What Type of Anesthesia to Have?

There is a continuum of anesthesia possibilities. You can have just a swab on the skin or gums or you can be put to sleep and be on a respirator because you cannot breathe by yourself. In between are many choices.

Two Aspects of Anesthesia

1. Pain Prevention – done with a local anesthetic
2. Sedation – done with a systemic medication that reduces awareness

These two aspects intertwine because when your awareness is reduced enough, you feel no pain even if no local anesthetic is given.

How a Local Anesthetic Works

The mildest form of local anesthetic is a topical anesthetic, applied to the body surface but not injected under the skin. You may have a dentist who uses a large swab on the gums before he uses the needle, because that numbs the gums and you feel the needle less. A cosmetic surgeon uses a cream or spray.

An injected local anesthetic diffuses through the surrounding tissue and affects the nearby nerves.

• If the dose is low, only sensory nerves are affected and cannot send pain messages to the brain
• If the dose is high, the sensory nerves cannot register touch, pressure, or temperature as well as pain, and the motor nerves cannot cause local muscles to contract

Depending on where the anesthetic is injected, it can affect many nerves that innervate a large area, or just one or two nerves. As an example, for eyelid surgery a very small area is anesthetized, whereas for abdominoplasty (tummy tuck), a large area is numbed.

General Anesthesia

A general anesthetic works systemically, meaning that it affects the entire body. By putting you to sleep, these drugs block consciousness of everything, including pain. You are not aware that any surgery is being done, or of where you are or who is in the room. You remember nothing from that period of time.

Because general anesthesia renders you so helpless, it is always administered by a doctor or nurse with special training. An anesthesiologist or a nurse anesthetist will calibrate your dose and administer it through either a mask or an intravenous line (IV line) which sends it directly into a large vein.

Your anesthesiologist will remain with you throughout your unconsciousness, monitoring your vital signs and the effectiveness of the drug. He or she will connect you to a respirator after you are “under”, using an endotrachial tube. It carries oxygen into the lungs for you, since your muscles are incapacitated. Your blood pressure and heart rate will also be watched.

If you were to have any allergic reaction to the anesthesia drug, that would be quickly noticed and appropriate steps taken to cancel that drug and its effects on you. Typically there is no allergic reaction. The anesthesia drug flows continuously into your bloodstream while your surgery proceeds and then is stopped. Gradually you then regain awareness.

The anesthesiologist is the person who decides when you are awake and alert enough to go home if you are not staying overnight at the hospital or medical center. You would need a ride home.

IV Sedation and a Local Anesthetic

There has been a trend away from always using general anesthesia for major surgery. You will typically be given a choice for a major cosmetic surgery such as breast augmentation.

Most cosmetic surgeons now use local anesthesia combined with a sedative given through an IV line. The sedative makes you feel calm and drowsy and is sometimes called “twilight anesthesia”. It wears off more quickly than general anesthesia, and requires no respirator, as you can breathe by yourself. It also causes milder side effects.

By separating the two aspects of anesthesia, the surgeon can modify each one separately.

• If you feel restless or nervous, the anesthetist or anesthesiologist can give you more sedative
• If you feel some discomfort, you can tell your cosmetic surgeon and he will give you more anesthetic

Local Anesthetic Only for Major Surgery

Some surgeons offer this as well as the other choices. If you are anxious about being put under a sedative and want to remain fully conscious throughout your surgery, you can choose to have just a local anesthetic. You will feel no pain and your alertness is unaffected. The surgeon will talk to you as he works and make sure you are comfortable.

You would still need a ride home, however, since you would no doubt be given a pain medication as your anesthetic starts to wear off, and in any case you would probably feel a bit unsteady immediately after your surgery.