What anesthesia should I use for breast augmentation?

Question

I am considering Breast Augmentation and I've noticed that some surgeons use twilight anesthesia while others use general anesthesia. What are the benefits of one type over the other in Breast Augmentation surgery?

Ricardo L. Rodriguez, MD · Answer

Since I own my own surgicenter, I have a complete control over who my anesthesiologist is. I use exclusively MD anesthesiologists. Incredibly enough, it is hard to find an MD anesthesiologist who is proficient at Sedation anesthesia.
I myself had to learn how to use local anesthetics in an efficient and comprehensive way so as to minimize the amount of sedation given. A good team proficient in the technique will give you:
1) Great analgesia during surgery- you will not feel anything
2) Amnesia- I have yet, in a year and a half of using exclusively sedation for breast augs, have a patient tell me they remembered anything.  As a matter of fact, it is EASIER for a patient to get "light" during general anesthesia (while paralyzed with a tube down their throat) and remember stuff, than it is for a sedated patient with an anesthesiologist competent in sedation techniques. The reason is that during sedation the anesthesiologist will be better able to see and monitor the patient getting light than during general anesthesia.
3) Better analgesia AFTER surgery- Because the nerves were anesthetized BEFORE surgical injury, and because of the greater reliance on longer acting local anesthetics, the patient has less pain after surgery. There is plenty of experimental evidence backing this up.
Sedation gets a bad rep because many MD anesthesiologists learn mostly General anesthesia during their residency and don't feel comfortable with sedation. Sedation is harder and requires more concentration to find the "sweet spot".  An MD anesthesiologist not proficient with sedation techniques takes the patient on a roller coaster ride where sometimes the patient is too light, then he overreacts and overmedicates and you find yourself struggling to keep the patient's airway open. An  MD anesthesiologist proficient in Sedation techniques gives the patient a smooth ride and the airway is never in question.
I did Breast Aug with General anesthesia for many years, and the best testimonials come from patients who have had both types performed. There is no question they prefer sedation. I will never go back to general anesthesia. In longer cases General Anesthesia has higher risks of pulmonary embolus and pulmonary complications, and in all cases, patients feel much worse after surgery. If it was my daughter, or wife, (or even me!), sedation is the way to go.

Young R. Cho, MD, PhD · Answer

Thank you for your question. Both types of anesthesia can provide a safe and comfortable platform for breast augmentation surgery.  It is more important that you feel comfortable with your surgeon and the surgical plan as this is ultimately what you will be remembering after the procedure.

Otto Joseph Placik, MD · Answer

I always use general anesthesia for breast augmentation. You should really be asleep for the procedre for your comfort and also so the surgeon can work more efficiently. You are also sat up to make sure the implants are even. Being asleep is better.

Kelly Gallego, MD, FACS · Answer

During breast augmentation, I prefer to use general anesthesia. Patients are kept comfortable, and entirely relaxed during the procedure. Because patients are typically healthy, there is no added risk to having patients completely asleep with a general anesthetic.

York Jay Yates, MD · Answer

I was trained to do breast augmentation using exclusively general anesthesia.  For six years of residency and first year out this was my routine.  I had heard of colleagues doing breast augmentation under sedation and my initial thought was, why?  
Having spent five years since that time doing breast augmentations with deep sedation and excellent local anesthesia I have found a number of advantages and sedation is now my preferred method.
A little background regarding how I prefer to do this is necessary.  
The level of sedation that I use is moderate to deep sedation with propofol, deeper than what I would consider "twilight anesthesia".  I use a board certified anesthesiologists, which I feel is very important for patient safety.  After an initial bolus of propofol, the breasts are completely anesthetized with a large volume of diluted local anesthetic.  At this point the patient could be awakened without much pain.  However, my anesthesiologist keeps the patient at light to moderate sedation.  Any areas without adequate local anesthesia would be identified by patients response and additional local anesthesia can be used.  Long lasting local anesthetic for postoperative pain control is placed in the implant pockets through catheters after the procedure is complete.  There is little to no pain, remembered or forgotten during the procedure.
In my opinion, the disadvantages of this approach are:

Additional time and effort at the beginning of the procedure for placement of local anesthesia in exactly the correct place
Combining other large procedures at the time of breast augmentation is limited by the amount of lidocaine that can be safely used
The anesthesiologist has to be comfortable with titrating the correct level of sedation.  However, in 5 years and over 300 augmentations we have never had to intubate or even bag-mask a single patient.

In my opinion, advantages include:

Comfort - the local anesthesia HAS to be excellent.  Generally the patients have little to no pain immediately afterward when the pain is generally the worst.  (I don't want to be misleading here, that night when the blocks wear off it HURTS!!!)
Less "hangover" from anesthesia
Significantly less nausea (less anesthetic) 
Quick recovery - patients stay in recovery as long as they/ we need them to but this is generally only 15 - 30 minutes.  Patients are wide awake quickly and walk from the OR to recovery immediately afterward.
Cost - In office operating suite.

There are certainly advantages to both.  Your board certified plastic surgeon will discuss which he/ she is most comfortable with and which is most appropriate for you at the time of your consultation.

Steven H. Williams, MD · Answer

Thanks for the question Anesthesia can be performed in a number of ways and in combinations. Most plastic surgeons will perform the procedure under general anesthesia. This allows for maximum protection of your airway and provides maximum comfort of the patient allowing your surgeon to shape things perfectly. In our San Francisco office we typically do this procedure with general anesthesia but augment it with local anesthesia including pain pumps when appropriate. This allows our patients to safely have the procedure performed with the maximum comfort during and after the operation. I hope this helps.

Michael Law, MD · Answer

MAC anesthesia or general anesthesia can be administered. The choice would depend upon the presence of the patient, the anesthesiologist and the plastic surgeon. My preference is MAC. I always work with a board certified anesthesiologist  who remains at the bedside of my patients throughout the surgical procedure n my Joint Commission and AAAASF accredited  surgical suite.

Tom J. Pousti, MD · Answer

Thank you for your question.

I prefer General Anesthesia provided by a board certified Anesthesiologist.

I perform my surgeries in an out patient surgery center, and under general anesthesia only.  I use Board Certified Anesthesiologists  who monitor my patients from start to end so as to provide the safest environment for my patients.  I would recommend general anesthesia for breast surgery so that you are as comfortable as possible during the procedure.
	I would suggest that you be very careful with your surgeon  selection and experience. Safety should be the first priority in every surgery.

I hope this helps.

C. Bob Basu, MD, MPH, FACS · Answer

Breast Augmentation can safely be performed with general anesthesia or IV sedation with local. Either way, I recommend your anesthesia be performed by an anesthesiologist. In addition, I recommend you have your procedure done in a fully accredited hospital or ambulatory surgical facility. Accreditation, for example from AAAASF, means that the facility must meet certain standards to ensure your safety. Talk to your board certified plastic surgeon to see what he/she recommends/prefers.

Steven Wallach, MD · Answer

It really doesn't matter whether you use general anesthesia or sedation. The most important thing is that you have a experienced board certified anesthesiologist providing the anesthesia.

What anesthesia should I use for breast augmentation?

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