Awake Plastic Surgery? Newest and Bestest or Awake Mistake?

Andrew Kaczynski, MD

Article by
Sacramento Plastic Surgeon

There is a fascinating and terrifying article in the January, 2011 Self Magazine entitled "Under The Knife." This article is about the latest and scariest trend in plastic surgery, “awake surgery.” It documents several mind-bending horror stories for awake liposuction, breast implant surgery, and tummy tucks, which are essentially power screaming torture sessions. Awake surgery is being promoted by a group of non-plastic surgeons who have learned these procedures during weekend courses rather than years of plastic surgery residency. Typically the patients are given a small amount of oral sedation such as Valium. Then a Lidocaine containing solution is injected into the area of liposuction or into the breast to achieve numbness. After that the procedure is undertaken by a doctor who uses more hope than skill. Supposed advantages are that this avoids the risk of general anesthesia, which can cause one death in 200,000 to 300,000 patients. Unfortunately, the amount of local anesthetic that sometimes has to be injected for this to work flirts with the level of known toxicity and can also cause death. Death from too much local anesthetic can occur hours after surgery because the local levels actually build up in the blood over time. So in other words, the toxic levels may begin to cause reaction hours after the patient has gone home.

The worst problem however is inadequate pain control. In the end, some patients simply feel more than others for reasons that are not clear. So some patients undergoing these awake surgeries will not know that they are going to feel significant pain until the pain starts. Once the patient has been giving the limit of local anesthesia and they are still experiencing extreme pain, two things can happen. Number one, the doctor continues and tries to ignore the patient's screams, or, when the screaming is too much to bear the doctor stops and does an inadequate removal which will likely need to be repaired by a real Board Certified plastic surgeon.

In breast implant cases, this technique allows the practitioner to put the implant under the breast but not under the muscle. In order to release the muscle, which allows the implant to be inserted under, it takes general anesthesia. With an inadequate muscle release, the implants never settle and can often take on a funny shape. The article cites one case in Las Vegas where an implant actually began to work its way back out of the incision days later! That patient ended up needing emergency surgery where it was discovered that the doctor who placed the implants had done a butcher job on her and even left some random sutures in the pocket.

The other disturbing issue for these procedures is the amount of time they appear to take. Although technically it is safer to do a longer procedure under local then the six-hour limit which we accept for general anesthesia, there is no reason to keep the patient on the table for eight hours or spread a simple liposuction into two or three days which is apparently what these doctors do. In my hands a three area liposuction takes about three hours under anesthesia. A breast augmentation takes about 45 minutes. There is no reason at all why these should be expanded to eight hour torture sessions but for some reason, the skill levels or the difficulties presented by trying to do these surgeries under local appear to expand the surgical time by a factor of four.

Why is there this new interest in awake surgery? Well there are several reasons. Number one to do the awake surgeries you don't need an operating room. You can do it in any old exam room. Number two it opens up the procedure is to family doctors, gynecologists, internists, and emergency room doctors who are struggling financially with insurance reimbursements. It doesn't matter if they have often minimal or no surgical training or background. Number three monitoring of operating facilities is based on the level of anesthesia. So in other words, the less anesthesia you use for your procedures, the less oversight there is.

That is to say, if you have an M.D., you can do any surgical procedure in your office including a heart transplant if you do it under local. As soon as you do some sort of sedation you are subject to accreditation and oversight. Most of these offices that do awake procedures would never survive scrutiny in the light of day. Tiny cramped operating rooms, (and I use that term loosely), which are subject to contamination, lack of sterility, lack of gowning by the so-called surgeon and his staff are all issues. There is no accreditation or peer review. There is no one looking at these dirty deeds done dirt cheap.

Then what happens after the patient heals from the procedure. I just did a four hour liposuction revision on the patient who was the second experiment of her gynecologist who had just "learned" how to do liposuction. On-the-job training so to speak. This patient had a symmetric mounds of fat on the front of her abdomen as well as depressions and unevenness. Under proper sedation with an IV and a nurse anesthetist, the patient was extremely comfortable. She didn't have to have a tube in her mouth. And I had to redo everything which was more difficult than if I had seen her initially without any previous surgery. On top of that she had major asymmetries which had to be adjusted and needed fat removed certain places and placed into others. Lastly because she had so much rippling and wrinkling in her upper abdomen I had to do a reverse tummy tuck with incisions under the breasts. Fortunately, everything went very well and she had an excellent result. It's too bad that she had to have two procedures to get to that place. It would have been easier for me and cheaper for her if she had just come to me in the beginning.

I think everyone considering plastic surgery should read the article from Self Magazine. They should also realize that for all the posturing done by people that promot it, it is not about safety and it isn't about the well-being of the patient. It is about a group of unqualified untrained unscrupulous physicians trying to cash in on the demand for plastic surgery. Is there a place for awake procedures? Of course there is. I do some minor procedures and small revisions under local. These procedures are brief, the can-do anesthesia is excellent and everything goes well. There is no place in modern plastic surgery for eight hour torture sessions. Research your physician and the facility well. It's a jungle out there and it's full of predators just waiting for the unsuspecting patient.