and his own observations to monitor the patient, as does the physician. Note also that general anesthesia procedures of any length must be accompanied by "automatic leg squeezer" or “pneumatic compression” garments to help prevent blood clots. These "milk" the blood out of the leg veins and back into circulation.

One last issue is time under anesthesia. We believe short procedures are much safer than longer ones. Longer anesthesia times (longer surgeries) lead to more chance of blood loss, higher rate of complications such as blood clots, more surgical trauma, and possibly higher infection rates. They may even indicate a clumsy or inexperienced surgeon. There's no excuse these days to cater to a patient's request for a prolonged "total makeover." Some evidence has developed that such surgeries are much more hazardous than the sum of the risks of each surgery done on different days.

Don't be fooled by claims that as long as you're in a physician anesthesiologist's hands, you are safe under general anesthesia. There are always risks. Generally speaking the fewer medications used, the safer the anesthesia is. And for general anesthesia an average of ten (10) different drugs are used! It's a bit of an art and every anesthesiologist is different. The anesthesiologist has the skills to “rescue” you from not breathing, but who wants to get into enough trouble to need to be rescued? Feeling bad—especially nausea—after surgery is mostly related to use of Demerol®/morphine (opiate class) drugs, but using lots of medications together may also be related. Our patients compliment us on the anesthetic experience, often saying that they feel just great as soon as 10 minutes after they wake up. Remember we use only one, single—and diluted—sedation medication.