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Sunday, March 18th, 2012
If we are to have any type of surgery, whether cosmetic or not, some type of anesthesia is required. In simplest terms this means eliminating the pain of the procedure. In practical terms, this also means reducing or eliminating the anxiety and other sensations surrounding the procedure.
There are several ways to define anesthesia depending on what is used, how it is administered and what the goal is.
Strict local anesthesia is the simplest. It blocks the nerves from sending back information on painful stimuli. This can be accomplished several ways. Topical application of a nerve blocker (local anesthetic) works best inside the mouth, but also reduces the sensation from injections through the skin. I use this for Botox® and filler injections. Some fillers now come with a local anesthetic mixed with the filler or we can mix them. By using topical to prevent feeling the initial needle stick, the anesthetic in the filler eliminates the feel of the injection itself.
The same or similar medication can be injected into the skin or around nerves to numb either a small area or an entire body part (local or regional anesthesia). To remove small skin lesions, I generally numb only the area where the lesion is. This can be expanded to very large areas. This is what we do for liposuction; the skin is injected to allow insertion of an injection canula which injects the numbing solution into the fat. If I am injecting a filler or fat harvested from the above area into the area around the mouth or under the eyes, I generally block the nerves that go to that area. This is a type of what is called a regional block. By selecting the nerves to be blocked, we can block the entire face for peels and laser or an extremity. Much of the hand surgery I do is done with just the arm numb. This has the added advantage of providing prolonged pain control postoperatively.
Although it is possible to do almost any surgery under only a block of some kind, this is seldom done for any significant surgery. The reason is that the numbing process can be uncomfortable and most people are too anxious to sit still enough during the procedure and would prefer to not know what is going on. There are two ways to handle this problem when using nerve block anesthesia. One is sedation, simply using a small dose of a drug to make you less apprehensive. This is usually an oral medication and can be used safely in non-certified facilities such as the office. We do this quite frequently for peels, laser, larger office based surgery and some filler injections. The second is what is called conscious sedation. This takes you to where you do not care about or, frequently, are not even aware of the surgery. This state of sedation not only reduces your awareness but depresses your normal reflexes and, occasionally your desire to breathe. Because of this, it requires careful monitoring in a certified facility such as the hospital. This is the type of sedation used frequently for colonoscopies and what I use in the hospital with regional blocks. It is usually achieved with IV (intravenous) administration of the sedative medication (the case when rules for use of conscious sedation were written), but can be accomplished with oral meds. In fact, many non-board certified Plastic Surgeons are using oral conscious sedation to get around the strict rules requiring this type of sedation be done in a certified OR. This is cheaper for the patient but risks his or her life.
The other method of anesthesia, general anesthesia, is what most people are familiar with. This uses some IV agents and an inhaled gas. It causes total loss of consciousness, and sensation. Depending on the gas and how much is used, you may or may not lose your reflexes or the desire to breathe. Continuous monitoring by a certified provider is essential.
Each type of anesthesia has advantages and disadvantages. The trick is to find the one that will work best for you and the procedure you are to have and be the safest. For small things that create little anxiety, I usually use pure local, or add oral sedation for minor nervousness or apprehension. For procedures on extremities I use either a regional nerve block or general anesthesia for the surgery and a local block for postoperative pain relief. For most other procedures I prefer general anesthesia and, if possible, a block. I believe this is the safest type of anesthesia, and works best for most of what I do, especially here in the mountains. Patients quickly recover because the gases rapidly exit the body through the lungs. Thus most of the drugs that can cause nausea and other problems are quickly out of the body. IV sedation and narcotics require time for the body to metabolize them, occasionally 24-48 hours. We, therefore, try to use them as little as possible. The depth of general anesthesia is also easily controlled using new monitors. With many cases, including almost all facial procedures, the gas is used so you do not feel the local anesthetic injection and then lightened just to the minimal sedation necessary for safe surgery.
Frequently people today are sacrificing safety for cost, occasionally not even knowing it. Many physicians, some not even surgeons, doing cosmetic procedures are heavily advertising that they do their procedures under local anesthesia which is safer. There are several problems with this. First, it would be safe if the procedure were done under pure local using safe amounts of the local anesthetic agent. Most, however, either use too much of the local anesthetic agent or use heavy sedation in a non-certified facility. Both of these are quite unsafe. The reason they are touting this method is that they do not have privileges to do the procedures they do in a hospital or other certified facility and no anesthesiologist will work with them in their office OR’s. Use of local anesthesia is, thus, the only option they have available. As they say, “buyer beware.” Before consenting to surgery, always inquire about the anesthesia available and who will provide it. Insist that all types of anesthesia be available and that a certified anesthesiologist provide anything requiring significant sedation.