There is a movement afoot to try to legislate safety in Plastic Surgery by controlling what we do rather than taking the more difficult route of controlling the credentials and training of practitioners. State governments must find it less offensive to certain constituencies to legislate what we do and how we do it rather than more directly addressing the office surgical setting by requiring each and every practitioner to have a minimal amount of core training in the procedures legislators deem unsafe. When non-professionals try to address concerns on medical safety it always appears that some group of doctors may be affected and their arguments always seem to be based on possible financial restraints or financial hardships that fully trained and credentialed doctors may not suffer. The implications are that all doctors, regardless of training, are essentially equal. No such assumptions are proffered for neurosurgeons or cardiac surgeons. There is no legislation attempting to equalize specialty surgeons by defining what we do to make the entire group safer. No one has proposed the idea that cardiologists, with little or no surgeon training, should be allowed to do open heart surgery as long as they operate in a safe manner and do the operations in approved facilities. It would seem safer to address the training and credentials of those performing open heart surgery rather than restricting cardiologists to “simple” open heart cases. This is much like restricting non-Plastic Surgeons to “simple” or low volume liposuction searching for a safety standard by “dumbing down” the operation and its possible complications.
In another way, many surgeons and non-surgeon administrators have convinced people that surgery is always safer when performed under general anesthesia with an anesthesiologist in attendance. The fact is that almost all facial Plastic Surgical procedures done on adults for cosmetic reasons are safer when performed without general anesthesia, and its riskier counterparts, mask anesthesia and monitored anesthetic care. The latter two are basically general anesthesia without the benefit of a secure airway and in facial cases, a difficulty in administering oxygen as needed. It’s easy to declare that all patients need the most sophisticated and complex care in all circumstances with the assumption being that this is the safest way to proceed. One aspect of plastic surgical complications that seems to be consistently overlooked is the general anesthetic contribution to all complications. The fact that general anesthesia is related to complications is found in the surgical maxim that complication rates increase rather drastically after 2 hours under general anesthesia. I don’t believe that operations longer than 2 hours are inherently more dangerous. Many surgeons think that their meticulous technique, while sometimes slow, gives better results even though they may require hours longer under general anesthesia. As a general rule, those surgeons who expedite the operation to decrease operative time are the safest. The only way to further increase safety is to take the general anesthetic out of the picture. Interestingly, using local anesthetics and regional blocks requires an entirely new skill set and, most importantly, it requires patience. Adding sedation in the form of oral medication helps to make the experience more comfortable, but adds very little to the complication profile as these are the very same medications we use in our post-operative outpatient patients. We have found that the intravenous use of medications such as versed and morphine creates large increases of medications with a short half-life and is more likely to cause nausea and vomiting. Nausea is a much less common problem with oral medication especially if Phenergan or Zofran are used with the pre-operative oral medications.
In the past, the major complaint with local anesthesia with or without oral sedation is that it can burn when injected. There are a number of techniques that surgeons can utilize to make the injections much less painful. Almost all of these techniques require only a bit of patience from the surgeon. The most commonly used anesthetics are Xylocaine and Marcaine. Due to the acidic pH of Xylocaine, most surgeons have for years added bicarbonate to decrease the “burn” when injected. The problem with adding bicarbonate is that it decreases the ability of the Xylocaine to work as well and may require a larger volume of injection. Knowing the details of Xylocaine led to a search for better anesthetics. Our search led us to Paris, France where we discovered Septocaine. We found that Septocaine has about the same complications and dosage profile as Xylocaine. The difference with Septocaine is that it is less painful to inject, it tends to work faster, and provides what patients describe as a more “intense” numbness. We have used Septocaine as a primary local anesthetic for over 10 years and I am sure it is more comfortable for the patients. The downside is that it is more expensive to use. This is a small price to pay for patient comfort. It is important to understand that the reason for all of this discussion is to make sure our facial plastic surgery patients are comfortable, pain-free, and safe while having surgery.
From a medical/surgical point of view there is a very specific and important reason to use local anesthetics and oral sedation rather than general anesthetics. We are convinced that the vast majority of post-operative facial swelling after facelift surgery is caused by transient but significant changes in blood pressure during and immediately after surgery. In fact, I believe most hematomas and swelling occur in the period of time after the procedure is finished during the period of time when the patient emerges from general anesthesia. We believe that controlling the blood pressure at pre-operative levels throughout the operation and especially at the end has decreased swelling post-operatively dramatically. Blood pressure control and the judicious use of epinephrine in our local anesthesia with complete patient monitoring has completely changed the first 24 hours after surgery – much less bruising, swelling, hematomas.
One might ask why everyone who does facelifting wouldn’t do it with these techniques. The primary reason is probably the patience it requires and the fact each facelift should be done by itself each day. This fact resulted in our “One Facelift a Day” promise.