Other than post-mastectomy reconstruction, no cosmetic surgery has a medical reason or indication. Fatal surgery patient deaths are rare. it is the nature of cosmetic surgery that creates a media frenzy when deaths occur. It stands to reason that if you don’t have to undergo surgery, dying from it would be highly unacceptable and will attract a great deal of media attention.
General anesthesia (GA) is almost certainly the most common form of anesthesia administered for cosmetic surgery. It’s convenient but fraught with avoidable risks. There are no avoidable risks for surgery that has no medical indication, such as cosmetic surgery. Those possible risks include malignant hyperthermia (that is, recent death of a teenager in Florida), oxygen deprivation accidents leading to brain damage or death, blood clots in the lungs, vomiting, and edema of the lungs. These risks occur due to the significant degree of handover that depresses the patient’s ability to protect himself.
Fortunately, there is an alternative anesthetic technique that creates minimal carry-over and therefore maximizes patient safety while eliminating the risks associated with GA. In 1997, Dr. Friedberg developed the BIS-monitored propofol ketamine technique, now registered as minimally invasive anesthesia (MIA) ®
The BIS monitor generates a number from 0 to 100 generated by the information collected by a forehead sensor on the patient. The lower the number, the more asleep the patient will be.
Most patients do not want to hear, feel, or remember their surgery, a state associated with GA (BIS 45-60). MIA gives the same GA experience in BIS 60-75 with 20-30% less medication (i.e. propofol). Goldilocks anesthesia
it is made possible by not letting the BIS drift below 60 (‘too much’) and not letting it rise more than 75 (‘too little’). BIS between 60-75 is “perfect” along with adequate local analgesia.
A good number of anesthesiologists have adopted the concept of brain monitoring as useful in assisting in the administration of anesthesia. However, many anesthesiologists have been reluctant to adopt the technology approved by the FDA in 1996.
Given that the brain is what is being medicated, it stands to reason that using a device like the BIS that measures brain response would be a much more accurate way to give patients their anesthetic drugs. Rarely has a member of the lay public failed to understand this obvious point. Having patients request this type of follow-up can be a positive force for change.
Gradual administration of propofol while following the BIS up to 75 often allows patients to continue breathing on their own without requiring additional oxygen to be safe. Under these conditions, there have never been any mishaps from lack of oxygen with MIA.
Once the BIS reaches 75, ketamine can be administered. Propofol at BIS less than 75 prevents all historically reported negative side effects while preventing the patient from experiencing the pain of local anesthetic injection that is common to all cosmetic procedures. The numerical value of the patient’s brain response to propofol makes the administration of ketamine a predictable, reproducible and very safe experience.
Propofol is a powerful anti-nausea medication, which is why patients with MIA have the lowest incidence of vomiting (0.5%), even without additional anti-nausea medications such as Zofran®. Neither propofol nor ketamine are triggering drugs for malignant hyperthermia, which eliminates that risk.
The Doctors’ Company (TDC) is a medical malpractice insurer with a large number of insured plastic surgeons. The TDC Fall 2005 Newsletter on Deep Vein Thrombosis (Blood Clots) and Pulmonary Embolism (Blood Clots in the Lungs) stated:
“… immobility associated with general anesthesia is a risk factor for thromboembolism. New intravenous sedation techniques that include the use of propofol drip, often in combination with other drugs, have made it possible to perform prolonged or extensive surgeries without general anesthesia and without loss of the patient’s protective airway reflexes. ” reference # 11
11. Friedberg BL: Propofol-ketamine technique: dissociative anesthesia for office surgery. Journal of Aesthetic Plastic Surgery 1999,23; 70.
Some anesthesiologists are just as reluctant to administer ketamine to patients as they are to use brain activity monitors like the BIS. Patients will likely need to request MIA to receive it.
Any anesthesia provider has more skill than necessary to provide MIA. Giving MIA is more a matter of being asked to provide it than any technical difficulty in doing so.
Create a force for change! If you knew there is a safer (simpler and better) anesthetic for cosmetic surgery, wouldn’t you want to ask?