Hello, I'm 41 y/o & l've been searching for a Board certified surgeon who would perform local anesthesia with sedation. I had a consultation with one he is board certified & uses tumescent technique with IV sedation. I did my research & I've seen his great reviews, he's reputable surgeon but I noticed that not a lot of first rate doctors uses this approach, How safe is local anesthesia tumescent with IV sedation?
Local Anesthesia (Tumescent Technique) & IV Sedation for Breast Augmentation?
Doctor Answers 19
Local Anesthesia and IV Sedation for Breast Augmentation?
This is a good question and more complex than it appears on the surface. I would start to answer it by asking the question, why do you want to do it with IV sedation and local? Is it because you percieve it to be safer than general anesthesia? If so, you are mistaken. Breast Augmentation is a relatively short operation and can be done very safely when performed under light general anesthesia provided by a Board Certified Anesthesiologist. I personally only use board certified MD anesthesiologists. While local with sedation may have some benefit of quicker recovery from anesthesia with less risk of nausea, it is definitelly not safer, and potentially more dangerous depending on who is providing the anesthesia and what type of augmentation is being performed.
Are you talking about submuscular or subglandular augmention? There are multiple benefits to submuscular augmentation but it is definitely a more painful operation. If one attempts to do this with sedation and local it can be very difficult to get the patient comfortable thus requiring increasing large amounts of sedation. At a certain point, you are essentially recieving a general anesthetic. If there is an MD anesthesiologist performing the sedation they can safely monitor the level of sedation and intervene in a timely manner to keep you breathing. If the surgeon is performing the sedation they are focusing on your surgery (as they should be) and not on your anesthesia. And this is where things go wrong, patients arrest, and suddenly local with sedation is not so safe.
Subglandular augmentation is less painful and easier to do under local with sedation. But subglandular augentations have significantly more risk of visible rippling in the upper pole, particularly with saline implants, and with larger implant sizes. Several times a year I see patients with upper pole rippling problems and almost invariably they got talked into doing a subglandular implant under local with sedation, often because it was cheaper. Several years later they are looking at an expensive revision for a problem that is a direct result of how the original surgery was performed. Was that really a bargain?
While it is definitely possible to do breast augmentation under local with sedation, from what I have seen, breast augmentation done this way has more to do with maximizing surgeons profits, than it does with patient safety and optimal outcomes. Your are correct in noting that the highly rated surgeons use general anesthesia, and for good reason, and those that don't are certainly outliers, and may be compromising your outcome and in some situations your safety.
Breast Augmentation with sedation
First you said that you are looking for a Board Certified "surgeon". Please tell me that you are looking for a Board Certified Plastic Surgeon. This means that your plastic surgeon trained in an ACGME accredited specialty residency for 2 to 3 years and was deemed competent to perform plastic and reconstructive surgery by the program chairman prior to being allowed to take the boards.Plastic and Cosmetic surgery boards are not equivalent! The board of cosmetic surgery is not an ACGME accredited specialty. You don't want an ENT or maxillofacial surgeon doing your neurosurgery for you do you? Then why would you want them to do your breast surgery. Also, check the credentials of your plastic surgeon. This includes his or her hospital credentials and affiliations, any state actions in the past and standing with professional societies. Plastic surgeons are trained in breast surgery throughout their residency where they perform complex reconstructive and cosmetic breast surgery. Plastic surgeons are required to pass extensive written and oral examinations and most have had up to 7 or 8 years of surgical training. This is the minimum; then look at the skill of the surgeon and his or her artistic sensibilities. It is not just about placing an implant in the pocket, but understanding the varied breast anatomy and nuances, having a deft hand, sound clinical judgement and an artistic sensibility of space and balance. Most importantly find someone that you click with and has all of the above; someone who listens carefully to your concerns.
Your question about intravenous sedation versus general anesthesia is excellent and important. The safety of the procedure and anesthesia is one of the most common concerns of my patients. It is possible to perform breast augmentation safely and carefully with intravenous sedation with local nerve blocks or/and tumescent technique; I performed breast augmentation using this method early in my career, using a nurse anesthetist. I moved to general anesthesia using an anesthesiologist in the late 90's for safety reasons. An anesthesiologist is a specialist in critical care who is specifically trained to safely get you through your surgery and to respond to any anesthesia related emergency. They are specialist physicians that have a high level of medical training and must pass rigorous medical boards too. They are trained to respond to the most esoteric and unusual situation which provides a higher level of safety for my patients.
I perform primarily sub-muscular breast augmentation which has significant cosmetic and medical advantages versus above muscle implants for most patients. How are the implants going to be placed? Who is giving the sedation? Sub-muscular breast augmentation can be uncomfortable and if one is doing iv sedation then one can risk giving too much sedation and risking the patients airway and therefore oxygenation to that patient without the proper equipment and personnel. The use of proprofol with iv sedation must only be performed by a nurse anesthetist or anesthesiologist in the office setting. If iv sedation is used, there should be back up general anesthesia in order to secure the airway if pain cannot be controlled or in the event of an emergency. My equipment is state of the art and we have the capability and personnel to respond to all emergencies in the operating room. Very good studies have shown that general anesthesia is as safe as other techniques and in fact may be safer. With the short acting agents available and improved techniques to control nausea, and the ability of the anesthesiologist or nurse anesthetist to completely monitor and protect the patient's airway, when iv sedation risks loosing that control if the pain is not controlled otherwise, why would one want to use sedation, especially when the differences between sedation and general anesthetic agents is so minimal and the drugs are almost identical? Why do I want to give the blocks and tumescent and nerve blocks and risk complications from this when I have someone who can keep the patient completely comfortable and safely asleep! In the past year there has been a tumescent anesthesia related death in a liposuction case in a local, well known clinic. The marketing that iv sedation or local anesthesia is safer than general anesthetic is simply not true when there are not the right safeguards in place, with adequate equipment and personnel.
I encourage you to visit the clinics in the area and do your homework. It is not just about the type of sedation but the skill and expertise of your plastic surgeon. I have performed several thousand breast surgeries and continue to listen and treat each patient, one woman at a time. I perform many of the cases using a hidden incision, trans-axillary, (armpit), endoscopic approach, which my colleagues and I developed while I was a plastic surgery fellow and assistant professor of plastic surgery almost 20 years ago. The type of incision to use as well as the alternatives of implants size and style is best determined at the consultation. We have a Vectra 3D imaging system that allows you to compare the implants in your body.
Tumescent and IV Sedation for Breast Augmentation
Tumescent and IV sedation is appropriate if an anesthesiologist is present during the surgery. This is both to protect your airway and monitor vital signs and to switch to general in the advent of patient discomfort. Kenneth Hughes, MD Los Angeles, CA
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Local vs General Anesthesia
We never do a major surgery (and yes, Breast Augmentation is major) without a board certified anesthesiologist sitting at the patient's side. And I have not used local/sed for a breast augmentation in 20 years. General anesthesia with an anesthesiologist on a healthy patient has about the same safety that local/sed has and is far safer than local/sed without an anesthesiologist in the room. From talking with patients it seems that most of them that are offered local/sed without an anesthesiologist present were at a facility that was not built and certified for general anesthesia and that is all they had to offer. When a patient asks me if they can have the surgery with local/sed I smile and say of course, but not with me. I have yet to lose a patient because of that as they understand I take no short cuts and am as interested in their safety as I am in their comfort.
Anesthesia for breast augmentation
For me, it takes 35-40 minutes to do a standard augmentation and I only use MD anesthesiologists. For them, a healthy patient with a very short procedure is most safely done with an LMA general anesthetic. The patients usually answer the phone when I call them that night and don't look like they've had any anesthesia the next day because modern drugs are so fast acting and resolving.
I know of one case in my area where a surgeon was doing an augmentation under local, did nerve blocks to get the patient numb, and punctured both lungs resulting in a cardiac arrest and brain death. Therefore, for me, the quick LMA GA is the way to go.
General anesthesia versus IV sedation for breast augmentation
Awake breast augmentation
Your airway is actually less protected with local anesthesia and tumescent technique. Maybe these surgeons do not have certification for general anesthesia in their office which is a more stringent code
Local Anesthesia & IV Sedation for Breast Augmentation?
While either technique (general anesthesia or iv sedation) is perfectly satisfactory, my personal preference is for sedation. Whether the patient and the anesthetist choose one or the other, I will use local anesthesia including rib blocks to provide some relief from early post op discomfort. With either technique, an anesthesia provider will be responsible for your comfort and safety during the procedure.
IV sedation is equally safe, and I would not let the choice of anesthetic technique interfere with your choice of surgeon. All the best.
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