Anesthesia for Plastic Surgery Procedures

The transition period both going under and coming out of it can be frightening.  Most patients report a preference for Light Sleep Sedation (IV or oral sedation) with such analgesic narcotics or benzodiazepines such as versed, valium, or fentanyl.  This may be a wonderful choice for relatively most cosmetic procedures.  That is one of the reasons Dr Simoni has modified majority of cosmetic surgery procedures to a less invasive level so they can be done with only oral sedation. However, for procedures such as rhinoplasty (nasal plastic surgery) which may involves airway Dr Simoni usually prefers General anesthesia.  We will discuss the what, when and why in the following sections.

Types of anesthesia  

There are a few choices that you may have for anesthesia. The four main categories of anesthesia are:

• local anesthesia
• regional anesthesia (nerve blocks)
• sedation 
• general (deep) anesthesia

 Local Anesthesia

Local anesthetics are what you have when you receive a shot to numb the immediate treatment area. The treatment area feels very numb and it may feel like it is twice the size as normal.  It begins to wear off within an hour or more, depending upon the dose.  When feeling returns, it may feel tingly, almost like when your arm or foot "falls asleep."  You most commonly receive local at the dentist's office. However majority of dental procedures are done with some sort of regional nerve block. That is why your tongue and side of your face may feel numb in addition to your teeth.  Nerve block will be discussed more in detail later.
The injection is most commonly of Lidocaine (or Xylocaine, Marcaine), epinephrine (as a vasoconstrictor to impede bleeding in the treatment area and absorption of the Lidocaine by the patient) and sometimes sodium bicarbonate as a buffering agent.  Injections of anesthetic are thought to block nerve impulses by decreasing the permeability (think of  microscopic openings for the impulses to leak through) of nerve membranes to sodium ions.  There are many different local anesthetics that differ in absorption, toxicity, and duration of action.  There  is limitation to using lidocaine exclusively as local anesthesia for facial cosmetic procedures.  That is why Dr Simoni uses local nerve block to significantly reduce lidocaine usage.

Regional Anesthesia (nerve block)

Regional anesthesia was named such because a region of the body is anesthetized without rendering the patient unconscious.  You may have also heard them referred to as nerve blocks.  A nerve block is considered regional as an anesthetic is injected into a nerve cluster and it effects sensation in all areas which this cluster controls. There are nerve clusters all of your body; for instance, under the jaw, in the chin, and under the eye.  They sometimes feel like little holes in the bone where your nerves are clustered, then branch out to the different areas of the face or anywhere on the body. A good example of this is local nerve block that is done during dental surgeries.   Do not get this confused with an epidural as they are very similar in effects but a different locale is injected with the anesthetic.  In an epidural the injection is in the area outside the spinal fluid called the epidural space.  Rather will will cover regional anesthesia of the face as some facial surgeries can be and are routinely performed while under this type of anesthesia.  Such as brow lift touch ups, lip reduction and augmentation surgeries, chemical peels, sub-mental liposuction and more.
The benefit of nerve block is that a very small amount of injection needed to anesthetize a fairly large area. it works very fast this way and you need less injections than with typical local anesthetic.  Using less injection is more comfortable to patients while preventing any chance of lidocaine toxicity.  Dr Simoni utilizes this technique for majority of his facial plastic procedures. Even when general anesthesia is used, Dr simoni uses nerve block to reduce the need for more anesthetic agents which helps patients post operatively.

Sedation (Oral, Gaseous and IV)

Sedation can be oral, intra-muscular (IM), intra-venous (IV), or gas (in the order of intensity).

• Oral sedation is basically taking a sedative such as Valium (diazepam) or Xanax (alprazolam) by mouth an hour to an hour and a half before a procedure.  Oral sedatives make you very calm, drowsy and you may even fall asleep depending upon the dosage.  When you take the sedative either by swallowing or sublingually (holding it under the tongue to dissolve) as long as you can, and anywhere from 20 minutes to an hour from taking the sedative you will feel its effects.  You often feel calm, your balance may be affected, you may feel very peaceful and as said before, may simply fall into a light sleep. Most common agent used for oral sedation used by Dr Simoni is Lorazepam.  This is like a short acting Valium that is given ahead of time.  This type of sedation is great for liposuction, skin resurfacing (peels) or eyelid surgeries.  This type of sedation creates a ease of mind and relaxation while you are in control of your body and thoughts and can carry a normal conversation. Dr Simoni also recommends taking same sedative the night prior to surgery.  It takes the edge off of the anxiety you may feel the night before and morning of your operation.
  
• Intra-muscular (IM) sedation is slightly stronger and faster than oral sedation.  Dr simoni commonly uses Versed injection to arm muscle (just like vaccine).  This type of sedation will make you sleepy in addition to relaxed mode.  You can easily wakeup and still can carry a conversation if you like.  Most patients described the feeling like when you doze in front of TV.  Dr Simoni recommends this type of sedation for face lift procedures.
  Intra-venous sedation is when anesthesiologists uses the veins to deliver sedative and analgesic agents.  Having an IV inserted feels sort of like blood being drawn, but for a shorter period of time.  It's the initial placement of the IV catheter that may sting a bit.  After the needle is injected into the vein it is pulled out and a little plastic tube is left in your vein.  This type of anesthesia vary in intensity.  It can be very light just like oral sedation or as deep as general anesthesia.  Dr Simoni strongly recommends a certified anesthesiologist for this type of sedation.

General Anesthesia (Gaseous)

General can be given by an inhaled gas or by an IV liquid, or both simultaneously. General isn't fully understood, yet. But they speculate that it works in several ways:

• neuromuscular blocking agents which effect the spinal cord (resulting in immobility of the patient)
• "brain-stem reticular activating system" (resulting in unconsciousness)
• cerebral cortex (as seen as changes in electrical activity on an electroencephalogram)
• Inhalational agents to control autonomic responses and provide analgesia and amnesia
   (or)
• Benzodiazepines (such as Valium, my preference) for their anti-anxiety and amnesiac effects
  obstruction of nerve conduction
• interruption of synaptic transmission (It is more difficult to explain synapses interruption, so take my word for it - I don't even remotely understand it yet.)

Total Intravenous Anesthesia (or TIVA) is intravenous sedation only, it's what I prefer with Light Sleep IV sedation.  This is also done without a TCI pump and this is when the anesthesiologist calculates the needed dosage by skill and experience with the weight factors, other medications present and also by careful monitoring of the patient's vitals.

Dr Simoni prefers general anesthesia for rhinoplasty procedures for its superb airway protection.  Airway is manipulated in most rhinoplasty procedures as it involves improvement in breathing in addition to cosmetic aspect.