Understanding anesthesia: What patients should know before plastic surgery

One thing makes almost all humans uncomfortable: a lack of control over their situation. When we lack control, we feel vulnerable. Vulnerability, stress and anxiety are common emotions that patients experience when they know that a surgical procedure is going to require anesthesia, especially because there is a lot of confusion and misinformation about anesthesia and the role it plays during surgery.

ASPS Member Surgeons Josef Hadeed, MD, FACS, and Karen Horton, MD, MSc, FACS, offer practical advice for patients preparing for plastic surgery to help you prepare for what's ahead.

Understanding anesthesia

What is anesthesia? In plain terms, it is a medical treatment, or a cocktail of medications, that temporarily prevents surgical patients from experiencing pain or discomfort during a procedure. Different medications interact differently, depending on the type of anesthesia needed for a particular procedure.

Some of the most common types of anesthesia in plastic surgery include:

• General anesthesia: A patient undergoing general anesthesia for a surgical procedure will be given medications through an intravenous line, as an inhaled gas or a combination of the two, that render them unconscious and unable to move.
• Monitored sedation or twilight anesthesia: During twilight sedation, medications, such as sedatives, anesthetics and analgesics (medications that reduce pain without affecting consciousness), are administered to a patient, typically through an intravenous line. The patient is calm and relaxed, but still conscious and able to breathe on their own.
• Local anesthesia: Local anesthesia can include an injectable or topical medication that numbs or blocks pain signals to one localized area of the body. During the procedure, the patient is awake and conscious.

"Anesthesia is chosen based on the procedure's complexity, duration, patient comfort and surgeon preference," said Dr. Hadeed. "The main options are general anesthesia, where the patient is completely asleep; sedation or twilight anesthesia, where the patient is drowsy but can breathe on their own; and local anesthesia, which involves numbing the area and leaves the patient awake and alert."

In practice, these options give surgeons flexibility to match the level of anesthesia to the procedure while prioritizing patient comfort and safety.

"Plastic surgery is offered to our patients in my in-office surgery center either awake, under local anesthesia or under general anesthesia with a board-certified anesthesiologist present," said Dr. Horton.

Anesthesia options for nonsurgical patients

With nonsurgical procedures, plastic surgeons typically rely on pain management methods such as local anesthetics, either injected or applied topically, to help numb an area and dull the sensation of pain.

"For nonsurgical patients, numbing cream can be very helpful, or occasionally a nerve block is administered prior to injection in more sensitive areas," said Dr. Horton.

However, drugs are only one part of the equation. Distractions are also a tool used to keep patients calm and comfortable.

"Physical 'distractors,' such as a vibrating tool, finger tapping or a cold object placed beside or far from the treated area, can provide a different and competing stimulus to lessen treatment discomfort," said Dr. Horton. "We also offer a combination of inhaled laughing gas and oxygen, which the patient self-administers. Pro-Nox, the brand we use, causes natural endorphin release and a sense of euphoria and was designed to allow patients to have a treatment and drive themselves home safely afterward. We also give our patients breast implants to squeeze; they are actually quite soothing and comforting!"

For patients nervous about injections, a small snack or juice may also help prevent fainting and keep the patient more comfortable.

Preparing for general anesthesia

General anesthesia is typically reserved for more complicated or lengthy surgical procedures. A combination of medications is administered by a certified anesthesiologist not only to help block pain, but to render a patient physically paralyzed so the body cannot move during the operation. An anesthesiologist is a medical doctor who specializes in administering anesthetics and monitoring patients during surgery. They also play a vital role in evaluating patients before surgery, monitoring vital signs during surgery and providing aftercare to ensure a smooth transition from anesthesia to consciousness and recovery.

Before you are even wheeled into an operating room, you must communicate honestly and openly with your plastic surgeon and their anesthesiology team for your safety. Preparing for general anesthesia is critical.

"Omitting information is one of the leading causes of preventable anesthetic complications," said Dr. Hadeed. "Anesthesia relaxes the protective reflexes in your throat. Food or liquid in the stomach can be regurgitated and aspirated into the lungs, leading to severe pneumonia or airway compromise. Use of cannabis, alcohol or recreational drugs can interact with medications typically given during surgery and lead to alterations in blood pressure and heart rate."

When your plastic surgeon or anesthesiologist asks about your medications, supplements or lifestyle, it is not to judge you. They want to ensure your safety and prevent potentially catastrophic, even fatal, complications during surgery, which is why transparency matters.

"As your board-certified plastic surgeon, we need to know everything," said Dr. Horton. "This includes everything you put in your body, your exercise habits, sleep routine and other lifestyle choices. Many patients take GLP-1 medications, but since they are not technically prescribed by their physician or they might feel embarrassed, they don't always disclose it to their care team or list it as a prescribed medication. Taking a GLP-1 will increase the risk of aspiration, pneumonia and potential death related to surgery under general anesthesia or contribute to poor wound healing, which I personally have started seeing in patients who are on these medications."

As a rule of thumb, both surgeons recommend abstaining from the following before undergoing general anesthesia and surgery:

• Alcohol
• Anti-inflammatory medications
• Blood thinners
• Certain vitamins or supplements, such as Vitamin E, fish oil and ginkgo biloba
• GLP-1 medications
• Recreational drugs
• Tobacco products

There may be other medications and supplements that your doctor wants you to avoid. The timeline for avoiding these medications and products can vary. In the case of GLP-1s and other medications, plastic surgeons recommend stopping these drugs at least two weeks before surgery. Patients must also adhere to the strict fasting rules prescribed by their physician before surgery. Always follow your plastic surgeon's guidelines.

What to expect before and after anesthesia

One of the most frightening parts of undergoing general anesthesia is the unknown. Patients who understand what to expect before and after surgery, while perhaps not eliminating all anxiety, are better equipped to handle the process.

"Before going to sleep under general anesthesia, we give our patients an oral anti-anxiety medication that helps to relax them and get to sleep the night before surgery and relaxes them the day of surgery as well," said Dr. Horton. "The calmer and more relaxed you are, the easier the intravenous insertion is, and you will have a better experience overall. We play a song requested by our patient upon arriving in the operating room – after they are asleep, we play the music we like. Most patients don't remember going into the surgery room, going to sleep or even waking up! After surgery, I tell patients they will feel groggy, tired and possibly emotional. It takes a full 24 hours for all the anesthetic medications to leave your body. For this reason, another responsible adult must drive patients home and stay with them the first night."

Coming out of anesthesia after a period of unconsciousness can be disorienting and confusing for patients, leaving them feeling groggy for up to an hour post-surgery. Recovery from anesthesia can look different for everyone. Some patients feel sick, while others only feel mildly sleepy. Some may feel silly or giddy, and others can have a different emotional reaction.

"Some patients experience nausea, but this is something we always try to avoid," said Dr. Horton. "Limiting narcotics given while asleep and good communication with the anesthesiologist about the timing of surgery will allow the drugs to naturally wear off rather than needing to completely reverse a paralyzed patient and have a more rough awakening. We try to keep patients as warm as possible during surgery, as hypothermia increases the risk of blood clots, but some plastic surgery procedures require exposure of a large body surface area, and some patients wake up shivering. They won't remember it after the fact, but their family members may see them being warmed up with forced-air heat and warm blankets in the recovery room."

Postsurgical pain and discomfort may also vary from patient to patient and surgery to surgery.

"Some patients awake experiencing pain, while others feel mostly numbness," said Dr. Horton. "Nerve blocks or injection of local anesthesia while the patient is asleep can help with immediate postoperative discomfort, and pain medication is often required at home for a few days after surgery."

Safety practices during anesthesia

One of the biggest questions patients have about anesthesia is whether it's safe. The answer is yes; however, as with all surgical procedures and medications, there are risks involved. Understanding the process and why it is critical to follow your surgical team's instructions can help ease anxiety and decrease your risk of potential complications.

"Monitoring the 'ABCs' (airway, breathing and circulation) is key to ensuring patient safety," said Dr. Horton. "Patients are connected to monitors that measure and record their heart rate, blood pressure, respirations, oxygen saturation, temperature and other vital signs during surgery. The entire surgical team should be focused on patient safety, including the surgeon, nurses, scrub technician and anesthesiologist. Communication is key before, during and after the procedure and accreditation of the surgery center or hospital."

That constant vigilance is reinforced by safeguards built into the operating room, from emergency medications and airway equipment to backup systems designed for unexpected situations.

"Safety under anesthesia relies on continuous monitoring of vital signs," said Dr. Hadeed. "All accredited operating rooms are equipped with emergency medications, advanced airway equipment and backup power systems."

During general anesthesia, while the plastic surgeon works their aesthetic magic, the anesthesiologist monitors the patient's vital signs and watches for complications.

How do you know who is managing your care during surgery?

One of the most important questions a patient can ask is about who is managing their care during surgery. Knowing who is on the surgical team and what their credentials are is vital when starting your plastic surgery journey.

"Many practices, including mine, offer an optional anesthesia consultation ahead of surgery," said Dr. Horton. "Our anesthesia director, Dr. Caroline Dejean, will call patients ahead of surgery, if requested, and answer all their questions, educate them about the anesthesia process and ensure the necessary tests are ordered and reviewed ahead of the surgery day."

If you are unsure who your anesthesiologist will be for your surgery or want more information about their credentials, never hesitate to ask. Again, in some situations and settings, a nurse anesthetist can provide proper care and monitoring. However, in surgical settings, training, education and experience matter.

These are also crucial questions to ask if your plastic surgeon is performing twilight sedation or if you are undergoing sedation in an office setting. While this can be an option for patients who may be anxious about local anesthesia only, certain sedation methods can lead to complications if a patient stops breathing on their own due to the medication. When there is no one monitoring the airway or an anesthesiologist is not present, patients can potentially go into cardiac arrest, and there have been instances where events like this prove fatal, which is why asking questions and understanding who is in charge of your care are important.

Patients who may be anxious about anesthesia should feel comfortable asking any questions they have about the process, their specific issues, medical history or other concerns that may warrant additional attention. Asking questions is part of the process, and the more knowledge a patient has, the more confident they can feel about being placed in a vulnerable position where they lack control.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.