Medically reviewed by Mark D. Epstein, MD, FACS. Last updated: July 14, 2026.
For most of my 30-plus years in practice, if you had asked me whether breast augmentation should be done while the patient is awake, my answer was an emphatic no. Today I perform wide awake breast augmentation regularly. What changed was not my standards. What changed was the operation. This page explains every anesthesia option I offer, and why my answer changed.
The four anesthesia options
General anesthesia. You are fully asleep with no awareness, no discomfort, and no memory of the surgery. A breathing tube protects your airway, and your vital signs are monitored continuously. Modern general anesthesia is very safe, and a short general anesthetic clears your system quickly. For traditional below-the-muscle augmentation, general anesthesia also allows muscle relaxants, which make the surgery gentler on your pectoral muscle and reduce discomfort afterward.
Intravenous "twilight" sedation. The same type of anesthesia used for a colonoscopy. You breathe on your own, there is no breathing tube, and almost all patients have no memory of the procedure. This is what most of my Preservé patients choose.
Local anesthesia with light or no sedation. The surgical area is thoroughly numbed while you remain awake and alert. With traditional augmentation this approach has real limitations, which I explain below. With the Preservé technique, it works remarkably well for the right patient.
Wide awake. Local anesthesia only, no sedation at all. You are mentally clear throughout, can talk with us during surgery, and patients who receive no sedation may even drive the same day.
Whatever option you choose, a board-certified physician anesthesiologist, an MD and not a nurse anesthetist, is present for your entire procedure. Dr. Adrienne Levy has worked alongside me since 1994. You can read more about our anesthesia services here.
Why I said no to awake breast augmentation for 30 years
When "awake breast augmentation" was promoted years ago, it was built on the traditional operation, and my objections to it were serious ones. Traditional augmentation places the implant under the muscle, which requires cutting muscle and dissecting tissue. Under local anesthesia alone, there is a limit to how much numbing medication can safely be given, and if it proved inadequate mid-surgery, the patient had no good options. Many of these procedures were done without an anesthesiologist present, so if anything went wrong, there was no one to manage it. Some practices even had patients "participate in sizing" on the operating table, which is not how implant selection should ever be done; the immediate on-table appearance looks nothing like the final result, and proper sizing comes from tissue-based planning before surgery. I said then that I would never put a patient through that, and I meant it. For the traditional operation, I still would not.
What changed: the Preservé technique
Preservé breast augmentation removed, one by one, every reason awake surgery was a bad idea.
- No muscle is cut. The implant space is created above the muscle with gentle blunt dissection instead of sharp cutting, so the deep surgical work produces pressure sensations rather than pain, and muscle relaxants are unnecessary.
- The anesthetic demand is small. Because the dissection is so gentle, standard safe doses of local anesthetic numb the area completely, with a wide margin.
- An anesthesiologist is present for every case. If a patient wants more comfort at any point, sedation can be started or deepened immediately. Nobody has to tough anything out, and nobody is locked into their initial choice.
- Sizing is decided before surgery, never on the table. I use 3D imaging with computerized simulation at your consultation, so the plan is set before you ever enter the operating room.
As of July 14, 2026, I have performed 174 Preservé procedures, including patients who chose to be fully wide awake. The operation I refused to do awake no longer resembles the operation I perform today.
Which option is right for you?
For traditional augmentation, which I still perform and which remains the right operation for patients who want implants larger than 315 cc, I continue to recommend general anesthesia for the reasons above. For Preservé, the full range is open: most of my patients choose twilight sedation, and appropriate candidates who want to stay mentally clear can choose Wide Awake Preservé. You can read exactly how an awake procedure works, step by step, in my awake Preservé breast augmentation article. The surgical result is identical with every option, so the choice is about your comfort, not your outcome.
Frequently Asked Questions
Chapters – Breast Augmentation Guide
- Intro to Breast Augmentation
- Preservation Breast Augmentation – A New Era!
- Motiva Implants – What You Need to Know
- Five key decisions you need to make
- One-Day Recovery Breast Augmentation
- Anesthesia – General, Sedation or Local?
- Breast Lift (Mastopexy) with/without Implants or Fat
- What else should I know about breast augmentation?
- Important Things to Consider When You Decide to Move Forward With Breast Augmentation
- Revision of breast augmentation
- ALCL and Breast Implant Illness
