DR. EPSTEIN’S COMPREHENSIVE Breast Augmentation Guide

Anesthesia – General, Sedation or Local?

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Anesthesia – General, Sedation Or Local?

General Anesthesia

General anesthesia means fully asleep – you will have no realization that you are going to sleep, no awareness of what transpires during your surgery, no sensation of discomfort during surgery, no recollection of what went on during surgery and no recollection of waking up from surgery. Who could ask for anything more pleasant? Certainly, some people are fearful of general anesthesia, usually out of lack of understanding of what it entails. When performing breast augmentation, there are some distinct advantages to utilizing general anesthesia over other techniques. The following is a brief description of the differences between the three types of anesthesia:

General anesthesia – drugs are given intravenously to make you relaxed, all anxieties you may have will disappear, and you will slowly drift off to sleep. Once asleep, a breathing tube is gently placed through your windpipe through which oxygen and some anesthetic drugs in gas form are given to you. Your vital signs, oxygen and carbon dioxide levels are continually monitored for your safety. General anesthesia affords you the following: no perception of pain, no recollection of the period of time between when you go to sleep and when you wake up, muscle relaxation and a peaceful sleep. Your airway is protected via the breathing tube and the muscle relaxation is important to reduce post operative discomfort and facilitate the surgery (the muscles are not resisting the surgeon’s efforts). Overall, the anesthetic medications will be out of your system faster with general anesthesia than will intravenous sedation.

Local anesthesia – Medication is injected into the surgical site to make the tissues numb – so that the pain nerves in the tissues do not work. This will not afford you any degree of mental relaxation. For larger surgeries, it can be difficult to use local anesthesia because there are limitations as to how much of the local anesthetic drug you can receive before toxic doses are reached. This can pose a problem during surgery if the degree of numbing of the tissues is inadequate and more drug is required. There is also no muscle relaxation, which means that the surgeon will have to pull harder against your pectoralis muscle, resulting in more discomfort after surgery.

Local anesthesia + Sedation (oral or intravenous) – Local anesthesia is given as above, but also sedation is given to relax you. If sedation is given, you should be monitored by an anesthesiologist or nurse anesthetist as over sedation can cause you to stop breathing on your own. Proper monitoring would prevent this or at least allow immediate intervention should this be required. Sometimes if local + sedation is not working well (difficulty keeping the level of sedation at the right level), then the patient can be converted to general anesthesia. There is still no muscle relaxation with sedation. That requires special medication. Muscle relaxation means that none of your muscles are able to move, and while your pectoralis muscle will be nice and relaxed and not fighting the efforts of the surgeon, so will your breathing muscles be relaxed and not working, which is why general anesthesia is required when muscle relaxation is used.

You can read more about out anesthesia services performed by our two board certified anesthesiologists here.

Do I perform surgery under local anesthesia or sedation? Of course – all the time. however, for breast augmentation, the most optimal way to proceed for both surgeon and patient is, in my opinion, without any doubt, general anesthesia.

What is “Awake Breast Augmentation”?

“Awake breast augmentation” is a breast augmentation procedure performed using local anesthetic while you are awake. Some surgeons will also give you some sedation to relax you, some will not. This procedure requires injecting your breasts with a solution of local anesthetic (“numbing medicine”). The proponents of this procedure claim that you are “involved in the size selection” of your implants during surgery and that you will recover faster. While this might make sense on the surface, it really does not for several reasons:

  1. You must be fully sitting up at 90 degrees to see how the implants will look and this is very difficult to do on an operating table.
  2. For all breast augmentations, the result immediately after surgery looks nothing like the final result several months after surgery (the breasts are overfilled on top and underfilled on the bottom) – so how can the patient judge the result? At surgery, it is best for the operating surgeon who is experienced and understands how the augmented breast shape will change with time to determine if a specific implant selection is correct for that particular breast.
  3. If you are sedated, then how can you even begin to give input with a clear mind as to what you want to look like? Looking downward with surgical drapes in the way is difficult. Maybe a nurse holds a mirror in front of you. All of these efforts will not help you to provide educated input for sizing. I have even heard of the surgeon bringing the patients boyfriend into the operating room to give his input!!!! Ludicrous and dangerous!
  4. The principles of soft tissue based planning to determine breast implant size are not followed, and this will lead to errors in placing over-sized implants, leading to a much higher surgical revision rate and a longer recovery time.
  5. If the local anesthesia is not providing complete relief of pain, you will not have the ability to be put to sleep to complete the surgery – essentially, you will have to “grin and bear it”. I witnessed this many years ago when I was a resident in training. It was not pretty to watch. I will NEVER put a patient of mine through this.
  6. Any significant problems arise during surgery – again, you will not have the benefit of an anesthesiologist to help you to manage them.
  7. As for the recovery, a quick general anesthetic (about one hour) is out of your system very shortly after surgery. Therefore, recovery from the anesthetic is not an issue. In fact, if you require sedation during your procedure, it may take longer to recovery from your “sedative hangover” than from a short general anesthetic! In other words, using general anesthesia, you are given less drugs, not more, than if you received local anesthesia plus intravenous sedation!
  8. Post-operative discomfort – only a general anesthetic will allow the surgeon to perform the surgery with muscle relaxants. Muscle relaxants temporarily stop the pectoral muscles from contracting during surgery. Therefore, it is easier for the surgeon to divide and elevate the muscles during surgery to make the breast pocket. If the surgeon has to pull harder to fight the contraction of the pectoral muscles, then you will have much more post-operative discomfort. Muscle relaxants cannot be given except during general anesthesia, or you would not be able to breathe on your own. The end result is much less post-operative pain, 98% of the time eliminating the need for narcotic pain pills after surgery, as well as the nausea and vomiting that goes along with the narcotic use.

Have I performed “Awake breast augmentation”? The answer is “YES”, and furthermore, I would NEVER do it that way again! Ever!!!

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