Modern Anesthesia Technique For Aesthetic Surgery " MATFAS"
Modern Anesthesia Technique for Aesthetic Surgery
Interestingly, March is National Deep Venous Thrombosis (DVT) Awareness Month!
DVT is the phenomenon of clots developing in the veins of the legs which can break off and travel to the lungs. This is called a “pulmonary embolus”, it is very serious and potentially lethal. DVT and Pulmonary Emboli are the most dreaded complications of surgery, therefore this is a good time to discuss anesthesia techniques and how we do things differently and across the board at our Center.
Typically, “General Anesthesia” implies placing a breathing tube in the windpipe (Endo-tracheal Intubation) and administering a gas agent to put the patient to sleep. Usually, paralysis and narcotics are needed in order for the patients to tolerate the very stimulating tube in their trachea.
How does gas anesthesia work? Nobody knows! The inhaled gas agent prevents the brain from reacting, but the pain is still there, the brain perceives it, and experiences stress. For this reason, intravenous narcotics are standard with general anesthesia. The above factors are the reason nausea and vomiting are so common after surgery and why it takes so long to recover from the anesthesia and feel normal. It is not uncommon for the brain to take weeks or more to fully reset.
A much more serious complication of gas anesthesia is the potential for development of DVT and the very dangerous involvement of the lungs. The gas agents used have the effect of dilating the veins of the pelvis and the legs creating a pooling of blood in the lower body. This coupled with the immobility of surgery is the perfect breeding ground for clots to form.
Why is general anesthesia used? The very practical reason is that for the bulk of surgeries performed across all specialties, there is no other choice because you cannot numb the operative area i.e. the intestines, etc. The danger of DVT is simply accepted and other measures are tried for prevention, such as early walking.
The other factor for the popularity of general gas anesthesia is that it is “the way things have always been done”. This is the standard technique, and, in many ways, it is the convenient approach and relatively hands-off for the anesthesia provider. The fact that general anesthesia is appropriate for many surgeries seems to carry over to those that it may not. The stark reality remains that pulmonary emboli exist, patients die, and plastic surgical patients are not exempt.
The very good news is that gas anesthesia is not the only option! By nature of anatomic reality, most if not all aesthetic plastic surgical operations can be done with local anesthetic numbing and mild sedation. The area being operated on, for example the breasts, are thoroughly numbed by injecting a dilute local anesthetic. This effectively takes pain completely out of the equation. The anesthesia provider has administered intravenous sedatives to “quiet the brain” and keep the patient asleep. This degree of sedation can be quite mild since the patient is not experiencing discomfort. The surgeon has taken care of the pain at the operative site and the anesthesia provider takes care of the brain. Once the procedure is over, the sedation is stopped and the patient awakens without pain because they have not been in pain. Prior to finishing the surgery, a long-acting local anesthetic can be injected stretching out the time of numbness. In some procedures, an ultra-long-acting agent is used, which can last two to three days. This is a game-changing difference that has revolutionized the recovery for painful operation such as tummy tucks.
There are other important repercussions to this alternative mode of anesthesia. Unlike with gas anesthesia, the surgeon is aware if an area is uncomfortable and more local anesthetic can be used. When the patient awakens, there is no pain. The patient is not paralyzed and there is tone in the muscles of the legs. The patient can make subtle movements allowing the blood to move and not be static. Again, without gas anesthesia there is no pooling or stagnation of blood in the lower extremities. This is crucially important in preventing clots. Narcotics are very rarely used, and this coupled with no gas anesthesia results in dramatically reduced incidence of nausea.
If the patient should become more aware than ideal during the procedure, this can be readily dealt with without the patient remembering. The possibility of the patient becoming awake during surgery without the surgical team being aware of it, is only a phenomenon of general anesthesia. The fact that the patient awakens clear headed and without pain allows for earlier movement which also is preventative of clots. By the same token, the length of surgery is much less of a consideration and all patients are able to go home.
Why don’t more plastic surgeons use this advanced, minimally invasive anesthesia? Frankly, I don’t know. We say in medicine “tradition dies hard” and this may well be a factor. In hospitals and surgical centers, they do what they have always done and that is intubate and use gas. It is no longer enough to obtain great surgical results --- the patient should also have a great surgical experience. Gone are the days that it is accepted for post-operative patients to be in pain and nauseous. I developed our onsite surgical center largely so that I could control the anesthesia: With about 15 years of experience with this approach, I feel that the vastly improved comfort and safety speaks for itself. In consideration of placing patient safety and comfort first, I strongly believe that this should be the standard of care for elective plastic surgical procedures.