Recently the New York Times ran an article on using only local anesthesia for breast augmentation.  Although this was a relatively short article, my comments could almost go on ad infinitum.

The main point of the "Skin Deep" article was that patients now have the choice of having their breast augmentation done under local anesthesia with or without sedation when they choose to have their procedure performed by a certain subset of physicians.  According to one Texas cosmetic surgeon quoted in the article, when he performs breast augmentaions his patients are "talking to him the entire time". After insertion of the implant, his patients are "propped up on the operating table, look in a mirror and have their say."

Lets take it point by point:

1-The surgeon quoted in the article is not a board-certified plastic surgeon. He isn't even a plastic surgeon. He is an OB-GYN who we can generously assume has had some sort of recent post-residency training to learn how to perform this procedure (perhaps the two-day, weekend seminar mentioned in the article?).  

It would be unusual to find a board-certified plastic surgeon with years of training learning how to perform this procedures advocating local anesthesia only. I would never assume that I have the same capabilities to perform a cesarean-section to deliver a baby as a board-certified OB-GYN (even if I spent a weekend learning how!).  A board-certified plastic surgeon has spent 5 to seven years or more after medical school training and perfecting his skills. How can a weekend seminar possibly compare to that?

2- Breast implants are placed in one of two pockets: either above the muscle and directly under the breast (subglandular) or under the muscle itself (subpectoral). Subpectoral placement is, however, a much more painful procedure as the muscle is elevated off the chest wall and divided along its lower edge to create pocket in which to place the implant. This would be virtually impossible under local anesthesia without sedation - much too painful for the average patient.  Therefore, by limiting yourself to local anesthesia, you are effectively limiting the type of surgery you can have, perhaps resulting in a less than idea implant placement.

3-Are these practitioners advocating local anesthesia alone because it allows them to circumvent the need to have their operating rooms accredited?  Accreditation is a time-consuming and expensive ordeal in which every aspect of the facility (from physical lay-out of the operating room to meticulous maintenance of safety equipment to the proper training of all health care professionals) is subject to strict regulations and scrutiny.  The American Society of Plastic Surgeons requires all member plastic surgeons performing procedures under anesthsia in their offices to have the space accredited by a certifying organization.  Furthermore, New York State requires accreditation for physician giving any intravenous sedation in their office.  

4-Non-board certified practitioners claim that local anesthesia makes for safer surgery, but there are NO peer-reviewed studies of which we are aware that have shown that breast augmentation done under local anesthesia by non-board certified surgeons in non-accredited ORs makes for better outcomes with less trauma to the patient.

 I threatened to go ad infinitum, but I think I made my point.