Awake for breast augmentation?

Lavinia Chong, MD
Article by
Orange County Plastic Surgeon

I was recently asked to comment on a developing trend, in which some surgeons are performing breast augmentation on patients using oral meds and local anesthesia, in order to enable them to be "propped up", in the middle of the operation, in order to participate in the choice of the size of their implants.

Patient selection is a key component of any successful surgical procedure. As of this writing, I do not know of any practice which offers the technique of local and oral sedation for primary breast augmentation in Orange County, CA although some physicians do recommend this for liposuction, which is theoretically less invasive. Given a highly motivated and healthy patient, it would be feasible to implant a breast implant in the subglandular plane (on top of the chest muscle). By contrast, it would be technically impossible to elevate the chest (pectoral) muscles off the rib cage; it would simply exceed a patient's pain threshhold. Imagine an anxious, moving target in proximity with sharp instruments; the potential for complications (bleeding, infection, injury to surrounding structures, pneumothorax) is mind boggling. Technical considerations aside, this trend raises some medicolegal conundrums.

Consider three components of a cosmetic surgical package: Patient/Surgeon/"Disease". "Patient" is both an adjective and a noun, which describes what the individual lying on the operating table has to provide and be. The surgeon's responsibilities include but are not limited to evaluating the patient's pre-operative status, optimizing his/her health intraoperatively and providing consultative support, post-operatively. The "disease" is "unacceptable cosmetic appearance" not a life-threatening condition. While much is made of the patient-physician alliance, the physician always bears the greater burden both as patient advocate as well as discharging their professional duty. When offering an alternative anesthetic experience, the physician should ideally disclose all possible risks, benefits, alternate therapies as well as consequences of not proceeding. It appears that the surgeons quoted have abandoned their "patient advocate" role in yielding to patient request for autonomy in participating in their health care. Have they completely forgotten about the principles of "informed consent", which provide that the presence of altered levels of consciousness, such as that produced by medications, head injury, intoxications?

As the Health Care Reform package drives more physicians to fee-for-service medicine, I suspect that the envelope will be "pushed" further. My surgical training included five years of general surgery and three years of plastic surgery. Notwithstanding, I like to feel that I am progressive. All cosmetic patients are offered their choice of operating room (at the local community hospital, at a free standing surgery center and at my state licensed surgical suite). Both my patients and I frequently worry about "intraoperative awareness" and "slow emergence", so our Board Certified Anesthesiologists use brain wave monitors to dose the medications precisely to the patient's requirements. The anesthetic drugs used are powerfully anti-nauseagenic, have a gradual onset and are relatively quickly metabolized. In my experience, most patients want something safe, predictable with a set start and end. Having to shoulder the responsibility of choosing their breast implant size, while under the influence, doesn't conform to this.