Why I am angry about Preserve
I get very annoyed when I hear people discussing something that I have been doing for years as if it’s new. When I first started in practice, I realized that the breast does not live under the muscle, so why would I put an implant there? And after years of seeing the rough recovery involved with under-the-muscle breast augmentations, I decided to do things differently.
Is this really revolutionary?
Over my time in plastic surgery practice, I have received a lot of feedback from patients about what other plastic surgeons have said about things that I had told them. It was not uncommon for me to hear, “I told another surgeon that you put implants over the muscle, and he said you’re crazy.” There was a big debate about whether this was a reasonable thing to do, and some surgeons even insisted that the complication rate would be high and the results would be terrible. Now that there is a marketing push for a “new” procedure, all of a sudden, subglandular implants are all the rage.
Why I always preferred subglandular placement of breast implants.
Placing breast implants under the muscle requires making a space where none exists. You have to pull, rip, tear, and stretch the muscle to fit something underneath it and against the rib cage. Between the muscle and the breast, however, there is a natural space that opens easily. Without abusing the muscle, there is way less pain, swelling, recovery time, and deformity. This has always been the case. And I have been doing this forever.
Are breast augmentations under local really under local?
Yes and no. Breast augmentations performed under local anesthesia use a method called tumescent, where a large volume of fluid containing local anesthesia and medication to prevent bleeding is injected into the breast. Many times, the patient is also receiving sedation, which is IV anesthesia, to keep them comfortable. Because the pocket above the muscle does not require a lot of trauma to open (which is why I have been doing this for YEARS), you can place an implant in this plane as long as the general area is anesthetized. But saying that there is no anesthesia besides local is a misnomer. “Twilight” or “sedation” are still forms of anesthesia where you are sleeping and unconscious.
What is the difference between twilight anesthesia, sedation, and general?
“Twilight” anesthesia, or sedation, means that you have sedative medication in the IV and you go to sleep. From the patient’s perspective, you take a nap and wake up, with no memory of what happened in between. Many of the medications used, including the ones that make you forget everything that happened during the procedure, are the same as the ones used in general anesthesia. General anesthesia is a deeper state, which requires securing the airway. Patients have either a cuff tube on the back of their throats or a tube in their trachea. If they have a tube in their trachea, they need to be paralyzed.
Why I perform procedures under LMA
Patients are afraid of general anesthesia because they don’t like the idea of being unconscious. But what they do not realize is that they are safer comfortably asleep with their airway secure and their blood pressure controlled than awake and unpredictable. LMA procedures do not require paralysis, so they do not require reversal, and this means that you need less drugs and have less side effects. Being asleep and having the airway secure is actually the safest you could be while having surgery, and it avoids needing huge amounts of local anesthesia to make you comfortable. I have the ability to choose any type of anesthesia for my patients, and I can do procedures under local.
Choosing not to perform major operations under local anesthesia is a choice, not a lack of skill. I just prefer to make a sound medical decision rather than pretend I am re-inventing the wheel.
Take-home message about preservation augmentation
- Nice to see you all here. I’ve been sitting here alone for over a decade.
