Aside from post-mastectomy reconstruction, no cosmetic surgery has a medical reason or indication. Fatalities of cosmetic surgery patients are rare. it is the nature of cosmetic surgery that creates a media frenzy when deaths occur. It stands to reason that if you don’t have to have surgery, dying doing it would be highly unacceptable and would attract a great deal 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 for a surgery that does not have a medical indication, as is the case with cosmetic surgery. Those avoidable risks include malignant hyperthermia (ie, recent death of a Florida teenager), oxygen deprivation mishaps leading to brain damage or death, blood clots in the lungs, vomiting, edema of the lungs. These risks occur because of the significant degree of carryover that depresses the patient’s ability to protect themselves.

Fortunately, an alternative anesthetic technique exists that creates minimal carryover and thus maximizes patient safety and eliminates the risks associated with GA. In 1997, Dr. Friedberg developed the BIS-monitored propofol ketamine technique, now registered as minimally invasive anesthesia (MIA)®

The BIS monitor generates a number from 0 to 100 generated by information collected by a sensor on the patient’s forehead. The lower the number, the more asleep the patient is.

Most patients do not want to hear, feel, or remember their surgery, a state associated with GA (BIS 45-60). MIA provides the same experience as GA at BIS 60-75 with 20-30% less medication (ie propofol). Anesthesia ‘Goldilocks’
it is made possible by not letting the BIS go below 60 (‘too much’) and not letting it rise above 75 (‘too little’). BIS between 60-75 is “perfect” along with adequate local analgesia.

A good number of anesthesiologists have embraced the concept of brain monitoring as useful in aiding the administration of anesthesia. However, many anesthesiologists have been reluctant to adopt the technology approved by the FDA in 1996.

Since the brain is what is being medicated, it stands to reason that using a device like the BIS that measures the brain’s response would be a much more accurate way of giving patients their anesthetic medications. Rarely has a member of the lay public missed this obvious point. Getting patients to request this type of follow-up can be a positive force for change.

Gradual administration of propofol while following the BIS to 75 often allows patients to continue breathing on their own without the need for additional oxygen to be safe. Under these conditions, mishaps due to lack of oxygen have never occurred with MIA.

Once the BIS reaches 75, ketamine can be administered. Propofol with a BIS of less than 75 prevents all historically reported negative side effects and spares the patient the pain of local anesthetic injection that is common to all cosmetic procedures. The numerical value of the patient’s brain response to propofol makes the administration of ketamine a predictable, reproducible and very safe experience.

Propofol is a powerful anti-nausea medication, so MIA patients have the lowest incidence of vomiting (0.5%), even without additional anti-nausea medications such as Zofran®. Neither propofol nor ketamine are triggering drugs for malignant hyperthermia that eliminate this risk.

The Doctors’ Company (TDC) is a medical malpractice insurer with a large number of plastic surgeons as insureds. The Fall 2005 TDC Bulletin on Deep Vein Thrombosis (blood clots) and Pulmonary Embolism (blood clots in the lungs) stated:

“…immobility associated with general anesthesia is a risk factor for thromboembolism. Newer techniques for intravenous sedation involving the use of propofol drops, often in combination with other drugs, have made it possible to perform lengthy surgeries or extensive 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 as reluctant to give patients ketamine as they are to use brain activity monitors like BIS. Patients will likely need to apply for MIA in order to receive it.

Any anesthesia provider has more skill than is necessary to provide MIA. Giving MIA is more a question of being asked than of any technical difficulty in doing so.

Create a force for change! If you knew there was a safer (simpler and better) anesthetic for cosmetic surgery, wouldn’t you want to order it?