Full Text from Dr. Berman's Book

Chapter 3


In spite of all the trepidation that goes along with a surgical procedure, it's the anesthesia that tends to elicit the most anxiety.Patients are often apprehensive about being "put to sleep" under general anesthesia.Often accompanied by memories of uncomfortable post-anesthetic recovery, many patients are reluctant to have general anesthesia again. On the other hand, patients undergoing a procedure under local anesthesia are often worried that they are going to feel pain.

Today, many surgeons prefer the use of general anesthesia. Under the guidance of qualified anesthetists, general anesthesia has become safer than ever. Generally, cosmetic procedures require a considerably lighter level of general anesthesia than typical hospital type surgery. Also the newer drugs and monitoring equipment have helped increase the safety of general anesthesia. When under general anesthesia, an endotracheal tube is generally secured so that the anesthetist can monitor and control your breathing. Often today, instead of the endotracheal tube, a less invasive, but highly effective, device - an LMA or Laryngeal Mask Airway - is utilized.

On the other hand, by providing very safe levels of intravenous medication, the patient can also be put into so-called "twilight" sleep, i.e. sedated, to the point that while they are still breathing on their own, an injection of local anesthesia can be achieved without the patient feeling discomfort. This is called "local with intravenous sedation." It too is generally a very safe technique. Although an anesthetist is most often present to administer the sedation, in appropriately selected cases, it can be accomplished by the surgeon.

Local anesthesia without any sedation can be used in small cases, e.g. removal of a nevus, or scar revision. Some surgeons have even used it in body liposuction cases, the so-called "tumescent technique." The tumescent technique uses large quantities of dilute local anesthetic to numb the areas to be treated. I find it works particularly well with intravenous sedation.

Intravenous sedation has become a safer technique in recent years since doctors have learned to neutralize the local anesthesia we inject. Typically, when you inject a local anesthesia there are two causes of pain. First, the needle stick and second, and most significantly, a stinging pain from the local. The stinging pain is caused by the acidic nature of the local. You see, local anesthesia is shipped in a very acidic formula as a preservative. However, by adding a little sodium bicarbonate to the local, you can neutralize the pH (take out the acidity). Consequently, the injection won't hurt - other than the needle stick. But, you don't need that much anti-pain (analgesic) narcotic to block the pain of the needle stick. Today, we generally use half as much of these narcotics as we did in the 80's, and it was safe then.

Finally, it is good to know about the environment within which you'll be receiving your anesthesia. Generally, most cosmetic surgeons today operate out of their own surgical suites. The main reasons for the advent of private individual surgical suites (over hospital operations) are increased patient and doctor convenience, increased privacy, the ability to assemble and maintain a special and consistent surgical team, as well as the ability to limit expensive hospital costs. Although it varies from state to state, the trend is emerging whereby states will regulate all free standing surgical suites through some type of accreditation process. Again, between the lawyers and the regulators, safety (with some increased expenses) should be enhanced.