qu: general vs. local anethesia

[wasatchm]

hi,

could someone tell me what exactly local anethesia is?  are you awake during the surgery?  is one coherent shortly after the surgery?  (I do know what general anethesia is.)  I was hoping I could have the surgery and drive home myself (or drive to a friends house neaby the surgery center).  if I have to wait a few hours (or longer)  for anethesia to wear off that's fine with me.

I know when one goes under general anethesia, the patient (by law) cannot drive but must have someone sign a paper stating they will pick up the patient and drive them home.  

I don't suppose most Plastic Sugeons would provide transporation for an additional fee would they?  All I would want it transportation to a nearby hotel (after the surgery) if I am not able to drive myself.  I could then drive home the next day.  

thanks

BA

[DrBermant]

hi,

could someone tell me what exactly local anethesia is?  are you awake during the surgery?  is one coherent shortly after the surgery?  (I do know what general anethesia is.)  I was hoping I could have the surgery and drive home myself (or drive to a friends house neaby the surgery center).  if I have to wait a few hours (or longer)  for anethesia to wear off that's fine with me.

I know when one goes under general anethesia, the patient (by law) cannot drive but must have someone sign a paper stating they will pick up the patient and drive them home.  

I don't suppose most Plastic Sugeons would provide transporation for an additional fee would they?  All I would want it transportation to a nearby hotel (after the surgery) if I am not able to drive myself.  I could then drive home the next day.  

thanks

BA

Local anesthesia means that nerves are blocked at the surgical site itself and can include injection and tumescent techniques.  Local anesthesia can be done alone with the patient completely awake or under sedation that can vary from minimal to almost asleep.

General anesthesia means the patient is asleep with a combination of medications put into the veins and inhaled.  

I have not needed general anesthesia for my male chest sculpture for many years.  For my patients needing skin alone nipple reduction, I offer local anesthesia alone option.  With tumescent techniques, I have evolved a better system under local with heavy sedation.  Without the sedation, there are just too many possible problems.

Some surgeons use general with tumescent techniques. Some use general alone.  I found that general anesthesia can leave patients with a higher chance of nausea and discomfort after surgery.

Each surgeon has his / her preferences about anesthesia.  I typically use local with heavy sedation.  That is not general anesthesia, but the patient is not awake.  We use medications injected into an IV for this sedation.  That is how we help keep our patients comfortable for most types of gynecomastia chest sculpture.  Sedation itself is an art.  I will use local anesthesia alone when performing actual nipple reduction surgery.

You can look at other posts here in this forum where anesthesia and sedation are discussed:

I prefer to perform tumescent anesthesia with sedation over general anesthesia or local anesthesia alone for most types of male chest sculpture. We take the comfort of our patients very seriously. You can find a number of posts here in this forum where patients describe their anesthesia experiences under this local anesthesia with sedation:

http://www.gynecomastia.org/cgi-bin/gyne_yabb/YaBB.cgi?board=1;action=display;num=1021397758;start=0#0

http://www.gynecomastia.org/cgi-bin/gyne_yabb/YaBB.cgi?board=1;action=display;num=1030314533;start=0#0

http://www.gynecomastia.org/cgi-bin/gyne_yabb/YaBB.cgi?board=1;action=display;num=1037669367;start=4#4

http://www.gynecomastia.org/cgi-bin/gyne_yabb/YaBB.cgi?board=14;action=display;num=1052569996;start=0#0

http://www.gynecomastia.org/cgi-bin/gyne_yabb/YaBB.cgi?board=14;action=display;num=1062552462;start=0#0

http://www.gynecomastia.org/cgi-bin/gyne_yabb/YaBB.cgi?board=14;action=display;num=1065016337;start=4#4

http://www.gynecomastia.org/cgi-bin/gyne_yabb/YaBB.cgi?board=14;action=display;num=1073182463;start=4#4

Hope this helps,

Michael Bermant, MD
Learn More About Gynecomastia and Chest Sculpture

[wasatchm]

thanks for the info crunch and Dr. Bermant.  I think I will request local anesethesia with sedation.   I do have major gyne on one side (see pic) (although I have lost 20 lbs so it may not be quite as severe as the pic shows)

http://www.geocities.com/bray19702004/frontviewpic4

believe it or not, I've seen 5 plastic surgeons in the Salt Lake City Area and only one gave me the option of local anethesia with sedation.  (he said he has a board certified anethesiologist on site for all surgeries).  

he was also the only one that acted like he really wanted to do the surgery and even said he would make me "LOOK GOOD".  he seemed like a perfectionist and very detail oriented  (he's the only PS that gave me the impression he was an ARTIST along with being a surgeon).  he's really the only one I trust.   he was also the most expensive (which I consider a positive).  I figure the better he is at what he does, the more he can charge.  the only downside is he doesn't do gyne surgery a lot (maybe once a month) and he's quite young (probably only been practicing about 10 yrs).  I've been hard pressed to find any PS where I live that does the surgery more than twice a month.

all the other surgeons I visited with worked for an HMO and appeard to care less whether they do the surgery or not (I think the HMO gets them all the work they need).  

anyway, thanks for the info,  

BA
I may very well have a follow up surgery to remove excess skin (on the one side).  I'll keep my fingers crossed that my skin tighten a lot (I'm still young at 34) and maybe not need the skin reduction.   I'm hoping to find some type of cream I can use after surgery that will help tighten the skin in my chest area.

[wasatchm]

by the way, should the surgery be any cheaper if I request local anethesia (vs. general)?   the PS quoted me $4700  (but that was with general anethesia included).  I would like to shave 400-500 dollars of the total cost if possible.  

I'm hoping to do this totally on my own (the surgery and all it entails) including driving to the PS office for surgery and drive home after  (or take a cab home if I must).    guess I can always come back the next day to pick up my car.      

[nomenclator]

Dr Bermant: " Without the sedation, there are just too many possible problems."

Like for example, what?

I had 2 inguinal hernia operations. They were both done the way my doctors prefers. For the first one, I had oral anxiolosis (15 mg of Valium) and local anesthetic. They took the precaution of tying down my legs, and arms, to the operating table. I felt maybe a minute or so of mild to moderate pain during the surgery, gave them the sign, and they injected me with more local, and in another minute I was fine. Operation lasted 55 minutes.

For the second operation (a few days later), I had 20 mg of Valium oral, and in addition, was premedicated with 60 mg of meperidine, intramuscular. This combinatin made me feel "well" but I was quite awake for the whole 50 minutes of surgery. They didn't bother to tie me down this time, I guess because I had demonstrated, during the first operation,  that I could keep control of my limbs. There was no pain or discomfort during this operation, beyond an itch in my right arm that was unrelated to the surgey. By time I got off the table, the meperidine was at its peak, and I had very little post-op pain.  A few hours later they offered me some acetamiinophen with hydrocodone, but I didn't need it. I didn't need anything.

I'm not sure how breast reduction surgery compares to inguinal hernia surgery, but most anterior approach inguinal hernia surgery is done with either local anesthetic plus sedation, or general anesthetic. Very few doctors seem at all enthusiastic about doing it without intravenous sedation or general anesthetic. Yet my surgeon said he does 9/10 of his patients the same way I was done. I'm not sure why most surgeons insist on sedation, because without it, I was entirely comfortable. Premdicated with a bit of meperidine, I had more discomfort from the itching in my arm, then from the hernia surgery.

Part of the allure, for me, of no sedation, would be the decreased cost of surgery. Anesthesiologists can add quite alot to your overall surgery bill.

If hernia surgery patients can be as comfortable as I was, I don't understand why most doctors are reluctant to do hernia surgery  without sedation or general anesthetic. I wonder if the same factors apply to breast reduction surgery.

[wasatchm]

wow,

you have a lot of courage.  I myself wouldn't have a hernia operation with local anethesia (it may be just as safe as general anethesia).  I would be to fearful the anethesia wouldn't work correctly or would wear off and I would have an intense amount of pain (you know were) and think I was gonna die.  

however when someone (such as a plastic surgeon) is doing work just under the skin (near no major arteries or organs) I think general anethesia is a waste of money.   Although the biggest ripoff for breast reduction surgery where I live (from what my research shows) is the facility charges.   some off the plastic surgeons where quoting me up to $1500 for the facilities charges  (that's rediculous... I mean I'm only gonna be there a couple hours).  that was quoted from the plastic surgeons that worked for an HMO's and  always did there surgery at a hospital or surgery center.   they basically had to do the surgery where-ever the HMO told them to.  

the facilities charges for those surgeons who did the surgery in there office or an independent surgery center only charged $700-$800.  

I have insurance through this non-profit HMO (where I got the $1500 quote for facility charges) and did try to get coverage for the surgery.  I was surprised to find there charges (for all the surgery, facilities, PS fees, general anethesia... basically everything)  was more than what most independent plastic sugeons in the area charge.   shouldn't non-profit HMO's be the cheapest?    the largest HMO in my state is currenty fighting the state government in order to maintain its non-profit status.  I personally think they just use there non-profit status to make higher profits.  

[nomenclator]

wasatchm " you have a lot of courage"

Not really. I simply did a little research before chosing a doctor. Some comparison shopping. Once I had satisisfied that I had made a good choice, I simply abandoned all fear that the doctor might do something wrong and harm me. This is what enabled me to sit still for his invasions without getting afraid, and punching him -- trusting the doctor. If I had an emergency, showed up at the hospital, and didn't know anything about the doctor I was assigned, and needed similar surgery, I would have had a harder time not being afraid. Also, I was told that if the local anesthetic was not satisfactory, that there was an anesthesiologist on staff and they could put in an iv and sedate me; that could be a big factor in feeling comfortable about going ahead without sedation -- the fact that if you don't like it, you can always transfer to sedation (tho it might take a few minutes for the anesthesiologist to get there).

Yes, I felt some parts of the operation, but they were just feelings, of cutting, pulling, pushing, etcetera, and not feelings of pain, and since I trusted that my surgeon knew what he was doing, they didn't bother me. If I hadn't checked him out ahead of time, I might have been very worried that he was cutting the wrong thing, and inclined to get up and punch him in the nose. You just have to commit yourself to knowing that you've chosen someone that 1. knows how to do the operation well and 2, has a moral and ethical standard of always doing it well, and not risking your well-being in order to save time, money, etcetera. The way to do that is to comparison shop.

[wasatchm]

thanks for the insightful info.

well, earlier today I talked to the nurse of the plastic surgeon who I plan on doing my gyne surgery (I will probably go in tomorrow and pay the deposit and have the surgery in 4 weeks).  I did ask the nurse about general vs. local anethesia (the type of anethesia didn't make a different in what they were gonna charge me.... I think this plastic surgeon always has an anethesiologist on hand for all his surgeries).  the nurse was a bit surprised when I told he I would prefer local anethesia (I'm not sure why... I'm guessing most people just choose general anethesia since that is the default anethesia chosen by this PS when doing surgery).  she did say local anethesia is used with sedation (using IV) which is what I wanted. I would like to be pretty much out of it during the surgery but still somewhat familiar with what is going on  (isn't that what local anethesia with sedation does).    

she did also say someone must drive me to and from the surgery (even if I use local anethesia) which is fine with me.  however she did also say some MUST stay with me for the first 24 hrs after surgery (THAT IS A LITTLE HARDER FOR ME TO PULL OFF) .  the surgeon only does surgery on thursdays which means I would have to ask someone to miss a full day of work (on friday just to be with me).   every person I know works on fridays (like most people).  I'm certainly not gonna ask someone to miss a day of work just to hang out with me.  I think I'll just tell them I'll spend half the next day in their office if it's that big off deal.

do most surgeons demand this? ... person being with you for first 24 hrs after surgery (even when having surgery under local anethesia).   I  wonder how sticky  they will be on it (will I have to have someone sign a paper stating they will be with me for at least 24 hrs after the surgery).  are they gonna call me every 6 hrs and make sure I'm not alone.
 
I really thought I would be able to drive to and from surgery if I had local anethesia (instead of general anethesia).  if they want someone to stay with me the rest of that day and until the next morning I can accept that but anything more and there being pretty demanding.    

any thoughts?  I'm going in tomorrow to fill out all the paperwork.  .... thanks

[aux513s]

I would like to be pretty much out of it during the surgery but still somewhat familiar with what is going on  (isn't that what local anethesia with sedation does).

Yes. You're going to feel as if everything's surreal. It might seem a little like you've died and gone to hell. The worst part is, you're not going to be able to stop it once the operation's underway.

[wasatchm]

actually, my worst nightmare would be the first time I take the garment vest off after surgery (and look in the mirror)  I notice my areolas are completely gone.... instead of making that semi-circle cut around the edge of the areola, the surgeon made a full circle cut (removed the areola's completely, removed any breast tissue that needed to be removed and then closed the area a sticked it up.  I would die if that happened.  that would be considered GROSS NEGLIGENCE on the part of the plastic surgeon wouldn't it.  

by the way, what happens if the areola dies completely  (shrivels up til its practically invisible)?   the last PS I saw warned that it can happen although very unlikely.  

he said an artificial one can be created but didn't say how