Our Approach: Cosmetic Surgery with Only Local Anesthesia
COMBINING PLASTIC SURGERY WITH LOCAL ANESTHESIA
An April 2010 New York Times article discusses cosmetic surgical procedures - breast
enlargement, tummy tucks, etc. - done in doctors offices under local anesthesia
(Awake
for Breast Implants? If You Wish). This was represented as easy and safe without the need for
dangerous anesthesia. What wasn't obvious in this article was the fact the non-plastic surgeons touting
local anesthesia as a new a new and better way lack the qualifications to do this surgery in a hospital
with a choice of anesthetic methods.
While it is true that most cosmetic procedures can be performed with local anesthesia only,
the real question is: “Can it be done as safely and comfortably with local anesthesia only?” In the
interest of patient comfort and safety, most plastic surgeons do these procedures under twilight sleep
or general anesthesia administered by an anesthesia professional.
However, the type of anesthesia is only one part of a cosmetic procedure. Equally as
important as method of anesthesia, is the anesthesia provider, qualifications of the surgeon, the
suitability of the surgical facility, and appropriateness of the procedure. The how, where, and on which
patient surgery is performed should be determined by a qualified surgeon in consultation with an informed
patient.
Board Certification:
State laws allow physicians to perform any procedure in the privacy of their own office.
Weekend cosmetic surgery courses (“two day, $7000 courses” NYT) provide instruction about individual
procedures, allowing partially trained surgeons or even non-surgeons to offer a specific operation. The
American Board of Plastic Surgery (ABPS) regulates the training, testing and continuing education of Board
Certified Plastic Surgeons. The training is 5-7 years duration and provides the surgeon with judgment,
knowledge and experience leading board certification. Most important this training prepares a surgeon to
recognize and avoid and treat complications occurring in the operating room and after surgery. While any
physician can learn a step by step, cookbook procedure, and even obtain “experience” through repetition,
this is not the equivalent of Board Certification, which is an objective and verifiable qualification.
Medical Staff Privileges:
Hospital credentials are another valuable guide for a perspective patient to determine a
surgeon’s qualifications. Hospitals credential physicians and surgeons by documenting training, experience,
ethics, licensing and board status. Further the hospital has the legal and moral responsibility of
oversight and peer review of members of the medical staff to assure quality of patient care. Each surgeon
has a list of surgical procedures he/she is allowed to perform in that particular hospital (Hospital
Privileges). However, surgeons operating in a non-accredited office setting, have no such restrictions or
oversight, and are not limited in scope of procedures offered. Hospital privileges should be verified before for undergoing cosmetic surgery in a physician’s office.
Office Accreditation:
Accreditation of office surgical facilities provides assurance that a specific facility meets
national standards of patient safety. The American Association for Accreditation of Ambulatory Surgical
Facilities (AAAASF), American Association for Ambulatory Health Care (AAAHC) and Joint Commission are
recognized agencies that provide accreditation for ambulatory surgical facilities.
Board certified plastic surgeons are required to operate in accredited office facilities
(American Society of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, and American Board
of Plastic Surgery).
Most plastic surgery ambulatory surgical facilities are accredited by AAAASF, which requires
100% compliance with high standards relating to office surgery. These standards require appropriate
credentials and hospital privileges for surgeons using the facility, and stringent requirements for
the physical environment, equipment, personnel, monitoring and emergency equipment and policies affecting
patient safety. Data collected and published reflects an outstanding safety record for AAAASF accredited
facilities, comparable or exceeding those of hospitals (1.5 million procedures reported ).
Office Anesthesia:
Due to safety concerns, many states require special registration or even facility
accreditation for the use of sedation or general anesthesia in an office. However, the use of anesthesia
adds to the cost of equipment, drugs and personnel, which may be another reason some physicians rely on local
anesthesia and oral sedating medications. However, the elimination of these regulatory, financial
and professional burdens to the surgeon can significantly impact patient safety.
Major surgery with local anesthesia only may be tolerable, but often is uncomfortable and even painful.
Patients are usually given oral sedatives and are “talked through” the “rough spots” during the procedure.
However, over-sedation with oral medications can be a major problem in a marginally equipped and staffed
facility.
Is local anesthesia really safer for major surgery? It may not be safer if high doses of oral
sedatives are used to help patients tolerate surgery under local. It may not be safer if a drug reaction
or surgical complication occurs in a facility that is poorly prepared to recognize, treat, and transfer a
patient. It may not be safer in a situation that a general anesthesia is medically indicated (underlying
medical problem, anxiety, etc.), but not available. It certainly may not be safer when the surgeon lacks
recognized and verifiable qualifications.
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