Breast augmentation remains a very popular body contouring procedure. It is a relatively simple outpatient procedure that takes about an hour to complete under general anesthesia. No matter how it is done, it fundamentally involves placing an implant behind the breast tissue. The breast implant essentially does all the work in terms of making the final result.
There are numerous variations of the breast augmentation procedure including type of implant, tissue plane of the implant and location of the entrance incision. One other less common variable is the type of anesthesia used to perform such breast implant surgery. By far and away, and I would urge all patients to have it done this way, is to be put to sleep for the procedure. I think the overwhelming majority of plastic surgeons use this approach. But there are a few doctors out there who do not and even promote their practice based on the use of local or IV sedation for breast augmentation.
While I would normally scoff at the idea of breast augmentation under local anesthesia, I had a recent experience which provided me with some further insight into this approach. A 35 year-old mother of three consulted me for breast implants…specifically and only to be done under local anesthesia. While normally I would have convinced her otherwise, she had three close relatives who died under anesthesia. This suggested that she had a family history of possible malignant hyperthermia. (although this was never confirmed) But her psychologic resistance to general anesthesia due to this family history was understandable. And she was motivated…she was not choosing this anesthetic route because of economics or the perception that her recovery would be faster.
In agreeing to perform this operation under local anesthesia, this required several modifications to how I typically perform breast augmentation. First and foremost, the implant would have to be placed above the muscle in the subglandular position. There is no conceivable way that the pectoralis muscle could be lifted off the chest wall without general anesthesia. (at least no humane or tolerable way) While this increases the potential risks of infection and capsular contracture, these are the trade-offs for implant placement above the muscle. Secondly, the size of the implant would likely end up being smaller than what could be done under general anesthesia due to less comfort at making as significant a pocket size.
She ended up successfully getting her breast augmentation under only local anesthesia. (plus some oral valium and phenergan pills before) Silicone gel breast implants of 375cc size were placed in a subglandular pocket in an operation that took just over 2 hours to complete. Local anesthesia (lidociane and epinephrine) was injected into the inframammary incisions and the breast tissue was subsequently infused (tumesced) with Hunstad solution.
Having done it am I now sold on local anesthesia for breast augmentation? Absolutely not. While it is possible, I do not advocate it unless the reasons are compelling and the patient is highly motivated. Trying to save money is not a good reason to choose this method. The reasons being that the time to perform the surgery is more than twice as long. So while the anesthesiologist’s fee is saved, that cost savings is more than wiped out by the additional operative room and surgeon costs for the extra time needed. Breast augmentation under local anesthesia should be reserved for those rare occasions when a patient’s medical or psychological state make a compelling reason to avoid general anesthesia.
Dr. Barry Eppley
Indianapolis Indiana