Awake Surgeries: What To Know About Not Going Under

As the plastic surgery and aesthetic procedure industry continues to grow, so, too, does the demand for solutions that keep it as safe, simple, and affordable without sacrificing results. And many are answering the call with so-called ‘awake’ surgeries. Performed under local or regional anesthesia and often in combination with oral or IV sedation, awake procedures are a way to avoid pain and discomfort without general anesthesia.

Some critics say providers are simply using the option in an attempt to bypass the role of the anesthesiologist for convenience’s sake, but the board certified plastic surgeons who offer such procedures see benefits that make it feel like the best option in some cases. Below, the basics of what you need to know about awake surgeries.

What Is ‘Awake’ Surgery?

While general anesthesia renders a patient fully unconscious, ‘awake’ options leave the patient, well, awake. But that doesn’t mean they are aware. Some procedures can be done with just local anesthesia (often lidocaine or a tumescent solution containing lidocaine, saline, and epinephrine) to numb the area being worked on. But many also involve twilight or IV sedation, which, as Julius Few, MD, the board certified plastic surgeon behind The Few Institute in Chicago, explains, brings on a state in which “the patient is able to breath on their own for a comfortable, non-memorable surgical experience.”

And Dr. Few should know — not only does he offer awake procedures, but he also authored the first peer-reviewed, large study on facial cosmetic surgery under local anesthesia with oral sedation in a fully accredited surgery center. “The procedures performed included facelift, blepharoplasty, and even tip rhinoplasty,” he says. The results showed the option to be safe.

Why Stay Awake?

There are a few major reasons a patient may prefer the ‘awake’ route. The first is to simply to mitigate any fear that arises about the concept of going under. After all, there are complications associated with general anesthesia that run the gamut from nausea to (very rarely) death. And then there are certain conditions that may make going ‘awake’ the better option for your health. “Risk factors for general include allergies to anesthesia, diabetes, heart disease, high blood pressure, kidney problems, lung conditions, and obesity,” Dr. Few notes.

But it’s not as if one type of anesthesia carries potential side effects while the other does not. While local anesthesia is generally considered to have lower risk of complication, “[it] needs to be managed very carefully, as there could be toxic side effects of overuse,” explains Kevin Tehrani, MD, a double board certified plastic surgeon of Aristocrat Plastic Surgery in New York City. He does, however, see a psychological upside for some patients. For those more anxious about the outcome of their surgery, “the biggest benefit is one’s perception of not giving up control,” he says.

In some cases, surgeons actually feel the awake patients leads to better results. Thomas Su, MD, founder of Art Lipo Arm Liposuction & Plastic Surgery Center in Tampa, FL, exclusively offers what he calls “interactive lipo.” “I actually stand my patients up after completing part of the surgery to check my results because gravity and laying on the table distorts what you can see,” he shares. His method of awake surgery skips sedation via Valium or Xanax so his patients can, as he explains, “move in different positions and also hold their muscles tight and firm.” This allows for “much better control during the sculpting,” he adds.

Dr. Tehrani sees similar benefits. “[For] more limited areas like arms or buttock liposuction, I prefer [operating] under local anesthesia, as I like to have the patients actually activate their muscles so I can sculpt around it,” he says.

And then there’s the cost savings. If you opt for local anesthesia alone, it’s cheaper, as it doesn’t require the presence of an anesthesiologist. In some cases, the same is true of twilight sedation. Dr. Few understands this can be an alluring benefit for patients, but he warns to not make cost a primary deciding factor. “Bottom line, I will never put financial consideration ahead of patient safety or comfort,” he emphasizes. “If general anesthesia is needed, it is needed.”

What Procedures Can Be Performed Awake?

The treatments doctors offer as awake surgeries vary, however, they tend to be in finite areas. “In general, smaller areas are preferred under local anesthesia, so that the extent of anesthetic given does not get to a toxic level,” Dr. Tehrani says. Common examples include:

• Awake facelift
• Awake blepharoplasty
• Awake liposuction (neck, arms, buttocks)

Some research shows that breast surgery can also be safely performed under tumescent anesthesia as well. To mitigate risk as much as possible at his own practice, “general anesthesia is reserved for more aggressive surgical cases that involve complex or multiple treatment areas,” Dr. Few says. That includes full body liposuction, mommy makeovers, and body lifts. “These kinds of surgical procedures require significant commitment overall,” he adds.

What to Expect From Awake Surgeries

Though the area is numbed, there may be some level of pain involved with awake procedures. It is similar to what you might feel at the dentist. Here’s how Dr. Su breaks down the experience of his awake, local-only liposuction treatments: “During the procedure, there is some stingingness and weird movement sensations while the local anesthetic is being dispersed in the fat layer.” Once the fat layer is numb, he says there may be “occasional stings” during the liposuction step, but it is generally “pretty tolerable.” Additional lidocaine may be able to be administered, but it’s rarely necessary. “Fortunately, the instances where patients really don't tolerate this well is fairly infrequent,” he shares.

After surgery, he says, “the local anesthetic provides a more comfortable gradual tapering off of anesthetic compared to general, which wears off very quickly and leaves patients needing pain medication immediately.” For those who combine local anesthesia with IV or oral sedation, you’ll be awake but, well, out of it. When administered correctly, the patient comes away with no memory of their procedure.

Are You a Candidate for Awake Surgery?

Ultimately, the type of anesthesia you receive comes down to what you and your surgeon think is best. If your doc provides a local option for the procedure you’re having done, a few questions should help him or her determine if you might be a candidate. The first often goes back to that dental analogy. “Typically, I ask about their dental anesthetic experience in the past and whether or not that’s been something that he or she has tolerated well,” Dr. Tehrani says. That will give you some indication of whether you might experience discomfort.

Dr. Su also makes sure to get a feel for how skittish a patient is. “If there is a downside to awake liposuction, it is that the occasional very nervous or anxious patient may have a more difficult time during the surgery,” he cautions. “If someone thinks that they are too scared, they have a choice and may be better off being put to sleep.” Beyond that, “the requirements to safely do liposuction awake are not much different than doing any other plastic surgery,” he says.

How to Find a Provider

The first rule of plastic surgery is to look for a board certified provider who offers both general and local anesthesia. That way, you can be sure you’ll have access to what’s best for your needs. Beyond that, do your research. “There are reports of bad experiences with all surgeries whether awake or asleep,” Dr. Su says. His advice: Ask to see lots of before and after images. “The more results and the better the quality of photos, the more believable,” he shares. “And videos of live patients with their actual results is even more impressive and indisputable.”