Source: “Cosmetic Surgery Times”
by Lisette Hilton
October 21, 2005
Beverly Hills, Calif. — Using a special approach to administering local anesthetic, David Saadat, M.D., makes it possible for some patients to participate in their own surgeries.
These patients not only comment on how much or how little contouring the board-certified facial plastic and reconstructive surgeon does, but they also change positions — even standing for some procedures — so the surgeon and patient can better predict outcome.
Dr. Saadat, a clinical instructor in the division of facial plastic and reconstructive surgery, University of Southern California, Los Angeles, says he has some patients participate during such procedures as liposuction and the thread lift facelift because today’s patients tend to want to be involved and feel in control.
The other reason, which Dr. Saadat says is even more important, is that by keeping patients relatively awake during surgery, surgeons have the opportunity to evaluate results, step by step. “Under general anesthesia, patients usually lie flat. It helps, however, especially when contouring the body or face, to have them in different positions, including supine, standing or turned one side or the other,” he explains.
Today’s less-invasive surgeries allow surgeons to consider some patients for local anesthesia.
“The thread lift is a lot easier on the patients than a regular facelift. Obviously, the face and neck lifts are much more involved and much harder to do under local — especially if it is a long case,” Dr. Saadat says.
It is no secret that liposuction procedures for relatively healthy patients, during which surgeons remove only small areas of fat and focus on contouring the body, can be done under local anesthesia. Dr. Saadat gives the typical example of a patient with love handles who only wants what is equivalent to 20 cc or 30 cc of fat removed and contoured.
“A procedure like that is often best done under local and not general anesthesia, because once the patient lies on his or her back, it is difficult to evaluate the love handles. In these select cases, I might have patients stand while I contour the body,” he tells Cosmetic Surgery Times.
Dr. Saadat’s approach differs from traditional liposuction.
He first administers tumescent solution and asks that patients sit for 10 to 20 minutes. “Then we use a 12- or 14-gauge liposuction cannula attached to a 10 cc or 20 cc syringe,” he explains. “Using this approach, the surgeon has the opportunity to control the amount of suctioning that he does by pulling the syringe’s plunger.”
The approach puts the power of suction into the surgeon’s control, allowing surgeons to more exactingly remove fat from precise areas.
“The other advantage of doing this technique is that you can hide the scar, because your entrance wound does not need to be very close to the liposuction site,” he says.
Approaching the facelift
The thread lift with local anesthetic and patient participation is not for everyone. Patients who come to Dr. Saadat with significant jowl ptosis and ptotic platysmal muscles are best suited for facelift surgery under general anesthesia.
“But if the jowling is minimal and there is no significant neck ptosis, then we can get away with doing a thread lift alone or in combination with a short scar, short flap, minimal lifting, perhaps including fat injections or other procedures to add volume under local anesthesia,” he says.
The local anesthesia secret
Dr. Saadat uses more than local anesthesia to create conditions for successful patient participation. Whether using local anesthetic for the thread lift, liposuction or other procedure, he often takes the following approach:
First, he has patients take a sedative cocktail, which usually includes 10 mg of oral Valium (Roche Laboratories), one Vicodin (Abbott Pharmaceutical) or Darvocet (Eli Lily), and 50 mg of Dramamine (Pharmacia Consumer).
“We let them sit for an hour until everything has worked,” Dr. Saadat says. “We have them take these medications on a relatively full stomach. If we are doing the surgery in the morning, we will ask that they eat a light breakfast, or, if we are doing it in the afternoon, a light lunch.”
Once the sedatives have worked, Dr. Saadat and his staff bring patients into the procedure room, which, in itself, is carefully designed and prepared to be very relaxing. The patient’s choice of music plays in the background and the staff stores away — out of view — any metal or surgical instruments that might stress the patient. The bed is comfortable and padded, according to Dr. Saadat.
Dr. Saadat’s nurse anesthetist administers a dilute numbing medicine — usually the tumescent medicine — with added bicarbonate to avoid the burning sensation of anesthetic administration.
“We make sure that numbing medicine is not cold (it is room or body temperature), so that patients do not feel cold fluid coming into their body,” he says. “Then, we use small needles — 30-gauge needles — and the injection is done slowly around the area on which we are operating.”
So goes the first phase of injections. The team lets the patient sit for 10 to 15 minutes after administering the tumescent solution, which results in vasoconstriction. The vasoconstriction ensures that the second injection of medicine is not absorbed too quickly. Another benefit of waiting is that the first phase numbs patients enough so that they hardly feel the next (stronger) anesthetic injection.
Depending on the procedure, Dr. Saadat’s team usually uses one of two second-phase anesthetics. The stronger of the two is 1 percent lidocaine with 1/100,000 epinephrine; the medium- strength alternative is 0.5 percent lidocaine with 1/500,000 epinephrine.
“All the solutions include bicarbonate (even the tumescent),” he says.
His patients rarely report pain. Dr. Saadat helps to ensure their comfort by giving them juice and bathroom breaks throughout longer procedures.
Most patients who undergo the local anesthetic approach walk out of surgery.
“Because of the way we do the anesthesia and the type of liposuction canula we use (small, blunt and not aggressive), patients do not have a lot of soreness after surgery because the treated areas are numb, and we avoid the muscle damage or trauma that tends to occur with traditional liposuction because we can be so precise,” Dr. Saadat says. “Patients who come out of general anesthesia tend to be tired and it takes a couple of extra days for the anesthetic to get out of their bodies. But the way we do it, patients recover faster. Most of our patients are able to go to their regular activity a day or two after liposuction and most go to the gym three to four days later, if we’re doing a small area.”
Putting patients under a local anesthetic and having them participate in their surgeries is safest with the less invasive, less traumatic surgeries.
For example, Dr. Saadat refers to current guidelines that state patients having 1,500 cc or more of fat removed should be under general anesthetic during surgery.
In order to decide on anesthesia options, Dr. Saadat examines patients to determine how much work needs to be done to achieve the results they want.
If the patient is a candidate for local anesthesia, he then looks at whether the patient can psychologically participate in the surgery. Dr. Saadat says he uses one-hour consultations with patients to get a sense for how much confidence they have in their procedures, how much control they would like to have in their surgery and whether they could handle watching.
“Patients who have a mellow demeanor, say they want to be involved in the outcome and seem enticed when I tell them they can be involved might be good candidates. Other patients who express concern about general anesthesia might also make good candidates,” he says. “I think it comes down to personality issues. Most people who are really into their looks like to have control, and I think by doing it this way they feel like at least everyone tried their best to achieve what they were looking for. They therefore tend to feel good about the experience.”
Disclosure: Dr. Saadat reports no conflicts of interest.