Is A Medical Spa The Right Place For Invasive Surgery?

A recent article in The New York Times Style section relayed the unfortunate death of a young nurse as a result of a misguided liposuction procedure in a "medical spa".

Invariably, every year or so, a similar tragedy comes to awareness. Typically, a patient undergoes a surgical procedure in an environment which does not meet the minimum safety standards.

Often patients underestimate the complexity and potential hazards of any surgical procedure regardless of how anatomically superficial it may be. Yes, liposuction involves only suctioning that layer of fat directly under the skin. And, yes, no major body cavity, such as the chest or abdomen is entered.

In the Florida case discussed in the New York Times, the liposuction was performed and local anesthesia was used. Even just local anesthesia has hazards. Unlike a dentist's office where local anesthesia is used in very small volumes, perhaps just several cc's, liposuction usually calls for large volumes of the anesthetic solution with added epinephrine to increase the duration of the anesthetic and to reduce tissue bleeding. But both types of medications, local anesthetics and the epinephrine class of drugs, can have an effect on the heart. Should the medication be absorbed too quickly or should too-strong a concentration be formulated, then the risk of untoward reaction increases.



There are two issues which every patient needs to understand with respect to surgery. First, there is always the potential for problems and the best insurance against having a catastrophic outcome is to have the procedure performed in a fully equipped surgical facility. A medical spa is not a bona fide surgical facility.

The facility should be either licensed by the state, accredited by the United States Department of Health and Human Services (accredits facilities to qualify for Medicare payments) , or by one of three well-known private accrediting organizations: Accreditation Association for Ambulatory Health Care (AAAHC) , the American Association for Accreditation of Ambulatory Surgical Facilities(AAAASF) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO), which accredits hospitals. Fully accredited, licensed facilities must have the same resuscitative equipment, emergency drugs and supplies and infection control standards as a hospital. They have passed the test.

Finally, I would never have any type of significant surgical procedure, whether done under local anesthesia or with local anesthesia with sedation or general anesthesia, without the services of a board certified physician anesthesiologist. Certified Registered Nurse Anesthetists (CRNAs) may be appropriate in some situations. In any event, you want an anesthesia specialist at the controls. Such specialists are another "insurance policy" for you because they will not work in a substandard facility.

Yes, there is some added cost to have an anesthesia specialist on your side and at your side. But, the incremental cost in having such specialist is very reasonable. After all, what is your comfort, safety - and even your life - worth?

- Robert Kotler, MD, FACS

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Considering Cosmetic Surgery? Don't Bother If You Smoke!

Many patients are disappointed when they have a consultation and are told that, despite their wishes and the probability that the surgeon is capable of delivering a satisfactory result, surgery is not advisable. The number one reason for patients being "turned down" for cosmetic surgery is that their cigarette smoking is of such a magnitude that chances of complications - both from the surgery and anesthesia - are unacceptably high.

Smoking carries significant risk for both the surgery and anesthesia. One should not willingly increase the risk by smoking.



Typically in cosmetic surgery, one does not require a deep anesthetic because the surgeons are able to anesthetize the tissues using local anesthetics producing a pain-free zone. The tissues are numb, just like during dental procedures. Usually, with a minimal amount of drugs, the anesthesiologist or nurse anesthetist creates a state of unawareness for the patient to reduce the chance of the patient moving or acting otherwise inappropriately during the operation. Naturally, the less medication the better, plus a quicker wake-up and less chance of nausea and vomiting after surgery.

Anesthesiologists and nurse anesthetists are unhappy with smokers because the smoke creates a state of chronic irritation and inflammation of the bronchial passages in the lungs. During the surgery, the lungs will be unduly sensitive to the gas anesthetics which are frequently used. Because of that, to avoid coughing, wheezing and the production of abnormal thick mucus, the anesthesiologist will have to "deepen" the anesthesia.

If a patient is capable of stopping their smoking for weeks before surgery, that is ideal. Luckily, the body's phenomenal regenerative powers will allow the irritated tissues of the lining of the lungs to settle down and repair themselves. The longer one has smoked and the greater the number of cigarettes smoked per day, the longer it takes for such healing to take place.

Regarding the operation itself, the risks are dependent upon the procedure. In rhinoplasty or cosmetic nasal surgery, the nose has been subject to the same type of irritation as the lining of the lungs. As a matter of fact, the lining of the nose structurally and microscopically is identical to that of the lungs, hence the similar response. The nose does not take to smoking very well because the smoking dries out the normal nasal mucus which is necessary to cleanse the incoming air. The smoke paralyzes the tiny hair-like fibers which help filter the incoming air. The smoke's heat dries and thickens the existing mucus causing immobility of the mucus and what we call the "post-nasal drip": the thick, rubbery mucus eventually gets to the back of the throat, causing the reflex to cough it out. Not what you want when recovering from surgery. In addition, there is a greater chance of bleeding excessively during surgery and after surgery because the smoking has generated a proliferation of blood vessels inside the nose.

For the nose, the cigarette is an enemy. Whether they are filtered or unfiltered, light or whatever. Smoke is smoke.

Other cosmetic operations carry different risks for the cigarette smoker. Facelifts which rely on the elevation and movement of large territories of skin on the face and neck are subject to a very negative effect of cigarette smoke which can be disastrous for the tissue. The noxious elements in smoke, such as carbon monoxide, carbon dioxide and nicotine, inhibit the flow of oxygen-carrying blood to those tissues and may threaten the very survival of the tissues. This could lead to wound breakdown, infection and then scarring. Obviously, this is an unacceptable risk for an elective operation. Therefore, surgeons respectfully decline to perform face and neck lifting on patients who smoke. Period. No appeals accepted.

The same risks exist for other operations performed on the body such as tummy tuck and breast surgery, particularly breast reduction where akin to the facial operation, large amounts of skin are elevated from their bed and moved to a new location.

Frankly, for everyone, there is not a single good thing that could be said for cigarette smoking. Medically, smoking takes its toll on the heart, lungs and all internal organs.

Smoking is a friend of aging, however. It prematurely ages the skin. The skin is the last stop along the circulation railway and is chronically deprived of oxygen because of the blood-vessel narrowing by the carbon dioxide, carbon monoxide and nicotine mentioned above.

The biggest mistake a patient can make is to lie to the doctor or anesthesiologist about smoking, past or present. After all, the surgeon and anesthesiologist are responsible for your surgical outcome, your comfort, your safety - and even your life. Unlike cigarettes, they are on your side.

Don't stub your toe. A better solution than denying you are a cigarette smoker is to seek professional help which is available everywhere to stop smoking. There are even medications that help the cause. Then, when your body has recovered from smoking's damage, you can schedule the proecedure(s) you want and feel comfortable that your body is in better shape for surgery.

- Robert Kotler, MD, FACS

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Today's Cosmetic Surgery Anesthesia Techniques

Photo: Robert Kotler, MD, FACS

Today's cosmetic anesthesia techniques and medications are extraordinary! The above photographs tell it all. The photo on the left taken at 2:26 pm shows a patient who has just completed a five-hour face and neck lift. The dressings are in place and the patient is about to be taken to the recovery room.

The second photo taken 3 minutes later at 2:29 pm shows the patient at her station in the recovery room fully responsive and when asked, "How are you feeling?" gives the thumbs up sign. That is a strong indication that the patient's faculties and brain function are intact.

The third photo is taken at 3:48 pm, approximately one and a half hours after the patient emerged from the anesthetic. She is alert, pleased, and particularly joyful because she had a history of having nausea and vomiting with a previous surgery. The patient will now be transported to a professional recovery facility where she will be observed overnight before she sees her surgeon the next day.

What is significant is that the patient had a particular cutting edge anesthesia technique. This technique is known as "PK" anesthesia. The "P" stands for propofol and the "K" stands for ketamine. Now propofol, which is the chemical name for the medication marked as Diprivan, has gotten a lot of attention recently because it has been implicated in the improper prescribing of medications for Michael Jackson. However, that should not at all dissuade anyone from availing themselves of this marvelous anesthetic which has a very quick onset and a very quick "wakeup." The "K" medication, ketamine, is a perfect partner for the propofol. The medication places the patient in a detached state whereby they are conscious but are totally isolated from any stimulation and, therefore, pain is not registered in the brain. While the patient is maintained on the propofol medication throughout the case, the ketamine is used only in anticipation of when local anesthesia is injected. Understand that the operation relies on local anesthesia - administered after the propofol-ketamine has been given intravenously - to render the tissues pain free.

It is remarkable that the patient required no oxygen, did not have a mask or tubes on her face or in her nose. She received no narcotics or any other medication that might be apt to make her nauseous and delay the emergence from anesthesia.

This technique has been popularized, worldwide, by anesthesiologist Barry Friedberg, MD. Dr. Friedberg, who is on the faculty of University of California, Irvine, is author of a very specialized medical textbook for cosmetic surgeons and anesthesiologists entitled, Anesthesia in Cosmetic Surgery.

- Robert Kotler, MD, FACS

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