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Plastic Surgeons Discuss Issue of Awake Cosmetic Surgery

A recent women’s health article on is getting lots of attention from those in the cosmetic medical field. “Nipped, tucked and wide awake? investigates low cost plastic surgery under local anesthesia, and presents some keen insight about this alarming cosmetic trend.

In response to the article, we asked two plastic surgeons about the issue. New York City plastic surgeon Dr. Tracy Pfeifer and Seattle plastic surgeon Dr. Robert Grenley responded, and they offer some great advice about how patients should approach decisions in anesthesia.

Both plastic surgeons agree that the physicians featured in the article are probably unqualified to perform cosmetic surgery. Worse yet, they may be unscrupulous and exhibiting a predatory type of behavior.

“This is yet another example of patients being preyed upon by unscrupulous physicians who seize on the patient’s unfounded fears about anesthesia and desire to reduce costs,” says Dr. Pfeifer. She explains that these doctors use price and local anesthesia in their marketing to potential patients. “The patient is more than happy to hear just what she wants to hear: It is less expensive and less “invasive” and therefore she thinks safer, because less anesthesia must be better.”

Dr. Grenley further explains why these unethical practices may be occurring: “Many of the self-designated cosmetic surgeons perform their procedures under local anesthesia because they do not have operating facilities that are equipped for administering general anesthesia, they do not want to go to the expense of properly outfitting an operating room for safely providing general anesthesia, and most physician anesthesiologists and even nurse anesthetists are unwilling to work in under-equipped and under-staffed operating rooms where patient safety may be compromised. Therefore, with local anesthesia as their only available option, they advertise that these procedures are performed under local anesthesia as if this is an advantage.”

So, is local anesthesia ever the right choice in cosmetic surgery?

“Local anesthesia can be very successful but it depends on what procedure is being performed,” Dr. Pfeifer explains.

“For very small areas of liposuction, local may be enough. For larger areas or multiple body parts, general anesthesia is usually better. Many procedures can be performed under local anesthesia with intravenous sedation and/or epidural anesthesia. Personally, I have found that patients can be comfortable either way for some types of liposuction and facial procedures including facelift and eyelid surgery.”

“I prefer abdominoplasty under general anesthesia, while other plastic surgeons prefer epidural. General is best because under epidural the upper abdomen is sometimes not numb. Breast surgery should always be performed under general in my opinion. The only time I saw a hematoma after breast augmentation was when the patient had breast augmentation under local with another doctor. With the patient moving around, a surgeon cannot totally visualize the breast pocket and she had something bleeding which was not seen during the surgery. “

“Small procedures may be safely and easily performed under local anesthesia,” says Dr. Grenley. “But operations involving extensive areas of the body (for example, extensive liposuction) or deeper structures (for example, sub-pectoral breast augmentation) may require such a large volume of local anesthetic that the toxic dose may be life threatening. If sedation is given to help the patient tolerate the painful procedure, there is the risk that, without proper monitoring, breathing may be suppressed and serious complications or death could result. And in some cases, as described in this article, the patient may just be expected to suffer through a long and painful procedure.”

Is general anesthesia something to fear?

“General anesthesia is very safe,” says Dr. Pfeifer; “and with new medications used now, side effects are minimal. “If the plastic surgeon uses local anesthetic during a general anesthesia case, the anesthesiologist uses less medication. Anesthesiologists are also very good at reducing the medication towards the end of the case so the patient wakes up very quickly. The most important thing for patients to realize is that their safety comes first. No ethical surgeon is going to use any type of anesthesia that is not safe.”

General anesthesia is just as safe, if not safer, than riding in an automobile and no one thinks twice about riding in a car. Make sure your anesthesiologist is board-certified and frequently provides anesthesia for the type of procedure you are choosing to undergo.

“Your comfort level is crucial,” she says. There is absolutely no reason for a patient to be uncomfortable during a procedure. It is not acceptable. The patient should also be comfortable post-operatively (i.e. pain scale 1-10 with 10 the worst pain, patient should be a 2 or 3).

In conclusion, Dr. Pfeifer advises that patients “never, ever make a decision based on cost or because someone is appealing to a fear (such as general anesthesia) that you have.”

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