Anesthesia for Facial Plastic Surgery

Facelift Alabama

Schedule your facelift consultation with Dr. Howard by calling 205-871-3361

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.

Read more about top facelift surgeon Dr. Paul Howard and his no general anesthesia facelift.

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The Stem Cell Revolution

The law of unintended consequences applies to President George W. Bush when he banned embryonic stem cell research.  The unintended consequence was the search for adult stem cells and the knowledge that there is an almost limitless amount of adult stem cells located in fat or adipose tissue.  This fact places Plastic Surgeons at the epicenter of the stem cell revolution.  Who better than a Board Certified Plastic Surgeon is in a position to obtain the necessary fat (liposuction) which is then processed to obtain adipose tissue derived stem cells?

These adipose derived stem cells can be utilized for a myriad of cosmetic and reconstructive procedures.  For our purposes, these all-purpose stem cells are the basis of all of our facial and skin rejuvenation procedures.  It is a well-documented fact that stem cells, when reintroduced into the face, causes any fat which is re-injected, to “take” better and as a secondary benefit the stem cells release a number of “growth factors” that improve  skin by reducing the visible signs of aging.

It is important to realize that you cannot share your stem cells with anyone else nor can you use stem cells from another person.  The fat must be processed immediately and re-injected with the stem cells during the same operation as it is difficult to store adipose tissue for further use.  We have developed a “stem cell lab” within the confines of our sterile operating room.  The lab equipment costs little and only requires basic laboratory experience (such as the experience obtained with a B.S. in Chemistry).

Every medical breakthrough goes through stages.  First, there is disbelief followed by hyperbole.  The hyperbole stage is manifest by over hyping the benefits and the beginning of named procedures such as the “Stem Cell Lift” which basically does not exist.  Realistically, stem cells do not tighten skin or “lift” anything.  They are a great addition to volume enhancement by increasing the take of fat grafts and clearly stem cells cause your skin to rejuvenate by erasing age spots, increase skin thickness, and improve fine lines and wrinkles.  Most patients who have had our stem cell rejuvenation describe their skin as smoother and typically glowing.  Stem cell augmented fat transfer has become a staple in our rejuvenation procedures and at a minimal charge to the patient.

Read more about top facelift surgeon Dr. Paul Howard and view facelift before/after photos.

Looking Younger is Not a Sin

Having spent the majority of my life in big cities such as Atlanta, Miami and Paris, I was taken aback by the responses of women in smaller southern cities such as Birmingham, Montgomery or Mobile to the notion of facelifting.  I have on occasion related an anecdote about women in the South; if one asks a woman on the street in Miami or Paris “who is your doctor?,” the usual reply will get you the name of her Plastic Surgeon.  The same question posed to a woman in Birmingham will get you the name of her gynecologist.  I have no particular problem with gynecologists but it does reflect a palpable difference regarding priorities in medical care.  Likewise, there always exists a group of women who proudly notify their friends and family of their impending surgery and show their friends the results the moment the dressings are off.   A more common scenario in the South is that most women are very private in their personal affairs and only confide in their families and closest friends.  We are not talking about people of wealth as no one knows how or why celebrities and the wealthy choose their healthcare providers.   Judging from what we see on cable TV, the Michael Jacksons’ of the world as well as many aging models and TV stars should reconsider their choices of doctors, especially those who are fighting the aging process in an attempt to remain on the ‘’A’’ list.

The best example is the Hollywood penchant to completely overdo lip augmentation. The reason this is an issue is because “normal” people who inquire about lip enhancement look at celebrities, think they probably get the best Plastic Surgery, and assume that the comical, overdone lips are necessary for lip enhancement. Two bad assumptions are at work here: the first is that celebrities get the best Plastic Surgeons and the second is that enhanced lips should be huge and comical in appearance.  Good Plastic Surgeons can usually enhance lips in any of a number of ways achieving fullness, a very youthful pout and accentuation of youthful lip anatomy without the “bee-stung” comical lips that we see all too often. The choice to overdo any Plastic Surgical procedure is entirely up to the patient and not a part of Plastic Surgery itself.  There is an unknown in this process, which is the individual talent and taste of the Plastic Surgeon involved.  This is why it helps to see examples of the surgeons work in order to get some idea of how aggressive or exaggerated the work is.  Surgeons will usually show pictures of work they consider exemplary so when viewing catalogues of photos it is good to evaluate each result carefully taking in to consideration your specific taste, even if the photos are of procedures you are not considering.

One of the most challenging operations for a Plastic Surgeon is rhinoplasty. This is why there are so many “challenged” noses out there in Hollywood.   It is a bit of a cliché to use the Jackson family as an example of rhinoplasty gone wrong but I’ll do it anyway.   I believe that at least one of the early iterations of Michael’s nose was an attractive change from his original ethnic nose into a slightly improved version.   I would surmise that it was an operation or two later that his final scar laden, next to nothing nose emerged was left of his original proboscis. Without the wonders of his handy, at home, hyperbaric oxygen chamber Michael may certainly have lost his nose in its entirety.  I suspect that the last twenty or so operations were not procedures chosen by his surgeon yet performed nonetheless.  The legacy of the Jackson family nasal nightmare should probably not be left with the surgeon but with the patients who are too famous, have too much money and succumbed to too much bad advice or a lack of good judgment.

Breasts have long been the subject of Hollywood photographers and celebrity magazines.  Ever since Janet Jackson’s infamous Super bowl wardrobe malfunction there seems a preoccupation with breasts, especially large ones.  Many women seem to have attached their femininity to their cup size. The trend to larger breasts is exemplified by today’s Victoria Secret models that are not as anorectic as the models of the 80’s and 90’s.  In the real world outside of Hollywood women who consult for breast augmentation also want larger, fuller breasts but they also want “plausible deniability.”   That requires breasts large enough to be sexy but not quite so large that they could not conceivably be nature’s gift.

Plastic Surgery and the “beauty business” as it is now called did not arise from the devil as a temptation to vanity but rather as a consequence of the very normal desire of human beings to appear physically attractive to each other.  The process of aging tends to extinguish some of the physical attractiveness of youth.   Aging gracefully is the excuse given not to intervene with Plastic Surgery but our “grace” does not preclude spending billions of dollars on products for our hair, skin and nails.   Recently, Plastic Surgeons have become facile and more creative with the surgical interventions we recommend to treat the aging face.  Our operations tend to be less one-size-fits-all and are uniformly less invasive.  Surgeons now are utilizing more of our scientific educational background to apply the latest in biology to scientifically improve our results and to stay abreast the latest research and findings.

Those of us in facial and body enhancement business are as different as our patients. The best we can do individually is to provide up to date, non-biased information including our training and certifications to the table and provide honest, accurate photographs of our work so that patients may get an idea of our preferences and our aesthetic sensibilities.  The more factual information out there, the better chance the patient can find the right surgeon for the right problem.