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Posts Tagged ‘anesthesia in plastic surgery’

Anesthetic Options in Plastic Surgery

Tuesday, November 13th, 2012

 

Anesthesia of some form is critical to every surgical procedure in plastic surgery. Even with some non-surgical procedures (e.g., laser hair removal, injectable fillers), some level of anesthesia may be desired. Every patient knows that there are different types of anesthesia and many will have a distinct preference for their procedure. But not every procedure can be done with a patient’s anesthetic of choice and often patients are confused about how anesthesia works.

There are four basic choices of anesthesia in plastic surgery ranging from topical, local, IV or conscious sedation and general anesthesia. Here are some basic concepts of how they work and when they are most useful.

Topical anesthetics are based on the application of creams that contain various types of well known anesthetic agents. They need time to work to penetrate the skin so ideally they should be applied at least 30 to 45 minutes before the procedure. To enhance their absorption the area may be covered or wrapped with a plastic dressing to allow maximum penetration of the active agents in the cream. They will make the skin numb but not tissues underneath it. Therefore, they are only good for procedures like laser hair removal and light to medium-depth laser skin resurfacing. They may also help lessen the feeling of injection needles as they pass through the skin.

Local anesthetics have been for a long time and just about everyone has received a local anesthetic injection for some procedure, often dental in nature. In plastic surgery, the local anesthetics used almost always also contain epinephrine to decrease the bleeding at the surgical site. Once injected local anesthetics take about 7 to 10 minutes to exhibit their maximal effects. Local anesthetics do burn on injection due to the low pH of the solution. (acidic) When buffered with sodium bicarbonate they are much less painful on injection. Their numbing effect will last up to 2 hours unless a more long-lasting agent is used that create numbness up to 24 hours. While local anesthetics are very effective, patient soften feel more procedures can be done under local anesthesia than really should be done. Fixing an earlobe tear, removing a mole or small skin cancer or even upper eyelid surgery can be comfortably done under local but bigger procedures like facelifts, breast augmentation and liposuction (even though they may be marketed this way) should give one pause. You want to make sure that the anesthetic selection will not limit the extent of the procedure and the final result.

IV sedation, also known as twilight or conscious sedation, has come a long way in the past 25 years. The drugs available today are so good that they can have an effect on the patient like they feel like they have had a general anesthetic.  (no memory) Sedation drugs can include just oral (pills) or different concoctions given through an IV. Oral sedation is good to take the edge off before a procedure that is using a topical or local anesthetic and the pills should be taken one hour prior to the procedure. IV sedation can range from very light to deep based on the drugs and their dosages used. It can be a difficult choice to choose between sedation and general anesthesia for many procedures as there is a lower risk of nausea and vomiting after sedation  and one may feel like they wake up quicker after it. The best way to think of sedation is that it is an extension of a local anesthetic. If getting the area adequately numb is the issue, then sedation can very comfortably get one past the injections. This approach can be very effective for isolated face or body areas but one should not think of larger surface areas such as in  multiple areas of liposuction, a tummy tuck, or even a more extended facelift as good for a sedation approach. This does not mean that some doctors do not do them but it pushes the balance between getting a comfortable surgical experience and the maximal result simultaneously.

General anesthetics are well known and the difference between them and a deep sedation is a fine line. The difference is that in general anesthetics patients lose control of their breathing and the anesthesiologist must take control. This is done historically with an endotracheal (ET) tube (between the vocal cords and into the lungs) or more commonly with an laryngeal mask. (LMA) With the exception of rhinoplasties and facelifts, most general anesthetics in elective plastic surgery today are done with an LMA. This produces less throat soreness afterwards as the mask stays well above the vocal cords in the back of the throat. General anesthetics provide comfort for every procedure to be performed. The aggressive use of anti-nausea drugs before, during and after a general anesthetic dramatically decrease the likelihood of after surgery nausea and vomiting, the most dreaded fear of most patients when considering a general anesthetic.

For the administration of deep IV sedations and general anesthetics, a board-certified anesthesiologist is the safest approach although the use of certified nurse anesthetists (CRNA) is permitted in some states. For procedures that only need topical, oral or local anesthetics, your plastic surgeon will give the injections or write a prescription for the anesthetic medicine.

Dr. Barry Eppley

Indianapolis, Indiana

Anesthesia Options in Plastic Surgery

Thursday, August 13th, 2009

One of the most common questions and concerns when one decides to undergo plastic surgery is what type of anesthesia will be used. Many people have misconceptions about anesthesia. Some believe that the procedure would be ‘safer’ if one does not have a ‘general anesthetic’. Others have been put to sleep before for other surgeries and had a difficult time after surgery with nausea, vomiting or feelings of prolonged disorientation or tiredness.

Anesthesia, of some kind, is of course needed for any operation. Anesthesia provides comfort from pain and reduces or eliminates one’s awareness. Based on one’s medical history and the type of surgical procedure, your plastic surgeon may recommend local, sedation or general anesthesia.

Local anesthesia refers to injecting around the surgical site to make it numb and reduce bleeding. With good nerve blocks and local infiltration, it is amazing what can be done under just local anesthesia. Many Smartlipo procedures, for example, can be done under local anesthesia which uses a special type of infiltrating solution. However, local anesthesia is most widely used for certain types of facial procedures but its use is quite limited in larger body areas. Because its effects last around an hour or so, the procedure should be capable of being done in that time. If it takes a lot longer, it will be more comfortable to consider more significant methods of anesthesia. If a procedure can be done comfortably under a local anesthetic, costs of the procedure will be reduced because the services of  an anesthesiologist will not be needed.

Some local anesthetic procedures are made more comfortable through the use of sedation medications. Sedation is known by a host of terms such as twilight sleep or conscious sedation. Sedation causes you to become very sleepy or temporarily unconscious during the cosmetic surgery procedure. Knowing you will be unable to feel sensations or remember the surgery can induce relaxation and relieve stress.

One of the biggest advantages of sedatives is that they don’t incite the post-operative nausea and vomiting that may occur with general anesthesia. There are numerous different methods of sedation based on different drugs. It is usually a combination of a narcotic and a sedative type drug. (e.g., valium, versed) :Light types of sedation may be done by the plastic surgeon himself. Heavier sedations are best managed by an anesthesiologist, lest one end up like Michael Jackson. All sedation methods require the use of oxygen and oxygen monitoring for safety.

More invasive or extended plastic surgery procedures should be performed under general anesthesia. In this case, an anesthesiologist will always administers the drugs and manage the airway. While one may initially go to sleep with the drug now made famous by Michael Jackson (propafol), the depth of anesthesia requires a device placed in the throat so air can exchange without obstruction. This airway device (LMR or endotracheal tube) provides a method to administer gases which are usually the main method to keep you asleep. Drugs and gases will make you unconscious and unable to feel or remember anything about the surgery.

Several fears continue to exist today about general anesthesia. One of these concerns is that one may not wake up. While anything is possible in life, I have yet to ever see this happen. And putting a healthy person to sleep for an elective operation makes this risk infinitesimally remote. I tell my patients in my Indianapolis plastic surgery practice that you have a better chance of dying from an auto accident driving home from your consultation than you do from not waking up after the surgery.

Another significant concern is the fear of nausea and vomiting afterwards. In todays plastic surgery, we are very focused on that exact issue and recognize the concerns about it. As a plastic surgeon, I don’t want it either. Besides the issue of comfort, such a postoperative problem could cause a complication of bleeding and excessive bruising. For this reason, our anesthesiologists provide prophylactic measures (anti-nausea drugs) before, during, and immediately after surgery. Such an approach keeps nausea and vomiting complications quite low.

Anesthesia options in plastic surgery are controlled by the type of procedure, your medical history, and the best way for your plastic surgeon to focus on performing your operation in the best manner possible. Local and sedation anesthesia are good methods for limited procedures of short duration but can be counterproductive for most more extensive procedures. Many concerns about the risks of general anesthesia are based more on fear and misconceptions than known statistics. Todays drugs and monitoring methods have made general anesthesia safer and more comfortable than ever before.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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