Global Courant
Other than post-mastectomy reconstruction, no cosmetic procedure has a medical reason or indication. The death of cosmetic surgery patients is rare. it’s the nature of cosmetic surgery that creates a media frenzy when deaths occur. It goes without saying that, if you don’t have to have surgery, dying without surgery would be very unacceptable and would also attract a lot of media attention.
General anesthesia (GA) is almost certainly the most common form of anesthesia given for cosmetic surgery. It’s convenient but fraught with avoidable risks. There are no avoidable risks with an operation without a medical indication, such as with cosmetic surgery. Those avoidable risks include malignant hyperthermia (i.e. recent death of a teenager in Florida), oxygen deprivation accidents leading to brain damage or death, blood clots in the lungs, vomiting, edema of the lungs. These risks occur because of the significant level of violation that undermines the patient’s ability to protect themselves.
Fortunately, there is an alternative anesthesia technique that creates minimal violation and thereby maximizes patient safety while eliminating the risks associated with GA. In 1997, Dr. Friedberg’s BIS-controlled propofol-ketamine technique, now trademarked as Minimally Invasive Anesthesia (MIA)®
The BIS monitor generates a number from 0-100 generated by information collected by a patient’s forehead sensor. The lower the number, the more the patient sleeps.
Most patients do not want to hear, feel or remember their surgery – a condition associated with GA (BIS 45-60). MIA gives the same experience as GA at BIS 60-75 with 20-30% less medication (ie propofol). ‘Goldilocks’ anesthetic
is made possible by letting the BIS drift no lower than 60 (‘too much’) and no higher than 75 (‘too little’). BIS between 60-75 is ‘just right’ along with adequate local analgesia.
Quite a number of anesthesiologists have embraced the concept of brain monitoring as useful to assist in giving anesthesia. However, many anesthesiologists were reluctant to adopt technology that was approved by the FDA in 1996.
Since the brain is medicated, it stands to reason that using a device like the BIS that measures brain response would be a much more accurate way of giving patients their sedatives. Rarely has a member of the lay public failed to grasp this obvious point. If patients ask for this kind of monitoring, it could be a positive force for change.
By gradually administering propofol while monitoring the BIS to 75, patients can often continue to breathe on their own without needing supplemental oxygen to be safe. Oxygen deprivation accidents have never occurred at MIA under these conditions.
Once BIS reaches 75, ketamine can be given. Propofol with a BIS of less than 75 prevents all historically reported negative side effects while preserving the patient from experiencing the pain of the local anesthetic injection common to all cosmetic procedures. The numerical value of the patient’s brain response to propofol makes giving ketamine a predictable, reproducible and very safe experience.
Propofol is a potent anti-nausea drug, so MIA patients have the lowest incidence of vomiting (0.5%), even without additional anti-nausea drugs such as Zofran®. Neither propofol nor ketamine trigger drugs for malignant hyperthermia, eliminating that risk.
The Doctors’ Company (TDC) is a medical malpractice insurer with a large number of plastic surgeons as insured. The Fall 2005 TDC Newsletter on Deep Vein Thrombosis (Blood Clots) and Pulmonary Embolism (Blood Clots in the Lungs) stated:
“…the immobility associated with general anesthesia is a risk factor for thromboembolism. Newer intravenous sedation techniques, including the use of propofol drops, often in combination with other drugs, have made it possible to avoid prolonged or extensive surgery. without general anesthesia and without the loss of the patient’s airway protective 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 give patients ketamine as they are to use brain activity monitors like the BIS. Patients will likely have to ask for MIA to receive it.
Any anesthetist has more skill than it takes to provide MIA. Giving MIA is more a matter of being asked to provide it than any technical difficulty in doing it.
Create a force for change! If you knew there was a safer (easier and better) anesthetic for cosmetic surgery, wouldn’t you ask for it?
Patient awareness – the key to safer cosmetic surgery Anesthesia
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