Chicago — The reduced risk inherent in the use of conscious sedation is a benefit that is appealing to both patients and surgeons.
Cosmetic surgeon Thomas Mustoe, M.D., uses conscious sedation in up to 99 percent of his procedures, and his partner, Neil A. Fine, M.D., relies on conscious sedation for approximately 70 percent of his cases. The pair are long-time proponents of conscious sedation and use it for every aspect of cosmetic surgery, including combined procedures that can be completed in less than five hours.
Drs. Fine and Mustoe are affiliated with the Feinberg School of Medicine at Northwestern University, Chicago. They discussed conscious sedation in cosmetic surgery here, at Plastic Surgery 2005, the recent annual meeting of the American Society of Plastic Surgeons. Conscious sedation is reportedly gaining a growing following, and Dr. Mustoe sees the trend as continuing to gain acceptance, "because of the reduced risk of some serious complications of deeper levels of anesthesia including pulmonary embolus, and because of the potential for quicker recovery with less nausea and vomiting."
Conscious sedation challenge
The primary challenge to safe and effective use of conscious sedation for cosmetic surgery, Dr. Fine says, is ensuring that adequate levels of local anesthesia are being administered. This is accomplished through a variation on the team's tumescent technique for liposuction. Some surgeons erroneously rely on conscious sedation to act as their anesthetic, but that's not its purpose, Dr. Fine says.
"Sedation is sedation, it's not anesthesia. So the real key to performing procedures under conscious sedation is achieving adequate local anesthesia."
The doctors' conscious sedation technique begins with preoperative intravenous Valium to create an initial state of sedation.
"We'll usually continue giving IV Valium in increments of 5 milligrams to 10 milligrams depending on the patient's age and alcohol tolerance until the patient's speech begins to be somewhat slow or slurred," Dr. Fine explains. "We then give a combination of Versed and fentanyl in small doses at five minute intervals keeping the patient in a state of conscious sedation, which means that they are arousable enough to do what's requested of them, but not to a point where they are too awake or conversant," says Dr. Fine. "This is especially important in the beginning of the surgery when we're putting the local anesthesia in," he adds.
Step by step
The next step, in the cases of an abdominoplasty, for instance, is to inject a small amount of 0.5 percent lidocaine with epinephrine along the initial abdominal incision.
"Then we'll put tumescent fluid in under that incision and follow that up with an infusion of tumescent fluid into the hip area on the left and right sides," explains Dr. Fine. The next step is to open the skin incision, go down to Scarpa's fascia and infuse the remainder of the tumescent fluid, usually about one liter to two liters.
Safe Triangle for Conscious Sedation
"Under direct vision we go below Scarpa's fascia and concentrate the fluid between Scarpa's fascia and the rectus fascia in an effort to concentrate our local anesthesia where the nerves are," Dr. Fine says. While that's being done, the local anesthesia has had a chance to numb the hip and liposuction can be performed in the hip area. By the time the liposuction is complete, the local anesthesia has had about 15 minutes to work in the area between Scarpa's fascia and the rectus fascia.