IV Sedation during gyne opp. Concern with venous insufficiency

[isambard]

Hello, I am a 25 year old male, non smoker, physically fit/active, 5'10'' 156 lbs/71kilos. I am booked to have surgery to remove a mild case of gynecomastia at a cosmetic surgery clinic in Brussels (I live in UK). The operation will last no more than an hour and I will be administered local anaesthesia with IV sedation. In addition to this embarrassing problem I've lately developed varicose veins on my legs. I’ve been diagnosed by doctors in the UK as having "Chronic venous insufficiency", more about this shortly.  My question is; Will this venous insufficiency create a potential danger to my life/well being whilst under IV sedation? I am worried about this but don't want to make an issue with the clinic (ie, tell them about venous insufficiency) as they might decide not to treat me if there is a small risk. Any input would be much appreciated, thanks!

Supporting information/symptoms:
LEGS- varicose veins starting to form though not yet tortuous. Pain when standing for long periods and a feeling of pressure and discomfort when sitting. Drinking even medium level of alcohol causes pins and needles type feeling in legs, this I fear might be a problem when I have sedatives coursing through my veins?
ARMS- pronounced/swollen arm veins, soreness in arms when arms are kept at my side for long periods, particularly in warm temperatures. Soreness is alleviated when I raise my arms higher than my heart.
In both legs and arms the symptoms have developed relatively quickly, really in the last 6 months. I've had smaller spider veins in my legs since I was 19 though.

HORMONES: Serum oestradiol levels normal-160 pmol/L. Serum testosterone on the higher range of normal – 30.8 nmol/L

I've had gynecomastia since adolescence when I was overweight. I have since lost the weight but of course must excise the little breast tissue left.

[DrBermant]

Hello, I am a 25 year old male, non smoker, physically fit/active, 5'10'' 156 lbs/71kilos. I am booked to have surgery to remove a mild case of gynecomastia at a cosmetic surgery clinic in Brussels (I live in UK). The operation will last no more than an hour and I will be administered local anaesthesia with IV sedation. In addition to this embarrassing problem I've lately developed varicose veins on my legs. I’ve been diagnosed by doctors in the UK as having "Chronic venous insufficiency", more about this shortly.  My question is; Will this venous insufficiency create a potential danger to my life/well being whilst under IV sedation? I am worried about this but don't want to make an issue with the clinic (ie, tell them about venous insufficiency) as they might decide not to treat me if there is a small risk. Any input would be much appreciated, thanks!

Supporting information/symptoms:
LEGS- varicose veins starting to form though not yet tortuous. Pain when standing for long periods and a feeling of pressure and discomfort when sitting. Drinking even medium level of alcohol causes pins and needles type feeling in legs, this I fear might be a problem when I have sedatives coursing through my veins?
ARMS- pronounced/swollen arm veins, soreness in arms when arms are kept at my side for long periods, particularly in warm temperatures. Soreness is alleviated when I raise my arms higher than my heart.
In both legs and arms the symptoms have developed relatively quickly, really in the last 6 months. I've had smaller spider veins in my legs since I was 19 though.

HORMONES: Serum oestradiol levels normal-160 pmol/L. Serum testosterone on the higher range of normal – 30.8 nmol/L

I've had gynecomastia since adolescence when I was overweight. I have since lost the weight but of course must excise the little breast tissue left.

All of my sedated patients have sequential compression devices on their legs during surgery.  However, not all patients are good candidates for elective surgery. Irritated veins such as phlebitis or significant venous insufficiency can increase risk of blood clots in the veins after elective surgery. Such clots can break off and kill patients. A vascular surgery clearance may be requested if I have concerns about a specific patient. Such issues are best discussed with your doctor.  This is not a black and white issue. Grays make this decision making a challenge.

Hope this helps,

Michael Bermant, MD
Learn More About Gynecomastia and Male Breast Reduction

[Dr. Elliot Jacobs]

You are young and your height and weight are excellent.  Some young people do develop varicose veins -- but at this stage it should not pose a problem for you.

Surgery under local anesthesia and IV sedation is the way to go -- I use it myself on virtually all cases.  And in all my cases, I use a machine that gently and periodically squeezes the calves to keep the blood moving.  This will probably be used in your case as well.

I do not believe that your vein problem will pose a threat to your life while undergoing this procedure.

Good luck and keep us informed.

Dr Jacobs

[isambard]

Thank you Doctors Jacobs and Bermant for your quick and helpful responses.

I suppose ultimately I must breach this subject with my surgeon, I will write him. I wanted to add one final detail which I neglected to mention in my original post: I am being treated for this venous insufficiency and have been referred for the "VNUS Closure" procedure. This will effectively close the great saphenous veins in both of my legs using a heated catheter. The Vascular specialist believes doing this now (before it becomes very servere) will save me from problems in the future but it gives you an impression of the level of venous insufficiency I am headed for. If I were one of your patients would this new information affect your willingness to treat me at all? Would it be best to wait to do the gyne opp after I have this procedure or get it over and done with before as my veins could get worse over time and make the gyne opp more of a risk?

Thanks again.
Best,
Isambard

[DrBermant]

Thank you Doctors Jacobs and Bermant for your quick and helpful responses.

I suppose ultimately I must breach this subject with my surgeon, I will write him. I wanted to add one final detail which I neglected to mention in my original post: I am being treated for this venous insufficiency and have been referred for the "VNUS Closure" procedure. This will effectively close the great saphenous veins in both of my legs using a heated catheter. The Vascular specialist believes doing this now (before it becomes very servere) will save me from problems in the future but it gives you an impression of the level of venous insufficiency I am headed for. If I were one of your patients would this new information affect your willingness to treat me at all? Would it be best to wait to do the gyne opp after I have this procedure or get it over and done with before as my veins could get worse over time and make the gyne opp more of a risk?

Thanks again.
Best,
Isambard

I have operated on patients with increased risk, but sometimes with additional prophylactic measures.  At other times, I advise against the elective surgery. For my patients, safety comes first. It is not "you are a good candidate" to anything that walks through the door nor for that matter, for someone that I have little details about over the internet. Vein inflammation, irritation of the lining of the veins is a significant extra risk for clotting off veins that I would ask a vascular surgeon to assess the risks for elective surgery.  My microvascular training has given me a great respect for such issues.  There are many in the Plastic Surgery community who have been trying to increase awareness of DVT and pulmonary embolism in elective surgery, perhaps to an excessive extent.

Hope this helps,

Michael Bermant, MD
Learn More About Gynecomastia and Male Breast Reduction

[isambard]

Thank you again Dr Bermant for your reply. I understand what you are saying. With regards to asking a vascular surgeon about my suitablity: I have tried in an indirect way to get a sense of my gyne opp risk with my vascular surgeon. I asked,
"Does my condition now or after the VNUS Closure procedure mean i should be cautious about undergoing surgery in the future? For instance would i be at risk if I had an operation requiring a general anaesthetic?"
to which his reply was "no, it would not effect you at all". Though I don't know how definitive that sort of answer is as it was only based on a visual examination of my veins and an ultrasound scan of only the main veins in my legs. (By the way, my deep femoral vein is healthy and competent.) What concerns me about being operated on with sedation is that i already experience tingling sensations after drinking or even after sitting for a long period of time. I don't know if there is anyone that can asnwer this question more definatively. The only way to know is to try..or go without?  

Theoretically, if I were to have the operation with only a local anaesthetic would that diminish the risk of complications such as blood clot etc?

Thanks -Isambard

[DrBermant]

Thank you again Dr Bermant for your reply. I understand what you are saying. With regards to asking a vascular surgeon about my suitablity: I have tried in an indirect way to get a sense of my gyne opp risk with my vascular surgeon. I asked,
"Does my condition now or after the VNUS Closure procedure mean i should be cautious about undergoing surgery in the future? For instance would i be at risk if I had an operation requiring a general anaesthetic?"
to which his reply was "no, it would not effect you at all". Though I don't know how definitive that sort of answer is as it was only based on a visual examination of my veins and an ultrasound scan of only the main veins in my legs. (By the way, my deep femoral vein is healthy and competent.) What concerns me about being operated on with sedation is that i already experience tingling sensations after drinking or even after sitting for a long period of time. I don't know if there is anyone that can asnwer this question more definatively. The only way to know is to try..or go without?  

Theoretically, if I were to have the operation with only a local anaesthetic would that diminish the risk of complications such as blood clot etc?

Thanks -Isambard

These are issues best explored with the doctor you are trusting for your surgery, who has had the opportunity to properly evaluate you, and then help you better understand risks, benefits, and alternate methods of care.

Hope this helps,

Michael Bermant, MD
Learn More About Gynecomastia