Local Anesthesia with Valium on a Severe Case

[jajolt]

So I am booked to have my surgery with Dr. Lebowitz in November.  I have a severe case (cup size: 46C) and I much prefer local anesthesia to even twilight sedation (I personally find the medications like versed quite unpleasant).  I was recently just browsing the forums and found that most doctors here don't find local anesthesia sufficient for anything more than minor direct glandular excision cases, saying that the pain from the liposuction will cause you to move and be generally unpleasant.  I am a heavier male and will be given 5mg valium orally before the procedure.  Is this sufficient enough to get me to "not care" about the pain and maximize the results?

He states that his patients only feel an initial minor discomfort then feel nothing.  For reference, here is a video of him doing the procedure on a man with a similar case:
https://www.youtube.com/watch?v=Y-hUH3eTSg0

[Dr. Elliot Jacobs]

Most of the surgeons who contribute to this site feel that local anesthesia should be limited to small excisions (mostly of gland).  Understand that the vigorous pushing and pulling motions used during liposuction of the male breast are performed against a lot of fibrous tissue.  No amount of local anesthesia can deal with this type of pain -- that is, if the lipo is done adequately. And if one wanted to inject much more local anesthesia, it could theoretically exceed a toxic dose.

There is a reason that most gyne surgeons prefer either general anesthesia or deep sedation provided by an anesthesiologist.  The patient is comfortable (not writhing around) and the surgeon can then certainly do a better job.  

Above all, this operation will hopefully be a successful, once in a lifetime experience -- why not be kind to yourself and make it a comfortable experience as well?  To me there is nothing worse than going into surgery with the anticipation that one must bite the bullet and endure pain in order to get the result one wants when it could also be done in a more comfortable way.  If it is only the additional money for anesthesia, then it might be worthwhile saving for it.  

But this is just my opinion.

Good luck!

Dr Jacobs
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[DrPensler]

First  I have performed correction of gynecomastia under local. I typically perform the procedure on a select group of individuals who are in the military ,ie seals, marines ,army rangers. I almost invariably recommend I.V. sedation but this small group likes local in spite of my recommendations. As one of these fine people once said to me "pain is weakness leaving the body". You do not sound like one of these guys. If you are concerned if  5 mg. ( a minimal dose in any patient but a particularly minimal dose in a heavy patient) which is absorbed inconsistently orally will be "  sufficient enough to get me to "not care" about the pain and maximize the results?" my answer is highly unlikely. 
I looked at the video and I would say a result with someone lying  flat on their back is not the the view I would use to evaluate a technique.
As one of my mentors once told me "Surgery is tough but it is even tougher on a moving target."

[jajolt]

Thanks for the replies.

Dr. Jacobs--  The reason I wanted to avoid sedation if possible is due to some trauma where I was given versed by paramedics even though I requested an alternative and they didn't explain anything to me, refused and held down my arm while they forced the drug to me.  This makes any sort of sedation have almost the opposite effect than it should have at least going into it, it's unpleasant and while I won't say it's traumatic, I will say that I hate it.  With that said, your post made more sense as to why many surgeons prefer it. Thank you for your input.
Dr. Pensler-- Yeah I'm not a marine, seal, etc haha.  I'll probably end up revisiting this topic, but out of total curiosity: When you get someone who can tolerate it, do they usually face somewhat compromised results?  Or can they tough it out so much that it make zero difference?  Appreciate the input on the valium and the video, thanks.
Fun bonus story: I'm travelling for this procedure from Buffalo, NY.  I went to see Dr. Robert Perry (excellent craniofacial plastic surgeon from what my doc said), however he clearly isn't the best with Gynecomastia.  He wanted me in the hospital for the procedure, under general anesthetic, where he would then only do gland excision (he said he never does lipo, even though I would need it), and leave the excess skin.  Then he would do a second operation under IV sedation a year later to take the nipple off, tuck the skin under it, and place it back on so what remains of the excess skin is little "ruffles".  Needless to say, that's when I decided I would need to visit someone who's done a fair few. 

[Dr. Cruise]

I perform many of my gynecomastia cases under local anesthesia with great success. For my severe cases, Type 5 & 6, I do ask my patients to go under general anesthesia for the purpose of their comfort and so the surgical result is not compromised. My severe cases generally require a chest lift w/ free nipple graft.  http://lagynecomastia.org/gynecomastia-overview/gynecomastia-types/
It's hard to say if 5mg will be enough for you to be comfortable during your surgery. Your surgeon will have to determine if more is necessary at the time of surgery. Some patients have a very high threshold for pain/discomfort as well, so you may be able to tolerate the procedure better than others. Again, hard to know. 
The goal here is to have one successful surgery, so you can move on from your gynecomastia. If that means going under general anesthesia, it might be worth reconsidering. You should be able to have a discussion with the anesthesiologist your surgeon uses, so you can voice your concerns and come to a final decision on which route to go. 
Best of Luck!

[DrPensler]

I would never do anything that I felt would compromise the final result. Clearly you want to have someone perform the procedure who has significant experience.

[Litlriki]

During the early years of my practice, I did these procedures with local and sedation, as it saved the patients considerable expense, and the option of intravenous sedation was there to help get past any rough spots.  Currently, the cost is the same in my practice with sedation or general anesthesia, so most patients go to sleep for their comfort. I agree that some sort of sedation needs to be available for MOST cases to allow for a single effective procedure, without holding back on the liposuction portion, which is the part that can be uncomfortable.  
I would comment that many bodybuilders are not the greatest at tolerating surgical discomfort.  We joke in our office that the biggest guys are the toughest to do any sort of touch up work.  Marines and martial artists are an exception to this rule, since they tend to have a more confrontational perspective toward pain, and they take pride in toughing it out. 

[Dr. Schuster]

I agree with Dr. Jacobs. I think that all the types of corrections can be done under local with IV sedation though I tend to prefer a general in the most severe cases when a nipple graft technique is used. Toxic levels of local anesthetic could become a real issue with an in-experienced surgeon, this could result in a real bad situation.