I received a phone call from a plastic surgery colleague and friend in Los Angeles today who had just done a breast augmentation. We often talk about interesting cases, and this phone call was no different. He described a patient who had a routine periareaolar breast augmentation that developed weakness in her arm after surgery. This is certainly uncommon, but it has been described in the literature. During breast augmentation surgery, often the patient is positioned with arms out-stretched. After the insertion of the breast implant, the operating room table is typically elevated to sit the patient upright. It is critical that the patient be situated properly and secured during this step. The patient and table positioning is controlled mainly by the anesthesiologist. If positioning is mishandled, traction can be placed on the nerves that run down the arm in the brachial plexus. This set of nerves starts in the neck. With too much traction related to poor positioning, nerve injury can result. Almost always the nerve function returns to normal. However, it is scary for both the doctor and patient to follow the progress of this unfortunate event. In this particular scenario that my friend described to me, there was no anesthesiologist. Wait, you say! How can that be? How can there be NO anesthesiologist with a patient under general anesthesia. Well, many centers cut costs by hiring nurse anesthetists which under California aw can provide general anesthesia with supervision of a doctor. In this case? The doctor is a plastic surgeon. Many patients do not know this, nor do they even think to ask about the qualifications of the person putting them to sleep. EVERY patient that signs with me gets a phone call the night before from my anesthesiologist. I do not use nurse anesthetists, not because they are not qualified – many are very qualified to control anesthesia during surgery! However, anesthesiologists as doctors have far more training and are more equipped to diagnose and manage the more unusual (and sometimes more serious) issues that may arise during surgery, like subtle heart monitor changes, peek airway pressure or ventilator changes, complex positioning with proper padding to elbows, and odd drug reactions (malignant hyperthermia which is rapidly deadly). To me, that is more important than cutting costs. So, while choosing a plastic surgeon to do your surgery is important, never overlook the credentials and qualifications of the person putting you to sleep and reading your heart monitor throughout your surgery. I will only operate with an anesthesiologist, and only with an anesthesiologist that I would trust with my own life. My anesthesiologists of choice are Board Certified Michael Simon-Baker and Dean Allgeyer. I’d put my life in their hands. That’s the type of confidence you should have with the team you choose. Be sure to ask to speak with your anesthesiologist (or nurse anesthetist if the center and plastic surgeon you have chosen operate with one) at least a day before surgery. You MUST be comfortable with your team. Indeed, your life is in their hands.
by Dr. Tim Neavin