Anaesthesia and Cosmetic Surgery

Just as for any type of surgery, providing optimum anaesthesia for plastic surgery carries its own particular challenges. In cosmetic plastic surgery more than most other areas of surgery, anaesthesia which is less than optimally suited to the type of surgery, can detract from the ultimate result. So as well .as keeping the patient unconscious, immobile and ventilated (i.e. breathing actively or passively) the anaesthetist endeavours to control/regulate the patient’s circulation so as to minimise blood loss. This control continues into the post-operative period, particularly in surgery on the face, nose and eyelids.

Many operations in all surgical specialties can be done under local anaesthesia, and the same applies to cosmetic plastic surgery. However, surgery on deep tissues and surgery involving extensive body areas are best done under General Anaesthesia (i.e. when the patient is fully unconscious). Surgical preference is a most important consideration. For all these reasons the commonest technique at the Cosmetic and Reconstructive Surgery Clinic is the combination of general and local anaesthesia.

Some patients express a wish to remain awake so that they can “oversee” the surgery. While we understand that the need to be in control is part of our psychological and emotional make up, ultimately all forms of surgery require that the patient trusts his/her surgeon and anaesthetist to make the right decision, at the right, crucial time.

Local Anaesthesia

A lot of patients are confused about what is the difference. Local anaesthesia is similar to that which occurs in most dental offices where an injection is given around the site of the surgery or into nerves near the site, so that the nerves are non-functional for the duration of the operation.
The patient has therefore no sensation in the area of surgery. This is ideal for cases such as resection of small skin cancers, removal of lipomas or small lesions in the skin and occasionally for laserbrasion in isolated areas.

Twilight Anaesthesia

The second form of anaesthesia is called “Twilight Anaesthesia”. This is used for smaller
operations such as chemical peels, laserbrasion, otoplasty or ear surgery. One hears the term “twilight sleep” anaesthesia used to describe techniques using local anaesthesia in combination with sedative drugs given intravenously. Such techniques are used in the Clinic only for a limited number of brief procedures. Their use in major cosmetic work can be unsatisfactory usually because the patient’s breathing is depressed (i.e. slowed down), a side effect of sedative drugs. An anaesthetist should still be present to administer the twilight anaesthetic. It would be unthinkable and very unsafe for a surgeon doing major cosmetic surgery to also be responsible for providing the sedation and monitoring of the patient. With “twilight sleep”, quite often the patient can become so sleepy that they tend to “lose their airway”. There are a lot more complications associated with “twilight” anaesthesia than general anaesthesia as regards the airway. Respiratory arrest has occurred in the Sydney Metropolitan area using “twilight” anaesthesia although we have never had such a complication as we generally use general anaesthesia for the majority of larger procedures.

General Anaesthesia

For larger procedures, the anaesthetists at the Double Bay Day Surgery perform general
anaesthesia. Although there may be great fears about the use of general anaesthesia, this is completely unfounded in modern day anaesthesia in healthy patients. Fortunately, in our facility, we are operating on healthy patients. General anaesthesia is the most controlled of all anaesthesia; the airway is controlled and the anaesthetist helps you breathe during the operation.

The newest medications – Propofol is white milk which is injected into the patient’s vein and the patients have the highest quality monitoring equipment attached to them. With our anaesthetists and a combined experience of over 20 years in plastic surgery, we can control the surgical environment for cases such as facelifts, liposuction, breast reduction and breast augmentation.

Complications from general anaesthesia remain the same as for “twilight” anaesthesia – the main complication being nausea. With the newest medication such as Zofran which we give our patients if they have a history of nausea, the incidence of nausea is much lower. Since using the Diprafuser (a computerised deliverer of propofol) our nausea rate from anaesthesia has been dramatically lower.

The Advantages of General Anaesthesia over Local Anaesthesia for Cosmetic Surgery

Some cosmetic surgeons in Sydney are advertising that they perform their surgery under local anaesthesia and “twilight sleep”. They claim that this is in some way better for the patient than general anaesthesia. We disagree with this for the following reasons:
•  Local Anaesthesia limits the extent of what a surgeon can do. Some parts of the body are
very difficult to anaesthetise properly as there is a limit in the amount of local anaesthetic
drug that can be used. In large doses, local anaesthetics are very toxic.
•  Regardless of how much local anaesthetic is used, there are some areas that cannot be
made totally pain free such as the deeper tissues involved in breast implants.
•  The injection of local anaesthetics distorts the area to be operated on and therefore, can
make it very difficult to get excellent surgical results.
•  A degree of pain is often felt when operations are performed under local anaesthesia.
Therefore, surgeons usually need to supplement their local with small doses of general
anaesthesia. It may be called deep sedation or “twilight sleep” but in reality, it is general
anaesthesia without the necessary safeguards. For general anaesthesia to be safe, it must be performed by a specialist anaesthetist who has extensive training and works with
appropriate equipment and monitoring. It is impossible for a surgeon, even if they had the
skills and training, to concentrate on both the surgery and the patient’s safety at the same
time. In other fields of medicine such as endoscopy, the practice of the same doctor
sedating the patient and performing the endoscopy at the one time is regarded by both the professions and the Department of Health as being unacceptable because of the danger to the patient.

General Anaesthesia, in the hands of experts, is very safe. It allows the surgeon the ideal
operating conditions and therefore gives the patient the best chance of an excellent result
with the least risks and discomfort.

Day Surgery Anaesthesia

Day surgery presents the Anaesthetist with the challenge of having the patient fit to leave the Clinic a few hours after their operation. Before being discharged a patient must meet criteria including being wide awake, able to walk unassisted, pain free or very nearly so, not vomiting and having stable pulse and blood pressure.