Awake During Surgery? Some Doctors Let Patients Make Decisions During Their Procedure

A relatively new trend in breast augmentation surgery has little to do with the implants themselves and everything to do with making sure a woman is satisfied with her implant's size and shape – the first time. Imagine spending months making decisions about surgeons, type of incision, saline or silicone, sizes, textures, and profile; and thousands of dollars in the process – only to wake up in the recovery room after surgery and discover that your new look was not what you had hoped it would be. What is the solution that some doctors are offering? Be awake and make some of these decisions during surgery.

The vast majority of augmentation mammoplasty (i.e., breast enlargement) surgeries – and cosmetic procedures in general – use general anesthesia, which puts patients in a sleep-like state from start to finish. However, to keep patients alert, a small but growing number of practitioners are offering candidates for breast enlargement the option of sedation and local anesthesia, which dulls pain sensations only in the area being operated on and keeps the patient awake and able to communicate.  Specifically, tumescent – a fluid that contains epinephrine and lidocaine –  is pumped into the area. Proponents claim that local anesthesia is safer than general anesthesia, offering a faster recovery period and the added bonus that patients are granted more control over their final appearance.  However, the doctors who are performing breast augmentation (and also tummy tucks) this way have become the subject of harsh criticism from vocal opponents. 

The critics argue that  using local anesthesia and sedation is a way for doctors to perform the surgeries outside of hospitals or other accredited facilities.  They also observe that the majority of the 100 or so physicians who are offering the “awake during surgery” option have not completed training in cosmetic surgery (usually a 6-year program).   In fact, a good number of them were medically trained in obstetrics and gynecology and completed a training program on how to perform aesthetic procedures with this type of anesthesia.  Compared to a plastic-surgery residency, the two-day, $7,000 course seems a bit, well, unbelievable.  Another complaint that numerous plastic surgeons have about the “awake” option is that patients are making decisions while sedated; they may be conscious and able to speak, but their decision-making abilities are compromised by high doses of medications like Ativan and Valium.  Furthermore, not having an anesthesiologist present while the surgery is underway could be a safety risk for the patient in case complications (like a panic attack or dizziness, for example) occur.  Moreover, the claim that a patient needn’t be “completely under” for the procedure may propagate the false belief that breast augmentation is not really a major surgery and that it needn’t be taken as seriously as it should be.

But this hasn’t stopped a number of women from choosing this anesthesia alternative.  What’s best for any individual will depend on her preferences; make sure that you ask the right questions and fully understand the surgeon’s background, the risks of the procedure and anesthesia options, where the surgery will take place, and what will happen in case of an emergency.  Although it would be best to get multiple opinions from doctors with different philosophies, it may be difficult to find someone willing to perform this procedure.