Awake Breast Augmentation - fad or fantastic?

The New York Times not long ago published an article touting the benefits of breast augmentation while "awake" (link here). The supposed benefit of this technique is that the patient, who has been given valium and other sedatives for the procedure, can participate in the sizing process during surgery, and help to select her implant size.

The NYT article implies that anything other than a full general anesthetic could be considered "awake" - which is really quite misleading, as anyone who has experienced the drunken state that a good dose of IV sedation creates will tell you!

I've got some issues with this whole concept. First: the best time for you to pick the implant size is BEFORE surgery, rather than DURING surgery when there are sedative agents floating in your bloodstream, impairing your judgement. Before surgery, you have plenty of time to think about the many options, and ask your surgeon about the implant choices that would best give you the desired results and would best fit your frame. It's really hard to imagine how a sedated patient can give any kind of valid "informed consent" after getting medicated.

Second: if the breast is pumped full of tumescent local anesthesia fluid, as is recommended by the practitioners of this technique, then the shape and size of the breast is obviously going to be distorted, and the intra-operative appearance wouldn't be very accurate anyhow.

In the New York Times article, the surgeons doing this were not Board-certified Plastic Surgeons, but general surgeons and OB-GYN's dabbling as cosmetic surgeons. Active blog readers will recognize this as a red flag. Searching the internet doing research for this post, I was unable to find any board-certified plastic surgeons who perform breast augmentation under straight local anesthesia. Only wanna-be's.

Many of these non-plastic surgeons do this procedure in their office because they do not have hospital privileges to perform it in an accredited operating room, such as a hospital or surgery center. That's another red flag. Only ever have surgery in an accredited surgical facility.

Impression: Consider me underwhelmed by the evidence for this technique. Our careful pre-operative sizing method, with exact measurements, tissue-based planning and actual try-ons of implant sizers in an alert, well-informed patient well in advance of surgery works far better than asking a woozy and drugged patient to OK the result in a breast distorted by large volumes of injected fluid. And I've yet to see any published clinical data documenting happier patients, better outcomes or fewer complications with this technique in any peer-reviewed publication. Show me the science!

Does that mean I'm totally against operating with just local anesthesia? No, but I only use it when it's safe, comfortable and appropriate for the patient.