Sweet Dreams, Comfortable and Safe Anesthesia w/ Dr. Kalman Friedman

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. The title of today's episode is "Sweet Dreams, Comfortable and Safe Anesthesia." Dr. Bass, as we've said many times on the podcast, we all want to be beautiful, but some of us are afraid of the experience or the risks involved with having plastic surgery. What would you say to those of us in that category?

Dr. Lawrence Bass (00:39):
Everyone would like to achieve the results they're after in the least invasive way possible, ideally without surgery. And there's been a revolution in the past three decades in aesthetic medicine and plastic surgery with many nonsurgical offerings, which are extremely valuable. However, plastic surgery is still often the only meaningful option depending on what stage of aging you're at or which beauty feature is involved. Fortunately, there's been a revolution in how and where aesthetic plastic surgery is performed over those same past few decades. Some of this is fueled by the advent of minimally invasive procedures, and the evolution of open surgery has been refined and focused. almost all aesthetic plastic surgery procedures in almost all patients can be performed in an office operating room, which in compliance with accreditation standards for such facilities provides a very safe, private, and comfortable setting to obtain your plastic surgery. Safety and comfort are the key. Much of what has enabled this shift to office surgery relates to improvements in anesthesia. This follows the same pattern as what has happened with non aesthetic surgery in the United States with a shift of a large percentage of all procedures to an ambulatory setting without a hospital stay.

Doreen Wu (02:25):
Going under anesthesia is a source of concern to many as much as the surgery itself. How much should I worry?

Dr. Lawrence Bass (02:32):
As I said, modern anesthesia has made tremendous advancements. I've asked one of the senior anesthesiologists from the group that works with my practice to discuss some of these issues. Dr. Kalman Friedman is a senior anesthesiologist with the Caliber Anesthesia group. As I said, they provide anesthesia services in my practice and for many other esteemed plastic surgeons up and down Park Avenue in New York City. He also has a great deal of experience in running and managing ambulatory surgery centers and all of the demands of, of ambulatory anesthesia and distinction from hospital surgery. Welcome, Dr. Friedman.

Dr. Kalman Friedman (03:22):
Thank you. It's a pleasure and an honor to join Dr. Bass on this podcast.

Doreen Wu (03:27):
So, Dr. Friedman, can you tell us what kinds of anesthesia are typically options for office-based plastic surgery?

Dr. Kalman Friedman (03:35):
So most office-based plastic surgery is done under either general anesthesia or IV sedation or MAC, what some may call twilight IV sedation kind of runs on a continuum. At one end, it could be just a bit of medication to relax you while the numbing medicine is injected to the other end, deeply asleep or anything in between tailored to the situation.

Doreen Wu (04:00):
And how risky is that really? How worried should I be?

Dr. Kalman Friedman (04:04):
It's very normal for a patient to be apprehensive regarding having anesthesia. However, nowadays with advances in medications, our scientific knowledge, and our monitoring devices, anesthesia is very, very safe. Of course, there is always some degree of risk. One must accept and undergoing any procedure, but it is extremely minimal. The risk of having any anesthetic related problem. Mim known a serious problem is very, very low. One of my mentors used to tell all of his patients that it is safer to go under general anesthesia than it is to cross the streets, not the way we usually look at things, but it is certainly true.

Dr. Lawrence Bass (04:41):
And I think that that's absolutely right. The anesthesia capabilities in terms of monitoring and keeping an eye on patients' vital signs, oxygenation is a totally different place than where it was a few decades back. That greatly amplifies safety and many of the medications are short acting without the anesthesia hangover. That was true 40, 50 years ago. That allows people to wake up quickly, feel well, and be ready to go home.Well, let me ask you this, Dr. Friedman. A a lot of patients feel that general anesthesia has more risk than IV sedation. Is that true? I mean, why do patients think that and and what are the issues?

Dr. Kalman Friedman (05:40):
That's a great question. It is probably the most common question I get from patients and find myself discussing this with patients. So I'll spend a few extra minutes on this question. I'll start off by saying that both general anesthesia and IV sedation are both very safe. There are some surgeries where one is more appropriate than the other, often either can be done and there is a discussion between the surgeon, the anesthesiologist, and the patient to find the best fit. I do want to clarify that with both general anesthesia and sedation, the patient is asleep and safe. The real big difference is in the level or depth of anesthesia. And that is usually dictated by the nature of the surgery. I think what you are referring to Dr. Bass is the breathing tube or being intubated. What comes to mind for some people is a patient on a ventilator in the ICU or they imagine someone putting a breathing tube down their throat while they're, they are in, in reality, most of the time we could form a general anesthetic with a so thro airway device called the LMA that sits in the back of the tongue and the patients breathe on their own through this device.

(06:45):
It is placed when the patient is a sleep and is removal, which before the patient wakes up. In reality, most considered general anesthesia as safer, given that the airway is secured with the LMA or a similar such device.

Dr. Lawrence Bass (06:58):
And I think that's a really important point that often general anesthesia is going to be a more even level of oxygen intake, a more even level of blood pressure than something that's done under local anesthesia or with the barest minimum of sedation. So in that sense, it's less physiological stress and really a safer experience overall. And the other point you made that I thought was really important is that, that the magnitude of the surgery often dictates what level of anesthesia is required for someone to be completely comfortable while the procedure is going on. So that kind of drives the situation to some extent in terms of anesthesia selection, and it's important for patients to realize that.

Doreen Wu (08:00):
But Dr. Bass, can I just have my procedure under local anesthesia? As the surgeon, what do you think about having more anesthesia versus just having local? What's your take on this?

Dr. Lawrence Bass (08:12):
As I said, you know, a lot of it has to do with the extent of the procedure. If you're having a skin biopsy or an earlobe repair the local anesthesia works perfectly well. You're very comfortable, it's easy to do. The procedure is short, and so it's easy to sit still for a few minutes while the procedure's completed. But as the procedure gets larger in magnitude, the length of the procedure becomes longer. It gets harder to manage that just under local in a way that's really comfortable for people. And so having a comfortable experience and gauging the amount of that you have as an individual is important in deciding what kind of anesthesia is really going to be right for you. Some people are a lot more anxious than others. Some people just seeing the operating room, hearing the monitors beeping, really gives them a lot of anxiety, or in some cases a panic attack.

(09:18):
In those circumstances, enough anesthesia to be relaxed, comfortable, or even asleep and dozing is going to be more appropriate. So you can get through the procedure and it's not a in ordeal for you to go through. The other thing is when the anesthesiologist is present in the operating room, it allows the surgeon to focus just on the surgery, concentrate on giving you the most precision, the most artistry, the most perfect result that's possible rather than having to split attention between the procedure, your vital signs and your state of mind and level of comfort having excellent anesthesia allows for very extensive interventions. It allows you to push the procedure to the maximum. Perfect example of this is liposuction. A lot of liposuction is done just with tumescent anesthesia, essentially local anesthesia. And for small liposuction, that works well in some cases.

(10:31):
But if you're trying to treat two or three areas where you're really trying to bring things down to the barest minimum of fat, that's a lot more stimulating and uncomfortable. And you may succeed better at achieving your goals if the procedure is done under anesthesia and it lets you do multiple procedures at once. And having another physician there who's an expert in cardiac and pulmonary physiology and understands how to monitor and manage that makes you safer, it reduces again, the split attention of the rest of the staff in the room. So I think those are some of the reasons why as the procedure becomes substantial and magnitude, anesthesia is really the right way to go.

Dr. Kalman Friedman (11:27):
I think Dr. Bass covered all the points. Of course, for certain minor procedures that can be numbed up completely and the cooperative patient, it can be done safely and comfortably with just a local anesthesia. I'll just add that I hear from colleagues of mine at other practices that they're tending to do procedures that should have an anesthesiologist, and for one reason or another, they decide to do with just local anesthetic. They run into all the issues that Dr. Bass mentioned. The surgeon is preoccupied with an uncomfortable and often swarming around patient. There are also practices that will heavily sedate the patients themselves under the disguise of a local anesthetic without an anesthesiologist where we not a good and safe idea.

Dr. Lawrence Bass (12:09):
And an important thing about that is that, you know, it varies in each individual state, but in New York state where Dr. Friedman and I practice, there are very specific rules about what procedures can be done in just an office operating room and what has to be done in an accredited office operating room, and how much sedation can be given if it's not given by an anesthesiologist or other qualified anesthesia provider. So the idea of taking an awful lot of oral medicine, which has variable absorption really is not a safe approach. And if the procedure is of a sufficient magnitude to require that, it's better to have the quality and control of having an anesthesiologist who can make sure that you're safe and comfortable.

Doreen Wu (13:11):
Now, let's look on the flip side. What are the disadvantages of having more anesthesia?

Dr. Lawrence Bass (13:17):
So of course, you know, there's a cost to everything. So if you're bringing an anesthesia provider, the anesthesiologist adds a cost medical clearance will be required over a certain age. And people who have had anesthesia need to go home with an escort. Again, in our state, New York state, that's mandatory. And of course there's a little bit of time to recover from the anesthesia. For minor procedures or a small single intervention, those may be unnecessary added impediments. But if you start to get to a more extensive procedure, even if you do it under local, you're not going to be good to drive yourself home. You're going to need an escort. You may need medical clearance if you're older or have medical conditions just for the surgery to be performed safely. So you're not necessarily foregoing all of those disadvantages just because you're doing it under local.

Doreen Wu (14:30):
Okay. So now, Dr. Friedman, I want to pick your brain for a moment. I wonder what do you feel are the advantages of care in the office setting and with the kind of ambulatory anesthesia that is available today?

Dr. Kalman Friedman (14:44):
I just want to start off saying that today the majority of all surgeries are done in an ambulatory setting. I am not just talking about elective cosmetic surgeries that we're discussing, but hernia repairs, tonsillectomies, knee and shoulder repairs are all mostly done in the ambulatory setting. The advantages are manyfold. I'll start off with safety. The risk of acquiring infections is lower, medical error is reduced. The surgeon has what we'll call home court advantage, having his handpicked instruments, nursing staff, anesthesiologist. From that anesthetic end, ambulatory anesthesia has become a specialty on its own, meaning that your anesthesiologist, who will be taking care of you in the office setting has been trained and has experienced this. We have the same medication, supplies, and equipment available as in the hospital, and are trained to deal with any situation that can arise. And of course, you have the convenience factor.

(15:38):
Anyone who has had to deal with hospital bureaucracy knows this all too well, your surgery starts on time and not delayed many hours into the afternoon while you are still NPO not eating or drinking for the morning. The patient's responsibility for facility costs are usually much lower than an alternative setting as well. You'll also know beforehand who your anesthesiologist will be, and he or she will call you before and go through your medical history and will discuss the anesthetic options and plans. At this time, you would also have the opportunity to ask any questions and then discuss any particular concerns that you may have.

Doreen Wu (16:14):
Finally, before we conclude Dr. Bass, what should our listeners take away from today's episode?

Dr. Lawrence Bass (16:21):
So I think there are a number of important points that, that I could summarize. As you heard, you know, anesthesia's very safe. There's a small risk, not zero, because there's not zero risk in anything we do in life. And, and it's very much like driving a car. Every time you get in the car and drive somewhere something terrible could happen. You could get in an accident, but the chance is very low. So you don't hide at home in a dark corner. You get in the car and drive. But you know, you look both ways before you pass into an intersection. You follow the rules of the road and drive cautiously. And even though the risk isn't zero, you're very safe and you get a lot of benefit from the mobility of being able to drive. Having anesthesia allows the procedure to be very controlled.

(17:21):
It's an added layer of safety overall for patients. And working in an office-based surgical facility is private. It's cost effective, comfortable. It's very efficient. As Dr. Friedman just pointed out, it's the whole team that's all optimized and used to working together. Dr. Friedman knows what I'm going to do. I know what he's going to do. We've worked together many, many times. It's not whoever the hospital sends in that day with a brand new team almost every day in the facility. And so overall, this makes in office plastic surgery the safest, most comfortable and pleasant experience possible. For aesthetic plastic surgery. You know, the plastic surgery experience is about service, comfort, privacy, and getting the chance to enjoy making yourself image according to your desires. It's a boutique, premier experience, the best in quality and with safety most important. The kind of anesthesiologists who work in the office space plastic surgery setting are committed to all of the principles I just listed. Anesthesia advances have been central to enabling that entire experience, even for extensive plastic surgery. And it allows patients to be asleep totally comfortable during even extensive procedures than wake up rapidly, be alert enough and comfortable enough to walk out of the office, able to eat and drink and recover in the comfort and privacy of their own homes.

Doreen Wu (19:22):
Dr. Friedman, would you like to add any takeaways?

Dr. Kalman Friedman (19:26):
That was a great discussion we had today and hopefully informative to the audience. Remember that your anesthesiologist is there to keep you safe and comfortable. Consider him your primary care doctor for the day, and always discuss with him or her all of your medical conditions and any questions or concerns you have, and you'll have a great experience.

Doreen Wu (19:44):
Thank you Dr. Friedman and Dr. Bass for sharing your insight and expertise on this very important topic in plastic surgery.

Dr. Kalman Friedman (19:52):
Thank you Dr. Bass for having me on as a guest. And thank you, Doreen, for hosting this discussion.

Dr. Lawrence Bass (19:57):
And thank you, Dr. Friedman, for joining us and sharing so much useful information. And thank you for providing such excellent care along with the rest of your team to my patients. I really appreciate it.

Doreen Wu (20:10):
Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review, and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.