In the past, the only thing that could be done for scars was to try and treat them if they healed badly.  There are many different creams, gels and injections which have been developed for this.  Why not try to prevent the problem from the outset?  The new Quill Self-Retaining System (SRS) suture, (which was developed by a plastic surgeon), is the latest advance in suturing and I have absolutely found that its application in plastic surgery clearly leads to better scars.  The Quill sutures have tiny barbs in them that allow for better closure.  They eliminate the need for knots and tighten up the incision like a zipper and then provide for, “controlled tension,” which means that the incision is closed and held closed in a very controlled way.  This method also makes is less likely that the incision may re-open. I have used them in my plastic surgery practice for breast  augmentation surgery, breast lift, tummy tucks and body lifts with excellent results and better scars than ever before.  The introduction of these Quill sutures a few years ago was actually the first major advancement in suture technology since the 1970′s! This is just another example of using new technology to achieve excellent results at Advanced Concepts in Plastic Surgery.

Now, I do perform some plastic surgery procedures using local anesthesia pretty much every week.  A little scar revision, a facial contour in a small area, or a micro-liposuction on the face.  But most of the plastic surgery I perform at Advanced Concepts in Plastic Surgery in Sacramento are performed with sedation or with a general anesthetic.

First of all what is sedation? Sedation is when the patient has an IV and receives sedation medication through it but remains conscious.  There are several different kinds of drugs that put the patient in a particularly happy place.  This means you’re not completely asleep but you are also not aware of what’s going on, you are very comfortable and breathing without the help of a breathing machine.

So why would you not want to be aware of what is being done to you?  I’ll use myself as an example.  Several years ago I had a wisdom tooth erupt.  I guess I’m a late bloomer. I had it removed under local anesthesia only.  The dentist did a great job as I did not feel any pain.  But it was a very unpleasant experience with all the rasping, grinding and pulling.  In addition to that, my mouth and jaw was very sore from staying open.  So, how do you think I would have felt after two or three more just like that?  So let me state the case.  If I have to do that again, I just don’t want to know about it, and I assume my patients would rather not experience that kind of discomfort during their plastic surgery procedure either.

Where does strict local anesthesia work best?  Local anesthesia works in small areas and in a very limited short plastic surgery procedure.  When do you want sedation?  When doing a longer procedure with larger areas where they may still have feeling in spite of the local anesthesia, like scar tissue or when working under the muscle.  When you have a longer procedure it’s difficult to lay in one position for hours.  The local anesthesia may wear off and need to be freshened or it will become uncomfortable.  My goal for all my patients is to have everything as painless as possible on all levels.  When you do it under strict local anesthesia, there is always some amount of pain involved.

Another issue has to do with the regulations of surgery centers.  In California, if you do plastic surgery with sedation or general anesthetic, the facility has to be licensed by an agency that licenses surgery centers.  Currently there are two main ones AAAHC and AAAASF.  I actually do inspections for the latter.  When you pass inspection for unique standards of organization, cleanliness, accountability, and safety that means that your physical plant has been approved, it also means that you have hospital privileges for the procedure being done.  However if the procedures are under straight local anesthesia, you do not need to meet the strict standards of the physical plant or hygiene and safety accountability.

That certainly doesn’t mean that everyone promoting, “local anesthesia only procedures,” is doing it to avoid regulation of shoddy or dangerous conditions, but… let the buyer beware.

What about general anesthesia for plastic surgery procedures?  Even when using lots of local anesthesia some surgeries are very stimulating to the nervous system.  This is because local anesthesia blocks the pain stimulus but not necessarily pressure, pulling or heat.  One of the worst horror stories I’ve heard about local anesthesia revolve around a patient that had a breast augmentation under local anesthesia, with some sedation, and “woke up” in the middle of the procedure and was told to be still,” because we have to finish.”  They felt and  experienced much more than they wanted to.  Sometimes you need what is called muscle relaxation sedation to do what you need to do, i.e., put in a breast implant or suture up the abdominal muscles.  A light general anesthetic is perfect for a breast augmentation, mommy makeover or total facial rejuvenation such as a facelift because it keeps you perfectly comfortable for those longer procedures and often times actually requires less total medication and sedation.

In summary: straight local anesthesia is great for very small procedures. But IV sedation or   general anesthesia are better solutions for making the patient comfortable for many plastic surgery procedures.  My goal for the patients is a painless plastic surgery, and local anesthesia is not the best way to achieve  that in every case.

Whatever the reason, a tummy tuck is a 2.5 hour operation with about 7 to 10 days recovery. Most of our patients are off pain pills within several days and taking Tylenol. By the time stitches come out at a week they are very comfortable.

Some patients who have had a tummy tuck performed elsewhere complained that it was one of the most painful surgeries that they have ever experienced. What’s the difference?

Like most things in life, prevention is better than the cure. Blocking pain upfront is better than treating it. Minimizing the damage to the tissues minimize the pain message that comes from the tissues to the nervous system.

Many surgeons when doing a procedure under general anesthesia don’t use local anesthetic in the incision. In our office, a local anesthetic is put into all the incision areas and we allow enough time for it to work before making an incision. In addition to tumescent anesthesia, ballooning up the area with a combination of a local anesthetic and saline, is placed in the area of lifting. And lastly when the lifting of the skin is done, most of it is done with a scalpel or scissors as opposed to a cautery unit. This causes minimal trauma. The traditional way of using cautery causes burn damage. These burns on the inside can be very painful and are best avoided.

With minimal trauma and damage a substance called substance P. is minimally released. The more substance P. there is, the higher your pain. By decreasing this up front, there is less pain. At the end of the procedure, a long acting local anesthetic is left inside the wound. Pain pumps have not been necessary. Finally, laser treatment is begun the next day to further decrease pain and inflammation.