By Dr. Juris Bunkis
Last week, Dr. Ekstrom and I had the pleasure of seeing one of the current hot shows in New York City, A Beautiful Noise, The Neil Diamond Musical.
Two weeks ago, we enjoyed Bill Medley & Bucky Heard (Righteous Brothers) at the Pacific Symphony Hall in Costa Mesa – and this past weekend, I took our office manager, Jo Cattell and her husband, Jeff, to see Mean Girls at the Segerstrom Center. Each was preceded by a lovely dinner – La Grenouille in New York, Leatherby’s Café Rouge and Vaca Restaurant in Costa Mesa, all a short walk from the theater. Walking out of the theater in New York and through Times Square was magical.
Exiting Pacific Symphony Hall or Segerstrom Center, walking past the beautiful fountain, and looking back at the stunning architecture of our arts complex, is equally spectacular. The Broadway series at Segerstrom brings in national touring shows of the top performers in the country. The Pacific Symphony and their various guests are likewise second to none in our country. Yes, it always is definitely fun to travel to New York to take in a show, but we are blessed to have restaurants and theater of equal quality right here in our back yard! Enjoy!
Spotlight on Plastic Surgery – “What kind of anesthesia am I getting?”
by Juris Bunkis, M.D., F.A.C.S.
Most of our surgical procedures are performed under local anesthesia (sometimes supplemented by oral sedation), intravenous sedation or a light general anesthetic in which narcotics and heavy gasses are not administered. The type of anesthesia chosen for any given procedure is determined by a combination of the type of surgical procedure performed, the patient’s health and, whenever possible, each patient’s personal preference.
Many of our patients have misconceptions about anesthesia and present with more apprehension about the anesthesia than they do about the requested surgery. While every activity in life does present with some risks, the job of every anesthesiologist and surgeon is to minimize the risks with every anesthetic and surgical procedure. With our type of work, we are doing elective surgery and only operate on healthy patients. All patients are screened for health issues and risk factors before even coming to the surgery center.
A medical clearance by a cardiologist or internist is required for patients with health issues or laboratory abnormalities. We make certain that patients do not take any blood thinners for a few weeks before surgery to insure that they will clot properly. Patients arrive with an empty stomach on the day of surgery to avoid any possibility of aspirating during surgery. All patients are placed in intermittent compression stockings to avoid the possibility of developing blood clots. And most importantly of all, every patient is carefully monitored, every second, by the anesthesiologist during surgery.
The majority of our patients receive a light general anesthetic consisting mainly of intravenous agents and a healthy amount of local anesthesia to minimize the amount of medication the anesthesiologist has to administer. The anesthesiologist rarely administers narcotics to patients (the prime cause of post-operative nausea). Rarely is a patient intubated (a breathing tube placed into the airway) but patients frequently receive a soft rubber tube into their food pipe, an LMA tube, to minimize the possibility of regurgitating some acid into the lungs during surgery and to keep the patient from distending the stomach by swallowing air during surgery. Such an anesthetic is necessary for larger procedures, like tummy tucks, with procedures during which it is important for the patient to be perfectly still, like lower eyelid surgery, and during procedures, like a facelift, where optimal blood pressure control is essential. All patients are closely monitored throughout every case.
Emergence from such anesthesia is usually smooth and patients wake up without much discomfort (because of the injected local anesthetic and presence of pain pumps, tiny catheters through which local anesthetics can continue to be administered to the surgical sites for the first two or three days after surgery). Nausea or vomiting are extremely rare with such an anesthetic.
Some patients prefer not to have a general anesthetic and can be managed by a MAC anesthetic. MAC stands for Monitored Anesthesia Care, a term I do not care for as ALL patients are equally and continuously monitored while in the anesthesiologist’s care! With a MAC anesthetic, patients also receive local anesthetics. But with the MAC, patients do not receive an intraoral tube, are not “as deep”, do not receive as much medication, can twitch or move, but rarely do they remember the procedure. Some procedures like a tummy tuck cannot be done safely under MAC because the amount of local anesthetic required to keep the patient completely comfortable would exceed safety limits. With the MAC anesthetic, emergence from anesthesia is also smooth, rapid and rarely is nausea an issue.
Straight local anesthesia can be used for smaller cases, in areas where complete numbness can be achieved without too many needle sticks and the amount of local anesthetic required falls within safe limits. Examples of cases where local anesthesia are appropriate include mole or skin cancer removals, minor scar revisions, upper lid blepharoplasties, lip lifts and labiaplasties.
Let us end this discussion with a look at anesthesia risks. As I stated earlier, every activity in life is associated with a measurable risk. Aspiration, cardiac events, injury to teeth and intraoperative fires have all been reported but I can say that I have never seen such complications in the 20+ years I have worked with Dr. Becker – and that is a safety record spanning thousands of cases. The key to safety is avoiding treatment of patients with major health issues in a surgery center setting and by treating every patient the same by obtaining preoperative lab work and EKGs, medical workups as necessary, and full monitoring during surgery! In his lectures on anesthesia safety, Dr. Becker points out that the risk of dying due to a fall out of bed is greater than the risk of a healthy person dying during anesthesia. For certain, patients are at greater risk of injury driving to the surgery center than they are during the procedure itself.