The concept of performing breast augmentation under local anesthesia continues to appear with some regularity in the media. Avoiding general anesthesia and its associated risks is the theme and that certainly seems laudable. If you could have an elective cosmetic procedure done without the expense and potential side effects of general anesthesia that is undoubtably appealing to some prospective patients.
But is breast augmentation under local anesthesia a good idea? Is it as simple and uncomplicated as it appears? Is it a better way to do breast augmentation? I recently read a news story on this technique where the specifics were detailed. For interest I thought I would go through this story and dissect the described technical methods.
The doctor who was interviewed for this story believes that all cosmetic surgery, regardless of what is done, should be done under local anesthesia. The reason, of course, is safety and to avoid all the desired sides effects of general anesthesia. (e.g., nausea and vomiting) He states that ’15 minutes after my surgery they walk out in no pain’. The surgery is preceded by oral sedation medication (Lorazepam and Clonidine) one hour prior to surgery and then Versed and Hydroxyzine by IV when on the operating table.
Surgery is done through the inframammary fold which is initially injected with local anesthetic. This then serves as the entrance for tumescent infiltration into and under the pectoralis muscle to make the implant pocket. The tumescent solution is not a traditional Klein’s solution but contains double the amounts of lidocaine and epinephrine. The volume instilled is around 250 to 500cc per side which is allowed to sit and numb for up to 30 minutes. Surgery is done through an inframammary fold incision and ‘twenty minutes later the patient walks out pain- free’. Oral pain medication is then started before the local anesthetic wears off. They ‘don’t go home in agony and nausea and unable to take their pain medication’. (if they had had general anesthesia) Recovery is purported to be easier as a result.
This local anesthetic breast augmentation protocol seems reasonable but, technically, it is not a true ‘local anesthetic’ technique. It relies significantly on the use of oral sedation medications for anxiety and relaxation and is better described as an IV sedation technique. Between Lorazepam, Clonidine and Versed, one is fairly well mentally adjusted. This may seem like a trivial point but there is pharmacology beyond just the lidocaine in the local anesthetic.
I have done a handful of breast augmentation cases over the years under pure local anesthesia because of patient’s insistence or medical concerns. (e.g., malignant hyperthermia) They took longer than my typical time for the procedure but were able to be completed satisfactorily. These breast implants, however, were placed in the subglandular (above the muscle) position and not under the muscle. It is difficult for me to imagine that patients have no discomfort at all going under the pectoralis muscle or that patient uncomfortability may not get in the way of optimal muscle release and ideal implant positioning. But those issues aside, the technical aspects of the operation seem valid. I do take issue with the operation allegedly taking just 20 minutes, however, as that is incredibly fast to have good implant placement, hemostasis and wound closure for two breasts.
Is breast augmentation under local anesthesia the best and preferred method for this surgery? There is no doubt that it can be done based on this article. But the real question is should it? Always remember one is having surgery for the breast implant result not for the type of anesthesia. Anesthesia should serve to aid the patient to get the best surgical result. Any anesthetic technique that prevents the surgery from being carried out in the best manner possible is not an ideal anesthetic method. A few dollars saved from not using an anesthesiologist is ‘penny wise and pound foolish’ if the implants are not well placed. This has to be considered when one is deciding whether breast augmentation should be done under local or general anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana