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Anesthesia Options

Anesthesia Options

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.

The Present State of Quackery

In the late nineteenth and early twentieth centuries quackery was personified by the Snake Oil Salesman. Just what was he? And, for that matter, what is Snake Oil? Snake oil is a traditional Chinese medicine made from the Chinese Water Snake (Enhydris chinensis), which the Chinese used to treat joint pain. When translated to our culture, it was never effective in controlling pain or anything else for which it was eventually sold. Therefore, the most common usage of the phrase is as a derogatory term for quack medicine. The expression is also applied metaphorically to any product with exaggerated marketing but questionable and/or unverifiable quality or benefit. In simplest terms, the Snake Oil salesman was a peddler who sold an unproven remedy for medical problems people had. They preyed on the unsuspecting who desperately wanted a cure for what ailed them, even if none existed.

Are there such people today? We would like to think not. We live in a scientific society and are sophisticated and knowledgeable. It should be hard to fool us. Besides, the FDA (Food and Drug Administration) was created in 1906 just to protect us from such. The unfortunate answer is that they are everywhere, just in different guise.

Today, exaggerated marketing for therapies, procedures, diets or products abound. These transcend all of medicine, but a large percentage of them are in the areas of cosmetic rejuvenation and lifestyle enhancement. This is partially because these areas are where people are already willing to spend their own money. The question is why they still exist. The answer lies in two basic facets of our present society and how complex it has become. We all need shortcuts in making decisions. Otherwise, we would never get anything done. One of the shortcuts we use is to trust authority. This works well as long as we are trusting real authority and what that authority is telling us is, indeed, factual. If the authority is not who he claims to be, or what he tells us is not factual, our shortcut fails us. The other problem is the sheer complexity of medicine itself. Here, the shortcut of consistency fails us. If a therapy or ingredient can do one amazing thing, to be consistent, we tend to believe it can do many other related things, when, in fact, it cannot.

Excellent examples of the latter are lasers and stem cells. Because lasers are extraordinary machines for some procedures, like resurfacing the skin to rid us of wrinkles or spots, when told they can also tighten loose skin and improve facelifts, breast lifts, tummy tucks or liposuction, we tend to believe they can. The truth is, they cannot tighten skin and those procedures done with the laser are no more likely to give a good result then those done other ways. Unfortunately, many of these myths get perpetrated by normally real authorities who have relied on another “authority” (the company selling the machine and the hype around it) without first checking the real data available.

Stem cells, too, are amazing cells and have fantastic, though yet to be proven, potential. Because Stem Cells have been found in liposuctioned fat, there is now a readily available source of them. Even then, they are quite sparse, concentrating them is very difficult and there is no data yet about what they are really capable of doing or, even, how to use them. Unfortunately, everyone has jumped on the Snake Oil Wagon and is touting wonderful rejuvenation, including Facelift, from the few cells injected, even without data that they make any difference.

In a similar vein, multiple hormonal therapies are offered based on one of their properties. Though not as popular as it once was, HGH (Human Growth Hormone) has been touted to build muscle and reduce weight. These are things it does help do, but only in conjunction with an exercise program and proper diet, which will accomplish your goals without the exogenous hormone. The new Snake Oil is HCG (Human Chorionic Gonadotropin) for weight loss. Again it is probably the accompanying diet alone (or the cost of the injections that cause you to adhere to the diet) that accomplishes your goal. The main problem with both these is the ancillary, unwanted effects they cause.

There are also multiple other unproven therapies out there, like Telomere Analysis, Mesotherapy, Ozone therapy, Platelet Rich Plasma for hair restoration and other things, and a multitude of “Marvelous” machines. These are all proffered by “authorities” in the field of cosmetic rejuvenation and lifestyle enhancement. They all have fancy certificates attesting to their expertise. The real question, as I said in a previous article, is who grants the certificate and, therefore, how much expertise do they really have.

So, since our normal shortcuts can fail us in this area, what do we do? To start, we need to question the expertise of the “authority.” How did they learn to do what they do, and who granted them their authority. Was it an American Board of Medical Specialists Board, such as the American Board of Plastic Surgery, or some other invented “Board?” Next, ask about the scientific data supporting the treatment, procedure or product. Has it been shown in multiple comparative studies to really be superior and to do what is claimed? Is the data specific for how it is now being used? If there are pictures, ask if they are typical and what else was done between the before and after. Also ask if the pictures are of the practitioner’s work. Remember, if it seems too good to be true, it frequently is.

Myths About Plastic Surgery

As Plastic Surgery becomes more popular, many misconceptions arise. Part of this is due to popular media that does not always research their subjects thoroughly before publication and how TV and the movies portray it to make their plots work better. I thought that I would try to deal with some of the most prevalent ones.

  1. All “Board Certification” is the same. In fact, it isn’t. If I wanted to create a
    “Board,” say for “Laser Zit Removal,” it would cost me just a few dollars in Raleigh. I could then issue “Board Certification” to anyone I wished. The original Boards, of which the American Board of Plastic Surgery is one, are certified by the American Board of Medical Specialties (ABMS). The only other Board certifying any cosmetic surgery is the American Board of Otolaryngology for facial cosmetic. The American Boards of Facial Cosmetic Surgery and Cosmetic Surgery are not overseen by the ABMS. Certification by an ABMS Board requires meeting vigorous, ongoing standards.
  2. Only surgeons certified by the American Board of Plastic Surgery can legally do Plastic Surgery. In fact, anyone with a medical or dental license can advertise and perform Plastic Surgery. This is almost always done outside a hospital, since most hospitals require some certification in the procedures performed. Highlands-Cashiers Hospital requires certification by an ABMS board in the procedures done.
  3. All Plastic Surgery is performed in a facility certified as safe. As stated above, many physicians, in order to avoid hospital privileging, do their surgery in an office setting. Many of these facilities have no oversight, since certification of the facility is expensive and requires hospital transfer agreements and physician privileging. Both the American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery require their members to do all surgery with sedation or anesthesia in a certified facility. Highlands-Cashiers Hospital maintains Gold Seal Approval by the Joint Commission, the oldest certifier.
  4. Plastic Surgery is only for the rich and famous. While this was somewhat true in the beginning, most people having Plastic Surgery are just like you. We now have ways of dealing with whatever bothers you that fit every pocketbook.
  5. Extreme Makeovers are routine. Though TV has made it seem like remaking the entire body is the norm, in fact, it is quite rare and most people have only one area treated at a time.
  6. It is disrespectful to ask the surgeon tough questions. Most physicians expect hard questions. We look upon them as an indication of how involved you are with your care. With surgery, especially, we see it as further proof that you understand the procedure and that your consent is truly informed.
  7. It is inappropriate to speak to former patients. While simply giving you the names of patients to call violates patient confidentiality, many patients are quite happy to discuss their procedure with you. We encourage this if you are having trouble deciding about a procedure, as it gives a totally unique prospective.
  8. It is inappropriate to ask about results and risks. Not only is this NOT inappropriate, it is imperative that you do. The only way you can decide between several options that are frequently available, is to know everything you can about each. Also, choosing a surgery or procedure really entails making sure the benefits outweigh the risks, The only way to do this is to understand both. It is also important to know what a particular surgeon’s problems have been, as they sometimes vary from surgeon to surgeon. We keep before and after pictures available so you can evaluate the possible results, but you must translate these to what the procedure can do for you.
  9. Plastic Surgery procedures cost the same no matter who performs them. Not true. They vary greatly, but you generally get what you pay for. Recently a number of people died or were hospitalized because they sought cheap Botox. The “Botox” used, to reduce the cost, was a nonstandard fake. Where I used to live, a family practitioner did Breast Augmentation cheaper than anyone in town. He did this by using poor quality, non-approved implants in a non-certified, unsanitary OR, and allowing only three visits. If his patients had a problem or question, he told them to “see a Plastic Surgeon.”
  10. Plastic Surgery is based on looks, not science. This is really not true. Most Cosmetic Surgery procedures are based on reconstructive ones. All those are based on extensive research. Plastic Surgery has, for many years, led the way in developing new procedures and techniques. Plastic Surgery developed tissue transplant technology in an effort to improve wound coverage. Presently, we have discovered that the fat removed during Liposuction contains multipotential stem cells. Research is trying to determine how we can best use their potential. Even “standard” procedures are changing as we examine our results and change our methods based on those findings. This is why I totally changed my Facelift technique nine years ago. I went to a technique that did not result in the problems I saw with the “standard” one. I continue to evolve it based on further observation.
  11. Silicone Breast Implants have not been scientifically proven safe. This was the contention in 1992 when they were withdrawn from the market. After more than fourteen years and exhaustive research that proved them safe, they were released again. There is now more data on these than on almost any other medical device known.

Minimally Invasive Procedures

I have previously talked about how you can improve your outer appearance using new less invasive surgery or noninvasive methods. What we use depends on what has caused your particular problem. The causes are a combination of sun damage, loss of skin support including fat, gravity and/or muscle action. Use of injections to fill wrinkles, creases or depressions or stop muscle action; skin peels to reduce wrinkles or correct other problems; and the use of different machines can give added benefit to both the non-invasive rejuvenation methods and surgery or correct enough of the signs of aging that we can forestall surgery.

We can reduce early, non-permanent wrinkles especially between the eyes and around the eyes caused by muscles with a relaxer such as Botox® and, now, Dysport®. They prevent muscle contraction and, thus, wrinkle formation on average for 5-6 months. Early treatment prevents the wrinkle from becoming permanent and requiring filling or a peel. With regular use, the muscle atrophies and your need for further treatment decreases. Even used late, we can improve the effectiveness of the fillers. These products are also useful to treat abnormal sweating and some migraine headaches.

Gravity also causes creases and depressions to occur. The most common areas are under the eyes, between the lips and cheeks, below the mouth corners, in front of the jowls and in the mid cheek. Filling these can restore normal anatomy or disguise the problem. Restylane™ (hyaluronic acid, a precursor of collagen that supports the skin) was introduced seven years ago, is easy to use, safe, reliable, and lasts about five-six months. Since then multiple new fillers have become available. Another hyaluronic acid is Juvéderm®, which lasts almost twice as long as Restylane™. Radiesse® (calcium hydroxyapatite, another natural body precursor) is useful for the larger folds and depressions and lasts an average 18 months. There have been problems with permanent fillers, though a new one, Artefill®, shows promise.

I use the hyaluronic acids for lines in the top level of the skin and around the mouth and Radiesse in folds and to correct contour irregularities. There have been few problems reported for any of these, in spite of millions of injections yearly. Another filler is fat. We harvest this as live cells from an area where you have extra, and use it to fill contour irregularities. New techniques have markedly improved reliability and longevity. This makes it an excellent alternative to correct those areas where loss of fill causes you to look older and as an adjunct to surgery.

Administration of most fillers is done with regional numbing using techniques similar to blocks by dentists. Newer products can be mixed with numbing or come ready-mixed to decrease discomfort. Down time is minimal, if any. The worst problem is occasional bruising, but this is easily coverable with camouflage makeup. We can also decrease this bruising with peri-injection medications.
Filling subcutaneously under small wrinkles can eliminate them. These can also be eradicated with different peels or laser. Both remove the outer layer of the skin, including the wrinkles, much like skinning one’s knee. When new skin grows back, the skin is smoother and tighter. Newer peel methods and lasers have reduced the healing time, minimized the red that occurs after such a procedure and made them safer (less likely to scar). Adding pretreatment with a product like the Obagi® Skin Care system reduces the risk of having pigmentary abnormalities (white, dark or spotty) after the procedure. It also improves collagen deposition that augments the tightening effect. You actually look better at a year than at one month.

New IPL (Intense Pulsed Light) machines are laser-like, putting out a spectrum of light waves rather than only one, and have almost eliminated reactions, such as blistering, prolonged redness, or down time when treating red or brown spots. It also has the ability to treat actinic keratoses (premalignant sunspots) and severe acne when coupled with a chemical that makes the abnormal cell more susceptible to destruction by light energy.
Many more minimally invasive products and machines have been introduced, but have not proven significantly effective to warrant continued use. One of the most dramatic is the “string lift.” These were barbed sutures placed with a simple needle and intended to accomplish a brow, neck or facelift. However, none were effective for longer than about three months. Therefore, few are used now. Many other machines and procedures have met similar fates, as they do not produce results comparable to other less or equally invasive methods.

In summary, we now have multiple methods to modify and rejuvenate the face and body. These methods are so broad they can meet almost anyone’s needs for down time, effectiveness, permanence and cost. To find out more, visit us on the Web at or call 828-526-3783 or toll free at 877-526-3784 for a complimentary consultation.

Non-Invasive Plastic Surgery

Innovations in Beauty

Non-invasive Plastic Surgery

Plastic Surgery has kept up with the demands of a busy lifestyle. Though the specialty name still implies surgery, fully half of what we do requires no cutting. This is due to the development of many ways to help you feel and look better with no down time, the so-called non or minimally invasive procedures. We can now markedly improve the appearance of sun-damaged skin, hide wrinkles and remove fat without any cutting.

We have learned a significant amount about how the skin ages. This has helped us formulate protocols to either truly rejuvenate the skin or hide the effects of aging better. Cosmetics simply hide the problems, and, in many cases, worsen them. Skin health restoration, however, is a process, not a product. Healthy skin is smooth, firm, evenly pigmented, & hydrated with a slightly acid pH and protective lipid layer. To restore Sun damaged skin we need to:

  • Remove the thickened outer dead cell layer using products containing Alpha Hydroxy Acids, &/or use Microdermabrasion, Dermaplaning &/or Micro-Peels by an aesthetician.
  • Restore the normal pH and protective layer with topical Vitamin-C and/or balancing toner.
  • Correct the Pigment by removing spots & making the rest of the skin a uniform color using Hydroquinone (or Kojic acid, Arbutin &, to some extent, topical Vitamin-C) occasionally supplemented with Micro-Peels or IPL light treatments.
  • Rebuild tissue & blood vessels & heal injured cells using Retin-A® and, to some extent, Kinerase®.

We need to protect our skin from any further sun damage. It is the long wave UVA rays that cause the most severe cellular damage leading to aging and skin cancer development. Not only are these present all the time and at all latitudes, they penetrate clothing and glass causing damage even when we think we are out of the sun. Because of this, we need to apply a UVA as well as UVB sunblock every day that lasts all day. Presently SPF indicates only the effectiveness of UVB blockage and protection from sunburn. Wearing a sunscreen with high SPF without UVA blockers only increases the length of time you stay in the sun, and, thus, the amount of exposure to the harmful UVA rays causing more cellular damage. We recommend you apply a sunblock containing CLEAR Zinc Oxide of at least 5% every day. Our office carries nothing but zinc oxide sun blocks from 6.8 – 18%.

The Obagi Nu-Derm® prescriptive system incorporates all of the above. The Theraderm® and Epionce® systems also utilize these principles. These and the other adjuncts are available in our spa. At the spa portion of the office, we have incorporated many of the products used in these systems in our facials to make them effective in aiding rejuvenation, rather than just a relaxing interlude, which they remain.

You can now enhance your eyelashes using an old medication in a new way. Many people using bimatoprost, a glaucoma drug noticed that their eyelashes were becoming longer, thicker and darker. The manufacturer reformulated the drug, and it is now available as Latisse® to enhance your lashes. It is safe and you see exceptional results in eight to sixteen weeks.

A new laser can melt fat without slowing you down. Zerona is a new low level laser that has been proven and accepted by the FDA to reduce fat and contour the body without surgery, pain or any down time (other than the brief times under the machine). We are using it with dietary modification to jump start weight loss and reduce the need for some surgical body modification.

All these modalities are completely non-invasive. They are available at the Medi-Spa part of the office.