Awake for Breast Implants? If You Wish

How? She was awake. Most women who get breast implants do so under general anesthesia. But Jane. Z.’s doctor was Dr. Robert L. True of Colleyville, Tex., one of more than 100 doctors nationwide who advocate local anesthesia and sedation for aesthetic surgeries like breast augmentations.

“They are talking to me the entire time,” Dr. True, an obstetrician and gynecologist by training, said of the 75 patients whose breasts he has enlarged in his accredited facility. Once the new implants are in, his patients are propped up on the operating table, look in a mirror and have their say. “They like that little bit of autonomy,” he said.

A lot of plastic surgeons consider it out of the question to do a breast augmentation without an anesthesiologist or nurse anesthetist on hand, partly because of the risk to the patient if something goes wrong. These doctors say they cannot do their best work — dissecting a pocket for an implant, then securing it — without total control.

But lately, a set of doctors, most of whom have not come up through plastic surgery, has been touting the awake option as a boon to patient choice and as a safer option than general anesthesia. Breast augmentation is often done in hospitals and accredited offices, but awake breast surgery is usually done in an office that might not have been vetted for safety by an accrediting organization.

“Problem is, doctors are doing large procedures on local with quote-unquote sedation to circumvent the need for accreditation,” said Dr. Lawrence S. Reed, the president of the American Association for the Accreditation of Ambulatory Surgery Facilities.

For most of surgery, Jane Z., 48, who reviews medical charts for a hospital, said she felt “pretty much out of it.” She added, “You’re technically awake, but you remember nothing.” In a more coherent moment, she did recall being asked, before Dr. True sewed her up, if her new breasts were adequate. She asked to go slightly larger, and got her wish for a DD cup.

“If you talk to 99 percent of women, they want input into what they are going to look like,” said Dr. Jeffrey Caruth, an obstetrician and gynecologist by training who now offers awake cosmetic surgery at his office in Plano, Tex. “People are not coming to me because it’s cheaper. They don’t want to be put to sleep.”

Doctors offering awake breast augmentation and awake abdominoplasty (a tummy tuck) advertise on YouTube.com and make the case for local anesthesia and sedation on their Web sites. In the last few years, marketing for awake breast augmentation has ramped up. No organization tracks how many doctors do the awake version of this surgery (or of tummy tucks).

Dr. Anil K. Gandhi, who performs both awake procedures at his office in Cerritos, Calif., said he had taught “more than 100 doctors” in two-day $7,000 seminars for the National Society of Cosmetic Physicians. His students are doctors who typically did their residencies in ob/gyn or family medicine and who take a weekend course (or two) to learn how to do aesthetic surgeries with local anesthesia and sedation.

This shortcut to practicing aesthetic surgery tends to outrage the traditionalists. After all, board-certified plastic surgeons spend five to eight years after medical school learning operations and then have their surgical skills vetted in exams.

“Two-day courses, it’s just crazy,” said Dr. William P. Adams Jr., a plastic surgeon in Dallas who teaches residents at the University of Texas Southwestern Medical Center. “It took us six years to fully train plastic surgeons to do breast augmentation.” He said it was irresponsible to let fuzzy-headed patients choose their implants. “They don’t let people drive after a six-pack of beers,” said Dr. Adams, who is an investigator for Mentor and Allergan, makers of breast implants (and a consultant for Allergan). “How well will people choose an implant size after narcotics?”

Dr. Adams and other plastic surgeons say that mid-surgery consultations can be harmful if the patient chooses implants too large for her chest. Overaugmentation can produce unsightly rippling, said Dr. Mark L. Jewell, a plastic surgeon who does breast augmentations with local anesthesia and intravenous sedation in an accredited facility in Eugene, Ore. “Decisions should be made ahead of time,” said Dr. Jewell, an investigator for Mentor and Allergan as well as a consultant for Allergan.

This article has been revised to reflect the following correction:

Correction: April 15, 2010

The Skin Deep column last Thursday, about breast-enhancement operations performed without general anesthesia, referred imprecisely to the ability of the anesthetic lidocaine to ward off infection. While it has antibacterial properties, they are present only in high concentrations.