Tuesday, March 29, 2011

Awake Cosmetic Surgery - Surgery Without Anesthesia

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The new and aggressively marketed Awake cosmetic surgery is performed under local anesthesia only without even an IV. Some doctors will add a mix or cocktail of oral medications such as valium. These procedures are heavily advertised as a cheaper, safer and more medically advanced alternatives to liposuction, abdominoplasty and breast enhancement surgery, especially liposuction. Awake surgery ads promise that patients remain lucid throughout the operation able to interact with their doctor and even voice opinions about such things as breast implant size at prices less than half of conventional surgery with general anesthesia. They may even propose surgery a doctor’s cozy office, not in an intimidating outpatient surgical center or hospital, which is dangerous distortion of the facts.

The facts are that with respect to liposuction this type of anesthesia is frequently inadequate so that the doctor has to use smaller shorter tubes for liposuction making many more skin holes, that leave scars, than otherwise would be required. The patient squirms around in pain making it harder to achieve a good result. General anesthesia is expensive, and the anesthetists/anesthesiologists who provide it prefer to work in hospitals or clinics that have met high safety standards i.e. are certified. Awake surgery has become a way for doctors who lack hospital privileges and requisite surgical training—but who want to cash in on the plastic surgery market—to exploit a loophole in the law by performing the operations in the privacy of their offices in rooms that are not accredited operating rooms and do not contain required safety equipment. The California state law requires all surgery under general anesthesia or medications that dull airway reflexes to be performed in a certified accredited operating room. Furthermore the cocktail of medications impairs judgement so that the patient although technically awake cannot hold a meaningful conversation or make any judgement decisions with respect to their care during surgery.

The amount of local anesthetic (lidocaine) injected can reach toxic limits and a number of deaths have occurred due to this overdose.

In September 2009 a Florida registered nurse and mother of 3 underwent liposuction in a Florida medispa under local anesthesia in an non-certified operating room. That medspa doubled as a tanning salon and was frequented for massages and manicures. She began to have seizures and was rushed to a nearby hospital where she was pronounced brain dead. After 2 weeks on life support she passed away. An investigation revealed her surgeon had taken only a 3 day course in plastic surgery.

In 2010 a patient died from lidocaine overdose during awake liposuction in Southern California. That doctor's license was immediately pulled. The lidocaine may depot in the fat layer and then slowly release after the patient leaves the doctor's office. The toxic level is then reached at home some hours later and there are multiple reports of patients dying alone at home in these circumstances.

The growing number of cases where this mode of surgery was employed under dubious circumstances is mind boggling. A radiologist with no surgical training opened an office in Beverly Hills to perform only awake liposuction in a non-accredited exam room. Patients complained of pain during surgery, bad results and non-medical office staff performing surgery on them. When the authorities came to shut down the office and take his medical license he had already disappeared. A general practitioner was performing awake breast augmentation in Northern California and advertising it on roadside billboards. Complaints were filed on the basis of the false advertising on the billboards. When some of his patient records were examined the evidence was so damning that he lost his medical license. The ex-wife of one of my patients underwent an awake surgery facelift in Beverly Hills and told him the pain was excruciating.

In the 1950s the death rate from anesthesia alone was 1 per 10,000 and more people died from anesthesia than polio. That changed to 7 per 1,000,000 by 1984 with the introduction of pulse oximeters that noninvasively measured blood oxygen and better medications. Since this is less than the rate of death from car accidents the patient has taken a greater risk driving to surgery than undergoing the anesthesia for surgery. General anesthesia remains the most utilized form of anesthesia for all elective cosmetic surgery. Awake surgery is not safer than surgery under general anesthesia when overdoses of lidocaine local anesthesia are given and/or the procedure is performed in a non-accredited operating room that does not contain the requisite safety equipment in case of an emergency.

July 22, 2011 Addition:
An Arizona emergency-room physician, certified as an internist, but who had never done a residency in plastic surgery or anesthesiology was convicted last week of murder and manslaughter for the deaths of his liposuction patients. Two died from an overdose of local anesthetic and another from an injection of fat into a vein. The fat traveled up to the heart and lungs killing the patient. The first 2 basically died from an overdose of the local anesthetic used in awake surgery. In one of the overdose patients the doctor inserted a breathing tube into the esophagus instead of the trachea and refused to let paramedics change the tube thereby contributing further to the patient's demise.

Addendum Apr 11, 2012:
A general practitioner in Toronto Canada’s Yorkville neighbourhood  had restricted his practice to cosmetic surgery in 1999 despite never completing a formal surgical residency or certification process. At his clinic he performed tummy tucks, breast augmentation, liposuction and facelifts under local anesthesia with sedation. He later admitted to six weeks experience in the United States with no “hands-on” training in anesthesia yet sedation at his clinic was performed by nurses that he trained. In December 2006, a woman died two days after the doctor performed liposuction and an abdominal panniculectomy, or the removal of hanging fat and skin. This initiated an investigation of his practice and the finding of 29 cases of incompetence and misconduct. A surgeon was sent in as an observer by the regulatory board and found he used “extremely dangerous drugs without proper training,” and had a “cavalier” attitude to risk. The surgeon observed a breast augmentation and had “major concerns” about the use of “conscious sedation,” as the patient had “obvious airway obstruction.” A chart review found several instances where anesthesia records about patient condition had been filled out before surgery rather than during the time of surgery. A tribunal then restricted the license of the doctor so he is now prohibited from performing cosmetic surgery.

Addendum July 18, 2012 :
Today I received a notice from a group of non-plastic cosmetic surgeons (academy) advertising a course for doctors to learn how to do abdominoplasty under local anesthesia alone. The whole premise is unsound because the vast majority of these patients require suture tightening of the midline abdominal muscles. You cannot get adequate anesthesia under local alone to do this and you cannot get effective tightening without first paralysing the patient. You cannot paralyze a patient under only local anesthesia because there is no machine to breathe for them and they cannot do it on their own while paralyzed. It is obvious that we will soon see advertisements for the surgery under local anesthesia. Most of these patients will be unhappy with the substandard result but many will not have sufficient funds to pay for revision surgery.

Addendum September 22, 2012:
A just published study, in the medical journal Lancet, of 21.4 million operations involving general anesthesia in countries around the world over the past 60 years revealed that before the 1970s 357 of every 1 million patients died within the first 2 days after surgery and that number dropped to 34 per million from the 1990s to 2000s. This was seen worldwide but 2 to 3 times more patients survive surgery in developed countries.

Addendum September 3, 2015:
In January of this year, 21-year-old Amy Rickhussmof Sydney Australia, was rushed to Westmead Hospital after she went into cardiac arrest during her breast enhancement procedure. Senior members of the Australasian College of Cosmetic Surgery were "concerned that The Cosmetic Institute [where the surgery was performed] may be placing patients at risk ... by providing surgery under deep sedation while not being properly licensed to do so" and requested a government investigation. The exact cause is unknown but the Australian Health Care Complaints Commission is investigating reports she was given the drug Intralipid, which is used to reverse the effects of local anaesthetic toxicity. The clinic where she had the surgery told local reporters that she was not given general anesthetics during the procedure and told a mortified investigating government minister that the patients he was observing were under deep awake basically general anesthesia.

Addendum April 19, 2016:
The Cosmetic Institute (TCI), a cut-price cosmetic clinic, is Australia's largest provider of cosmetic surgery. It has clinics in Sydney and the Gold Coast with plans to open in Victoria. The company's annual projected turnover for 2014-15 was $35 million to $40 million. According to the NSW Health Care Complaints Commission (HCCC) report, in the last 12 months six patients at TCI suffered potentially life-threatening complications while getting breast implants, including rapid heartbeat, seizures and cardiac arrest due to high doses of anaesthetic cocktails administered in facilities not licensed for deep sedation or general anaesthetic.

  • One patient went into ventricular tachycardia and requiring resuscitation 
  • One patient suffered pneumothorax 
  • One patient suffered a seizure 
  • One patient had an irregular heartbeat 
  • Two patients went into asystole and requiring resuscitation 

 Asystole meant they had not heartbeat. Doses were not being adjusted for individual patients' size and body weight which is sloppy and dangerous. These dangerous complications occurred at the hands of medical practitioners, anaesthetists and surgeons.

Aaron Stone MD - twitter
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