The Twilight Zone

With the advent of plastic-surgery TV shows, patients are more informed than ever—perhaps too informed?—about what they’ll look like after their procedures as well as what the procedures themselves look like. Whether they should be awake (if sedated) to witness their own nips and tucks or out like a light is a matter of debate between the city’s cosmetic dermatologists and plastic surgeons, and among plastic surgeons themselves.

The dope-or-no-dope question is hottest when it comes to liposuction—the most popular plastic-surgery procedure (according to the American Society for Aesthetic Plastic Surgery, 372,831 liposuctions were performed in America last year, compared with 249,641 breast augmentations, 156,973 nose jobs, and 124,514 face-lifts). Typically, general anesthesia is not used. Instead, plastic surgeons opt for IV sedation, or “twilight” anesthesia, which is administered by an anesthesiologist who monitors the patient’s vitals during the procedure. “My philosophy,” says Richard Skolnik, a plastic surgeon for 21 years, “is to provide the anesthesia that makes the patient the most comfortable—frequently that’s heavy twilight. Most patients don’t want to see me moving this metal tube back and forth and in and out and be aware that that’s going on.”

Cosmetic dermatologists, on the other hand, often prefer local anesthesia, particularly when using the tumescent technique, in which a saline solution with epinephrine and numbing lidocaine “wet” the area where the tube, or “cannula,” will be. An injection of Demerol plus Valium by mouth leaves the patient groggy but communicative. Renowned dermatologists Howard Sobel and Pat Wexler, for example, don’t like to perform liposuction on patients who are knocked out, even though improved medications and systems of monitoring have made going under markedly less risky than it was twenty years ago. “No one can argue that local anesthesia isn’t still safer than general anesthesia and IV sedation,” says Sobel.

It’s not the medications as much as the monitoring that separates the two alternatives, argues Jane Recant, an anesthesiologist who has attended at hundreds of liposuction procedures. When a dermatologist uses local, she says, the same doctor who does the surgery is often administering the anesthesia and therefore is not giving the patient’s pain threshold his or her full attention. Many dermatologists do have nurses keeping track of the amount of oxygen in the patient’s blood, the EKG signs, and blood pressure, but in Recant’s opinion, that is hardly the same as having a board- certified anesthesiologist on hand.

Recovery time is another point of contention. Dermatologists argue that the numbing agents they inject wear off rapidly; plus, with no sedation involved (other than Valium), there’s really not much to recover from, as it’s the sedation medication that makes patients weak and sometimes sick to their stomachs. Anesthesiologists counter that today’s IV sedation is fast-acting on either end—swift in putting you out and quickly metabolized after surgery. “For light sedation, it’s 20 to 30 minutes of grogginess and you’re fine,” says Sheldon Opperman, director of anesthesiology at Manhattan Eye, Ear and Throat Hospital, who notes that there is now a whole armamentarium of anti-nausea drugs called Trons that were developed for patients undergoing chemotherapy.

Sobel and Wexler say there’s another, and perhaps more important, reason for their preference for lighter sedation. With IV sedation, you’re missing a critical ingredient: gravity. During liposuction, many dermatologists like to actually stand the patient up and let him look at himself in the mirror to give input on the shaping—something you can’t do under sedation. “When you’re lying down, everything looks terrific,” says Sobel, “but when you stand up, it changes.

“Say we’re doing your thighs, right?” he says. “Your thighs are all numb, and I’m sucking out the fat. Now, in the middle of the procedure, I’m able to stand you up while you hold a chair rail because some of the drugs have worn off a bit. We let you look in the mirror, and we mark you. I’ll go back and forth like that three or four times until I get it just right. If you’re lying down under IV sedation, I have to guess. Very often we’ll take out too much because you don’t want the patient coming back for a repeat.” Sobel’s patients must have strong stomachs—when they’re vertical, there’s water, bloody water, dripping out of the incisions, not to mention the creepy vacuuming sound of the fat extraction while they’re still on the table.

Wexler says that a large part of her practice is correcting work plastic surgeons did with their patients under heavy sedation. “So many people come in for revisions,” says Wexler. “You need to see the way the skin drapes, the symmetry of the buttock folds or the hips. My analogy is, a designer would certainly never drape a dress lying down.”

“Skin is not fabric,” counters plastic surgeon Robert Silich, who performs everything from face-lifts to lipo. “Skin changes, so the analogy of draping clothes is misleading. You have to do lipo by feeling, not just looking. If you’re doing someone’s love handle, you’ll put your hand on it, squeeze it; toward the end of the case, you’ll feel a difference—the skin is thinner. We’ll run a hand up and down, feel for ridges and bumps, turn the patient from side to side to make sure it’s smooth.”

And, notes plastic surgeon Paul R. Weiss, because both dermatologists and plastic surgeons are adding three or four quarts of water to puff up the tissue so the cannula can more easily move back and forth, “that distorts the contour to some degree anyway,” whether you have gravity working or not.

Even when it comes to face-lifts, a more complex procedure, plastic surgeons disagree among themselves on what level of sedation is best. Many give general anesthesia, which usually requires being intubated for extra airway support. But some, like Silich, prefer that patients breathe on their own, so he opts for IV sedation. Removing a breathing tube at the end of the operation, he says, can cause a patient to gag or vomit, which can do serious damage to a face full of sutures.

Ultimately, the deciding factor in all procedures is what makes a patient comfortable. Is she a type-A who must be in control, or does she simply want to wake up in recovery? “You can never tell how someoneÂ’s going to react,” says Silich. “I had a six-foot-four policeman faint on me.”

The Twilight Zone