Medical & Trade Publications

July 2006

by Amy M. Ortega, M.D.
Medical / Plastic Surgery

Top Plastic Surgery Safety: Anesthesia Options

With the surge in media coverage of plastic surgery comes a surge of stories casting doubt on its safety. To continue last month's topic, I'll address one of the most common questions I am asked:

"Isn't it dangerous to 'go under' with general anesthesia? I think I'd rather have sedation so I'm awake. Isn't that safer?"

That's a complicated question that stems from a lack of understanding of the difference between "general anesthesia" and "sedation" as well as a myth perpetuated in marketing schemes.

In a worst-case scenario, deep sedation can cause the patient's respiratory muscles to relax so much that they cannot properly move air—a life-threatening situation.

What is general anesthesia?

General anesthesia typically refers to the use of drugs, which combine to produce a deep state of analgesia (pain relief) and amnesia (lack of memory of the experience).

This deep state of consciousness enables one's respiratory system to relax and permit the insertion of a breathing tube into the trachea (windpipe). There is a great advantage to this, as it enables the anesthesiologist to "protect the airway." In other words, the airway is forced to stay open, so the patient can breathe throughout the procedure. A breathing machine is then used to assist in the inflow and outflow of air during surgery.

During this time, the patient seems to be "asleep" and vital signs are monitored. The surgeon can then focus on the procedure knowing that the patient is completely free of pain and anxiety, with a protected airway, and with an anesthesiologist present to monitor the patient and to assist in an emergency.

What is sedation?

In comparison, sedation also refers to the use of drugs, but a different combination of drugs than with general anesthesia.

With sedation, the drugs produce a feeling of relaxation and amnesia, but the patient is not completely "out." The patient is still awake, although in a state of mind in which he or she is relaxed and permits the procedure without anxiety.

This state does not produce analgesia. Therefore the surgeon must inject local anesthetic into the area prior to operating. Because of a varying and less-controlled state of relaxation, the patient may wax and wane through states of "almost asleep" to essentially "awake."

Patients may feel pain and discomfort at times, causing them to reflexively move during surgery, which creates a situation where the surgeon tries to work on a moving target. This is a major consideration in certain areas, such as near the eye, where accuracy is critical.

All the while, because "sedation" doesn't necessitate an anesthesiologist's presence, the surgeon often gives the nurse instructions on injections of sedation medications while also trying to operate.

Since the sedation doesn't relax the patient enough to allow airway insertion, the airway is subject to contraction or collapse, which could be a life-threatening emergency. This is unlikely in light sedation. However, in some cases, inexperienced physicians actually administer enough medication to produce deep sedation, which causes the patient's respiratory muscles to relax so much that it cannot properly move air—a life-threatening situation.

Anesthesiologist: here or not

General anesthesia requires the presence of an anesthesiologist, while sedation does not. General anesthesia produces very predictable states of consciousness, which allow for a controlled situation and predictable pain control during the procedure.

Light sedation can relax a patient enough for certain procedures. However, the problem and true danger with sedation is that to get the patient relaxed enough to be able to perform some procedures, the sedation is sometimes so deep that it becomes general anesthesia, without airway protection and predictable pain control, and often with no anesthesiologist on site to deal with these issues in an emergency.

For that reason, sedation in inexperienced hands can actually be more dangerous than general anesthesia, and much more uncomfortable for the patient.

Plastic surgeons can often recommend, based on experience, which of these two options would be right for the patient and the procedure.

Trendy marketing

Be wary of the current marketing trend where some practices advertise that they do everything under sedation "to avoid the dangers of general anesthesia." As you may gather from the information previously stated, this statement simply makes no sense, and is nothing more than a marketing ploy.

One is no more or less "safe" than the other, unless you are a patient with known personal or family history of adverse reactions to certain drugs, in which case, those options would be avoided.

I would say that statistically, drugs producing general anesthesia or conscious sedation aren't any more dangerous than many other drugs, in terms of the likelihood of a deadly reaction. They actually pose less risk than many drugs, when in the hands of an experienced physician.

Regarding the risk of each of these drugs, I would say that on any given day, my patient is statistically more likely to be seriously injured in a car accident on the way to the surgical center than by any anesthetic of any kind (either "general" or "sedation") during the procedure.

Is plastic surgery ever safe?

As discussed in last month's column, no procedure is 100 percent safe, cosmetic or not. Everything has risk. Cosmetic plastic surgery is as "safe" as any other surgical procedure when a qualified surgeon performs a procedure on the appropriate patient, with the appropriate monitoring, in the appropriate setting.

Credentials are key

Remind patients to ask whether the surgeon is board-certified by the American Board of Plastic Surgery, the only accredited plastic surgery board (see www.abplsurg.org and www.plasticsurgery.org). Patients should ask who provides the anesthesia, and whether an anesthesiologist (medical doctor) will be available. Patients should also ask whether the room where the procedure is to take place is certified by the same criteria as the operating room at a hospital.

Patients should make sure that they are satisfied with the answers to all these important questions before proceeding.

Amy M. Ortega, M.D., is a board-certified, double-fellowship trained cosmetic plastic surgeon with special interest in cosmetic surgery of the face, breast and body. Her office is located in Atlanta, GA. To reach her, call (404) 751-2500. For more information ABOUT DR. ORTEGA, visit her website, www.ASAbeautiful.com.