Is "awake" plastic surgery right for you?

Have you ever heard of "awake" plastic surgery? It's a valuable alternative to the traditional approach, where you're under general anesthesia. This method allows you to stay conscious during the procedure, offering a different experience altogether.

We talked to ASPS Member Surgeons Michael Hakimi, MD, FACS, and Sara Dickie, MD, to explore what awake plastic surgery involves, its benefits and drawbacks and who might be an ideal candidate.

Understanding awake plastic surgery

Awake plastic surgery refers to procedures performed with the patient fully conscious but sedated. The plastic surgeon or their medical staff will administer local anesthesia and sedatives, keeping the surgical area numb while allowing patients to remain awake and aware. An anesthesiologist may or may not be present.

"They're very sedated and comfortable, but they're awake enough that if I call their name to move around, they can help me and they can converse," said Dr. Hakimi.

Some minor procedures, such as blepharoplasty (eyelid surgery), liposuction and fat transfer, can be performed with local anesthesia and oral sedation, and the patient remains awake but relaxed.

How general anesthesia works

General anesthesia is the most common form of sedation in plastic surgery. It renders the patient completely unconscious and requires intubation with a machine to help them breathe.

"Your anesthesiologist is present," said Dr. Hakimi. "They monitor your vital signs and your blood pressure. The anesthesiologist is able to adjust your blood pressure, if need be, by giving you medication, etc."

Most plastic surgeries, especially extensive procedures, typically require general anesthesia to ensure the patient is comfortable and motionless and that their pain is controlled.

The benefits of awake plastic surgery

General anesthesia comes with a set of risks and side effects, such as nausea and vomiting. What about death? It's a risk. In contrast, awake plastic surgery minimizes these risks.

• Patients avoid the groggy, disoriented feeling that often accompanies recovery from general anesthesia.
• Awake plastic surgery reduces the risks associated with general anesthesia, such as respiratory complications and adverse reactions.
• Patients typically experience a quicker recovery time since they avoid the side effects of general anesthesia.
• It can be more cost-effective as it eliminates the need for anesthesiologists and specialized equipment.

Plus, patients can communicate with the surgical team during the procedure, providing real-time feedback, which can be useful in surgeries where aesthetic outcomes are crucial.

"In some instances, an awake patient can help provide feedback to the surgeon to ensure optimal results, such as in some types of eyelid surgery or hand surgery," said Dr. Dickie.

An option for high BMI patients

Patients with a high body mass index (BMI) often face additional risks under general anesthesia, and it can tax their cardiovascular and respiratory systems. Awake plastic surgery can be a safer alternative for these patients, as it circumvents many of these risks.

"It is a safety valve for me for higher BMI patients that I can serve," said Dr. Hakimi. "If I can do surgery without general anesthesia, I pretty much minimize the risk to these individuals' health."

According to Dr. Hakimi, he has served many high BMI patients who want chin liposuction with awake anesthesia.

A niche within plastic surgery

The norm in plastic surgery is general anesthesia; not all surgeons offer awake procedures. Hakimi said many people seek out his practice because he is known for offering awake plastic surgery for several procedures, including Brazilian butt lifts (BBLs).

He said there are advantages to performing BBLs on patients who can move and talk to him during the operation. One of the reasons BBLs are known to be risky is that the surgeon might go too deep and accidentally inject fat into the muscle, causing a fat embolism that can enter the bloodstream and travel to the lungs, heart or brain and be fatal.

"To me, the beauty of doing BBL under local anesthesia is that I'm not able to numb the muscle," said Dr. Hakimi. "So, if my cannula goes slightly deep and even scrapes the surface of the muscle, number one, I get a huge twitch from the muscle. But also, the patient is going to very well let me know by saying ouch or moving their leg that, hey, I felt that one."

Who is not a good candidate?

Despite its benefits, being conscious during surgery might cause anxiety or discomfort for some patients, even with sedation. 

"Patients with higher levels of anxiety or fear of needles may have difficulty tolerating awake anesthesia since they are fully aware of the surgery taking place," said Dr. Dickie.

She said plastic surgeons can make efforts to reduce sensory input, such as playing soothing music, covering the eyes and giving patients earplugs. However, this may not be enough for some people.

"Patients can still feel pressure, movement or vibrations in areas where they are not numb or may hear the sounds of surgical instruments and other noises which can be disconcerting," said Dr. Dickie.

Dr. Hakimi said patients who take any anxiety medication regularly are probably not the best candidates for awake plastic surgery.

"The amount of medication that they're going to need to go through this procedure comfortably is going to be much more than many surgeons at the beginning of their career might feel comfortable doing," said Dr. Hakimi.

Surgeon's perspective: Benefits and challenges

From the surgeon's perspective, awake plastic surgery has benefits and risks. Surgeons can get immediate feedback from the patient, allowing for adjustments during the procedure, but awake surgery can take more time overall compared to general anesthesia. Plus, the surgeon must manage the patient's experience, adding more complexity to their work.

"An awake patient is also a member of the operative team in as much as the conversations taking place or the choice of music or operative ambiance needs to respect the patient's experience as much as the surgeons," said Dr. Dickie.

Also, not every plastic surgery procedure can be done with awake anesthesia. General anesthesia will be the only option for many procedures.

Is awake surgery an option for you?

Awake plastic surgery offers a compelling alternative to traditional methods, particularly for those seeking reduced risks and quicker recovery times. However, it's essential to weigh the benefits and drawbacks carefully and consult a qualified surgeon to determine the best approach for your needs.

When considering awake plastic surgery, choosing a board-certified plastic surgeon who is an ASPS member is crucial. These professionals have undergone rigorous training and adhere to high standards of practice, ensuring you receive the safest and most effective care possible.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.