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Do I need general anesthesia for my tummy tuck surgery?

Posted October 10, 2017 in Tummy Tuck (Abdominoplasty)

If you are considering a tummy tuck surgery and consult with more than one surgeon, you will likely get differing opinions about what type of anesthesia should be used. Do you need to have a general anesthetic and should the procedure be completed in the hospital setting? Or, is it better to use a deep sedation or even a conscious sedation anesthesia? Do you need an anesthesiologist or are certified nurse anesthetists (cRNAs) safe? The answers to these questions are not always clear and certainly can be debated. Here are my thoughts.

Anesthesiologist or nurse anesthetist?

If you talk to a surgeon who routinely uses an anesthesiologist for his/her procedures, you might be told that only an anesthesiologist has the training and knowledge to keep you safe during a tummy tuck. After all, do you really want to take your chances on having a complication by using an anesthesia provider who has less than the maximum amount of schooling and training? You might also be told that there just isn’t any reason to “scrimp” on your safety by trying to save a few dollars by using a nurse anesthetist.

Such statements seem convincing at first, but do they have merit? I can tell you that these statements were given to me as “selling points” by an anesthesiologist group that wanted me to use their services for my surgeries. They told me that even though they charged more for their services, I would more than make up for the extra costs by being able to “sell” the idea that I was providing a safer and more complete service. I could even charge my patients more for the surgeries because I would be easily able to convince them that they were getting a better product.

As a board certified surgeon, I certainly do not want to offer anything less than the best service possible to my patients and I certainly do not want to do anything that would compromise their safety. So I did some research to find the facts. And the facts are that there aren’t many clear facts. In all of my research, I have been unable to find a convincing study that proves that anesthesiologists are safer or provide better anesthesia than cRNAs for outpatient plastic surgery procedures including tummy tucks. Nor could I find studies that prove that cRNAs are better or safer.

There are two facts of which I am certain. One is that there are really good anesthesiologists and there are really good cRNAs. And two is that there are also really marginal anesthesiologists and equally marginal cRNAs. There are anesthesiologists that work almost exclusively in the hospital system and almost always use a general anesthetic. I would not feel very uncomfortable with such a person providing a deep anesthesia for a tummy tuck procedure because they just don’t do it all the time. There are cRNAs that spend almost all of their time providing deep sedation anesthesia in the outpatient setting that I would feel very uncomfortable giving general anesthesia for an open heart surgery because they just don’t do it all of the time. I would never want to minimize the importance of schooling and training, but like many things, schooling and training become less important the farther one gets into their career. At some point in time, it is the daily routine and knowledge gained from hands on experience that really matter most.

So anesthesiologist or cRNA? The answer could be either. I would choose the one that is the best at what they do. And the one that is the safest and most conscientious. I would choose the one that is the most caring and detail-oriented. And the fact is that such a person could either be an anesthesiologist or a cRNA. If you ask me, I would choose either of my two nurse anesthetists because I know their skill set, their attention to detail, their insistence on safety and protocol, and their track record of over 9 years of zero anesthesia complications while working in my operating room.

Is general anesthesia needed?

Just as there are myths spread about differing anesthesia providers, there are also untruths commonly discussed about the type of anesthesia needed to perform a world class tummy tuck surgery. I have often heard that general anesthesia is preferred or even required to complete an effective tummy tuck. Such statements are, of course, mostly made by surgeons who routinely use general anesthesia for their procedures. The basis for their assumption typically references one of the following ideas.

  1. Effective tightening of the abdominal muscles during the rectus plication requires relaxation of the muscles that can only be achieved with a general anesthetic.
  2. If muscles are tightened or plicated without general anesthesia, the post operative discomfort will be worse than necessary.
  3. Deep sedation anesthesia for tummy tuck surgery is too much of an airway risk.

If I were a patient and was told any or all of these statements by a surgeon, I would be rather easily convinced that I needed a general anesthetic. And if any of the above statements were true all of the time, I would agree that general anesthesia would be preferable. But there is little, if any, evidence that these statements are always, if ever, true.

I have been using deep sedation or MAC anesthesia for tummy tuck surgery for 15 years. I purchased a general anesthesia ventilator during my first year in practice because I thought I might need it for tummy tuck surgery, but ended up giving it to a medical team in Africa several years ago because I never used it. The reason I never used it was because I was able to develop a technique for muscle tightening in which the sutures could be placed during a patients natural exhalation with deep sedation that did not compromise how tightly the muscles could be approximated. This technique allows for very effective muscle tightening without unnecessary tension on any individual suture and it does not result in unnecessary post operative discomfort. My patients, almost across the board, report that their post operative discomfort is less than expected even without the need for long acting local anesthetics such as Exparel. And I can report that in my 9 years of private practice doing more than 50 tummy tucks per year, I have never had an airway compromise during a tummy tuck surgery. The above statements simply are not true for all surgeons and certainly do not apply to my practice.

Why could deep sedation be preferable?

There are many surgeons that perform tummy tucks using general anesthesia and many that use deep sedation. I would argue that the type of anesthesia does not affect the end result of the surgery in any measurable way. Many surgeons that use general anesthesia have before and after photos with great results and surgeons that use deep sedation do as well. So why would deep sedation be preferable if the end result is likely the same?

  1. If an endotracheal tube is not placed, the risk for sore throats is minimized or eliminated.
  2. If a laryngoscope is not used, the chances of a chipped tooth or injury to the mouth is eliminated.
  3. The risk of post operative nausea and vomiting has been shown to be significantly less with propofol than with general anesthetic medications including nitrous oxide.
  4. The speed of recovery from anesthesia is significantly faster with deep sedation anesthesia than with general anesthesia.
  5. The risk of blood clots (DVTs) and pulmonary compromise (PE) and death has been shown to be lower with spinal and epidural anesthesia when compared with general anesthesia. Deep sedation anesthesia is also thought to have this lower risk when compared with general anesthesia.

For these reasons, I have exclusively used deep sedation anesthesia for my tummy tuck patients. I strongly feel that I am doing so because it is the safest and most patient friendly method of anesthesia for tummy tuck surgery when given by skilled anesthesia providers.