COSMETIC SURGERY ANAESTHESIA FREQUENTLY ASKED QUESTIONS
Dr. Philippe Chout reviews the different anaesthesia techniques.
Dr. Philippe Chout and the team of Anaesthesiologist's information form is based on the Royal College of Anaesthesiologist recommendations.
The word ‘anaesthesia’ means ‘loss of sensation’ or 'numbness'. If you have ever had a dental injection in your mouth or pain-killing drops put in your eyes, you already know important things about anaesthesia. The anaesthesia may be general, local , or betwween these being sedation or epidural block.
It stops you feeling pain and other sensations. It can be given in various ways. Not all anaesthesia makes you unconscious. It can be directed to different parts of the body.
Drugs that cause anaesthesia work by blocking the signals that pass along your nerves to your brain. When the drugs wear off, you start to feel normal sensations again, including pain.
The different types of anaesthesia, local , general , sedation or block
Purely local anaesthesia
A local anaesthetic numbs a small part of your body. It is used when the nerves can easily be reached by drops, sprays, ointments or injections of lignocaine or equivalent drugs. You stay conscious but free from pain once the liquid is injected. You may feel when it is injected but after that for an hour you don’t feel the area involved.
Regional anaesthesia can be used for operations on larger or deeper parts of the body. Local anaesthetic drugs are injected near to the bundles of nerves which carry signals from that area of the body to the brain.
The most common regional anaesthetics (also known as regional ‘blocks’) are spinal and epidural anaesthetics. These can be used for operations on the lower body such as Caesarean sections, bladder operations or replacing a hip joint. You stay conscious but free from pain. The level of consciousness can be reduced by sedation if you wish.
General anaesthesia is a state of controlled unconsciousness during which you feel nothing and may be described as ‘anaesthetised’. This is essential for some operations and may be used as an alternative to regional anaesthesia for others.
Anaesthetic drugs injected into a vein, or anaesthetic gases breathed into the lungs, are carried to the brain by the blood. They stop the brain recognising messages coming from the nerves in the body.
Anaesthetic unconsciousness is different from unconsciousness due to disease or injury and is different from sleep. As the anaesthetic drugs wear off, your consciousness starts to return.
Sedation is the use of small amounts of anaesthetic or similar drugs to produce a ‘sleepy-like’ state, like midazolam. It makes you physically and mentally relaxed during an investigation or procedure which may be unpleasant or painful (such as an endoscopy). You may remember vaguely a little about what happened, or most often you may remember nothing at all. If you are having a regional or local anaesthetic, you may want to ask for some sedation as well.
Many cosmetic surgery procedures can be done without a general anaesthetic, under a sedation, such as mini facelift, model temporal lift, upper blepharoplasty to the upper eyelids, ear pinning back, nose alar base reduction, liposuction to one or two small areas…
The Anaesthetist or anaesthesiologist
Anaesthetists are doctors who have had specialist training in anaesthesia, in the treatment of pain, in the care of very ill patients (intensive care), and in emergency care (resuscitation). They will make major decisions with you, although if you are unconscious or very ill, they will make decisions on your behalf.
Your anaesthetist is responsible for:
• All medical aspects that are not related to the operated area and the surgery itself
• your wellbeing and safety throughout your surgery
• agreeing a plan with you for your anaesthetic, giving your anaesthetic
• planning your pain control with you
BEFORE YOU COME TO THE HOSPITAL
Here are some things that you can do to prepare yourself for your operation and reduce the likelihood of difficulties with the anaesthetic.
• If you smoke, you should consider giving up for several weeks before the operation. The longer you can give up beforehand, the better. Smoking reduces the amount of oxygen in your blood and increases the risk of breathing problems during and after an operation. If you cannot stop smoking completely, cutting down will help.
• If you are very overweight, many of the risks of having an anaesthetic are increased. Reducing your weight will help. Your GP or practice nurse will be able to give you advice about this.
• If you have loose or broken teeth, or crowns that are not secure, you may want to visit your dentist for treatment. The anaesthetist may need to put a tube in your throat to help you breathe, and if your teeth are not secure, they may be damaged.
• If you have a long-term medical problem such as diabetes, asthma or bronchitis, thyroid problems, heart problems or high blood pressure (hypertension), you should ask your GP if you need a check-up.
• Health check before your anaesthetic
Before your anaesthetic we need to know about your general health. You may be asked to go to a pre-assessment clinic or you may be asked to fill in a questionnaire. Sometimes the health check happens on the ward after you are admitted to hospital.
You may be asked about:
• your general health and fitness
• any serious illnesses you have had
• any problems with previous anaesthetics
• family members who have had problems with anaesthetics
• any pains in your chest
• any shortness of breath
• any heartburn
• any pains you have which would make lying in one position uncomfortable
• any medicines you are taking, including herbal remedies and supplements you may been prescribed or may have bought
• any allergies you have
• any loose teeth, caps, crowns or bridges
• whether you smoked
• whether you drink alcohol
• whether you use recreational drugs (drugs that are not prescribed to you or bought over the counter).
Nurses usually run this clinic. There may be a surgical team, doctor and sometimes an anaesthetist available for advice. If you need blood tests, an ECG (electro-cardiogram or heart tracing) an X-ray or other tests, these will be arranged. Some tests can be done in the clinic, for others you may need to come back another day. This is a good time to ask questions and talk about any worries you may have. If you want to talk to an anaesthetist, you should ask for this to be arranged.
Pills, medicines, herbal remedies and allergies
• If you are taking any pills, medicines, herbal remedies or supplements, it is important to bring these with you.
A written list of everything you are taking, whether they have been prescribed or whether you have bought them over the counter, would be helpful for your anaesthetist.
• If you have any allergies, a note of these will also be helpful.
Why does the anaesthetist may postpone or sometimes cancel some operations?
Occasionally, your anaesthetist might find something about your general health that could increase the risks of your anaesthetic or operation. It might then be better to delay your operation until the problem has been reviewed or treated. The reasons for any delay would always be discussed with you at the time. Your anaesthetist’s main concern is your safety.
ON THE DAY OF YOUR OPERATION
Nothing to eat or drink – fasting (‘Nil by mouth’)
The hospital should give you clear instructions about fasting. It is important to follow these. If there is any food or liquid in your stomach during your anaesthetic, it could come up into the back of your throat and then go into your lungs. This would cause choking, or serious damage to your lungs.
Your normal medicines
You should continue to take your normal medicines up to and including the day of surgery, unless your anaesthetist or surgeon has asked you not to. However, there are exceptions. For example, if you take drugs to thin your blood (such as warfarin, aspirin or clopidogrel), drugs for diabetes or herbal remedies, you will need specific instructions. If you are not sure, your anaesthetist or surgeon will advise you.
Premedication (a ‘pre-med’) is the name for drugs which are given before some anaesthetics. These days they are not used very often, but if you feel a pre-med would help you, you can ask your anaesthetist about having one.
Most are tablets or liquid that you swallow, but you may need an injection, a suppository (see page 29) or an inhaler. They can:
• reduce or relieve anxiety
• help to prevent sickness after the operation
• treat any health problems you may have
• help with pain relief after your operation.
They may make you more drowsy after the operation. If you want to go home on the same day, this may be delayed.
Needles and local anaesthetic cream
A needle may be used to start your anaesthetic. If this worries you, you can ask to have a local anaesthetic cream put on your arm to numb the skin before you leave the ward. The ward nurses should be able to do this.
Getting ready for ‘theatre’
• A bath or shower before your operation will clean your skin and reduce the risk of infection. You must avoid using make-up, body lotions or creams as they prevent heart monitor pads and dressings from sticking to your skin properly.
• You will be given a hospital gown to put on. You may like to wear your own dressing gown over this.
• You can keep your pants on as long as they will not get in the way of the operation. Sometimes, you may be given paper pants.
• Please remove nail varnish and ask for advice about false nails. These can interfere with oxygen monitoring.
• You wont wear your glasses, hearing aids and dentures to go to the operating theatre. If you are having a general anaesthetic, you will probably need to remove them in the anaesthetic room to make sure they are not damaged or dislodged while you are anaesthetised. They will be returned to you as soon as you want them. If you are not having a general anaesthetic, you can keep them in place.
• Jewellery and decorative piercings should ideally be removed. Bare metal against your skin could get snagged as you are moved. If you cannot remove your jewellery, it will need to be covered with tape to prevent damage to it or to your skin.
• If you are having a local or regional anaesthetic block, you can take a personal tape, CD or MP3 player with you to listen to music through your headphones.
• When you are called for your operation When it is time for your operation, a member of staff will go with you to the theatre.
• Most people go to theatre on a bed or trolley. You may be able to choose to walk but this will depend on your general health, whether you have had a pre-med and how far the theatre is from your ward. If you are walking, you will need your dressing gown and slippers.
The operating department (‘theatres’) and anesthetic room
The operating department includes a reception or waiting area, anaesthetic rooms, operating theatres and a recovery room. It looks and feels quite different from other hospital departments – more cold and clinical. Operating theatres are brightly lit and may have no natural light. The theatres may also be quite cool. As it is important for you to keep warm, a blanket will help if you feel cold.
You will then be taken into the anaesthetic room or, sometimes, into the operating theatre. Several people will be there, including your anaesthetist and the anaesthetic assistant.
To monitor you during your operation, your anaesthetist will attach you to machines to watch:
• your heart: sticky patches will be placed on your chest (electrocardiogram or ECG)
• your blood pressure: a blood-pressure cuff will be placed on your arm
• the oxygen level in your blood: a clip will be placed on your finger (pulse oximeter).
Setting up your cannula
Your anaesthetist may need to give you drugs into a vein. A small needle will be used to put a thin plastic tube (a ‘cannula’) into a vein in the back of your hand or arm. This is taped down to stop it slipping out. Sometimes, it can take more than one attempt to insert the cannula. You may be able to choose where your cannula is placed.
If you have not been able to drink for many hours before your operation, or you have lost fluids from being sick, you may have become dehydrated. Bags of sterile water with added salt or sugar can be given through a drip into your cannula to keep the right level of fluids in your body.
Local anaesthetics are injected close to the area of your operation. They can also be used to numb the skin before anything sharp is inserted, such as a cannula for a drip.
In the operating theatre: local or regional anaesthetics
This is often a busy place, with staff bustling to get ready for your surgery and noises echoing around. Music may be playing. You may be moved across from your trolley onto the operating table. Monitoring equipment will be reconnected, bleeps will start indicating your pulse and a cuff will inflate on your arm to take your blood pressure regularly.
A cloth screen is used to shield the operating site, so you will not see the operation unless you want to. Your anaesthetist is always near to you and you can speak to him or her at any time.
You can listen to your own music or ask for none at all.
Starting a general anaesthetic (induction)
Induction usually takes place in the anaesthetic room, although you may go direct to the operating theatre. If you have had premedication to help you relax, you may not remember this later.
There are two ways of starting a general anaesthetic.
• anaesthetic drugs may be given through the cannula (this is generally used for adults); or
• you can breathe anaesthetic gases and oxygen through a mask, which you may hold if you prefer.
Induction happens very quickly, and you will become unconscious within a minute or so. People usually describe a swimmy, light-headed feeling.
Once you are unconscious, your anaesthetist will continue to give drugs into your vein or anaesthetic gases to breathe (or both) to keep you anaesthetised.
In the operating theatre: general anaesthetics
When your anaesthetist is satisfied that your condition is stable, the monitors will be temporarily disconnected and you will be taken into the theatre. He or she will stay with you and will be constantly aware of your condition, checking the monitors, adjusting the anaesthetic and giving you any fluids or drugs that you need.
These are some of the drugs you may be given during your anaesthetic:
• anaesthetic drugs to keep you anaesthetised
• pain-relieving drugs to keep you pain-free during and after your operation
• muscle relaxants to relax or temporarily paralyse the muscles of your body
• antibiotics to guard against infection
• anti-sickness drugs to stop you feeling sick
• other drugs depending on your condition as it changes.
Your anaesthetist will choose a way of making sure that you can breathe easily. He or she may do this by simply tilting your head back and lifting your chin. You may have a tube placed in your airway. Keeping your airway open is essential for your safety.
For some operations, muscle relaxants, which will stop you breathing, are necessary. Your anaesthetist will use a machine (a ventilator) to ‘breathe’ for you.
At the end of the operation, your anaesthetist will stop giving anaesthetic drugs. If muscle relaxants have been used, a drug that reverses their effect will be given. When your anaesthetist is sure that you are recovering normally, you will be taken to the recovery room. Patients do stay usually in the recovery room one to two hours.
After a general anaesthetic
Most people regain consciousness in the recovery room. Recovery staff will be with you at all times and will continue to monitor your blood pressure, oxygen levels and pulse rate.
• You may receive pain-relieving drugs before you regain consciousness, but if you are in pain, tell the staff so they can give you more.
• Oxygen will be given through a lightweight clear-plastic mask, which covers your mouth and nose. Breathing oxygen keeps up its levels in your blood while the anaesthetic wears off. The staff will remove your mask as soon as these levels are maintained without oxygen.
• If you feel sick, you may be given drugs which will help this.
• Depending on the operation you have had, you may have a urine catheter. This is a thin soft tube put temporarily into the bladder to drain it.
• When you are fully alert, dentures, hearing aids and glasses can be returned to you.
• You may shiver after your operation. If you are cold you will be warmed with a warming blanket.
After the operation
Back to the ward
When he recovery staff is totally satisfied that you have safely recovered from your anaesthetic, and all your observations (such as blood pressure and pulse) are stable before you are taken back to the ward. The operation will affect how long it will be before you can drink or eat. After minor surgery, this may be as soon as you feel ready. Even after quite major surgery you may feel like sitting up and having something to eat or drink within an hour of regaining consciousness.
What will I feel like afterwards?
Most patient feel absolutely fine after the operation. How you feel will depend on the type of anaesthetic and operation you have had, how much pain-relieving medicine you need and your general health. However, you may rarely suffer from side effects of some sort. You may feel sick, dizzy or shivery, or have general aches and pains. Some people have during a few hours at blurred vision, drowsiness, a sore throat, a headache and breathing difficulties. You may have fewer of these side effects after a local or regional anaesthetic block. Until the block wears off, you will usually feel fine. However, when it has worn off, you may need pain-relieving medicines and you may then suffer from their side effects.
You may need to ask for help:
• when you first get out of bed
(although you may feel fine lying in the bed, you may feel faint or sick when you first get up)
Good pain relief is important. It prevents suffering and it helps you recover more quickly. Your anaesthetist will probably discuss different pain-relief methods with you before your surgery so you can make an informed decision about which you would prefer.
• Some people need more pain relief than others. Feeling anxious increases the pain people feel.
• Pain relief can be increased, given more often, or given in different combinations.
• Occasionally, pain is a warning sign that all is not well, so the nursing staff should be told about it.
Good pain relief helps prevent complications
• If you can breathe deeply and cough easily after your operation, you are less likely to develop a chest infection.
• If you can move around freely, you are less likely to get blood clots (deep-vein thrombosis or DVT).
It is much easier to relieve pain if it is dealt with before it gets bad. So, you should ask for help as soon as you feel pain and continue the treatment regularly.
Drugs you may receive
Opiates are the drugs often used for severe pain. They include morphine, diamorphine, codeine and pethidine. They may be given by tablets, injections or patient-controlled analgesia. They may also be added to a spinal or epidural to give longer and better pain relief.
Some people have side effects – the most common include feeling sick, vomiting, itching, constipation, and drowsiness. Larger doses can produce breathing problems and low blood pressure (hypotension). The nursing staff will watch you closely for these. These side effects can be treated with other drugs. Your reaction to opiates will affect you considerably. One in three people finds opiates unpleasant. If they make you very sick, controlling your pain may be more difficult.
Constipation can be a problem. Your nurses and doctors will check on this and treatment can help.
Drugs such as diclofenac or ibuprofen may be given during an anaesthetic, as a suppository or afterwards as tablets. They must be used carefully by people with asthma, kidney disease, heartburn or stomach ulcers. You may also be given paracetamol.
What will I feel like later?
You may feel very well especially for cosmetic surgery where anaesthesia and surgery are less invasive. For proper major surgery you may feel tired or even exhausted after the operation – sometimes for days. This is unlikely to be caused by the anaesthetic. Tiredness may be caused by many things, including:
• worry before the operation
• not sleeping properly before or after the operation
• pain or discomfort before or after the operation
• loss of blood (causing postoperative anaemia)
• the condition that needed surgery
• not eating or drinking normally before and after your operation
• the energy used up by the healing process
• your general health.
The risks, side effects and complication to you as an individual will depend on:
• whether you have any other illness
• personal factors, such as whether you smoke or are overweight
• surgery which is complicated, long or done in an emergency.
Everyone varies in the risks they are willing to take. Anaesthetists and patients may also hold different views about the importance of risk.
To understand a risk, you must know:
• how likely it is to happen
• how serious it could be
• how it can be treated.
SIDE EFFECTS AND POSSIBLE COMPLICATIONS OF ANAESTHESIA
Side effects are secondary effects of drugs or treatment. They can most often be anticipated but are sometimes unavoidable. Almost all treatments (including drugs) have side effects of some kind in some patients. Unpleasant side effects do not usually last long. Some are best left to wear off and others can be treated. Examples would be a sore throat or sickness after a general anaesthetic.
Complications are unexpected and unwanted events due to a treatment. Examples would be an unexpected allergy to a drug or damage to your teeth caused by difficulty in placing a breathing tube.The risk of something happening to one in 10 people means that, it will not happen to nine out of 10 people.If something is very common, this means that about one in 10 will experience it.
Common means about one in 100. Uncommon means about one in 1000.
Rare means about one in 10,000. Very rare means about one in 100,000.
COMMON SIDE EFFECTS OR MILD COMPLICATIONS ARE NOT COMPULSORY !
Most people do not have side effects at all for an average length general anaesthesia .
Feeling sick and vomiting after surgery**
Some operations, anaesthetics and pain-relieving drugs are more likely to cause sickness (nausea) than others. Sickness can be treated with anti-vomiting drugs (anti-emetics), but it may last from a few hours to several days.
If you have had a tube in your airway to help you breathe, it may give you a sore throat. The discomfort or pain lasts from a few hours to days and can be treated with pain-relieving drugs.
Dizziness and feeling faint
Your anaesthetic may lower your blood pressure and make you feel faint. This may also be caused by dehydration (when you have not been able to drink enough fluids). Fluids or drugs (or both) will be given into your drip to treat this.
You may shiver if you get cold during your operation. Care is taken to keep you warm during your operation and to warm you afterwards. A hot-air blanket may be used. However, shivering can happen even when you are not cold, due to the effects of anaesthetic drugs.
There are many causes of headaches, including the anaesthetic, the operation, dehydration and feeling anxious. Most headaches get better within a few hours and can be treated with pain-relieving medicines. Severe headaches can happen after a spinal or epidural anaesthetic (see the leaflet about this listed on the inside front cover of this booklet). If this happens to you, your nurses should ask the anaesthetist to come and see you. You may need special treatment to cure your headache.
This is a side effect of opiates (such as morphine), but can be caused by an allergy (for example, to drugs, sterilising fluids, stitches or dressings). If you have itchiness, it can be treated with other drugs.
Aches, pains and backache
During your operation you may lie in the same position on a firm operating table for a long time. Great care is taken to position you, but some people still feel uncomfortable afterwards when the operation has been very long (more than four hours).
Bruising and soreness
This may be caused around injection and drip sites by a thin vein bursting, movement of a nearby joint, or infection. It normally settles without treatment, but if the area becomes uncomfortable, the position of the drip can be changed.
Confusion or memory loss**
This is common among older people who have had an operation under general anaesthetic. It may be due to several causes. It is usually temporary.
A chest infection is more likely to happen to people who smoke, and may lead to breathing difficulties. This is why it is very important to give up smoking for as long as possible before your anaesthetic.
Some pain-relieving drugs can cause slow breathing or drowsiness after the surgery. If muscle relaxants are still having an effect (have not been fully reversed), the breathing muscles may be weak. These effects can treated with other drugs.
Damage to teeth, lips or tongue
Minor damage to your lips and tongue is common. Damage to your teeth is uncommon, but may happen as your anaesthetist places a breathing tube in your airway. It is more likely if you have weak teeth, a small mouth, a stiff neck or a small jaw.
An existing medical condition getting worse
Your anaesthetist will always make sure that you are as fit as possible before your surgery. However, if you have had a heart attack or stroke, it is possible that it may happen again – as it might even without the surgery. Other conditions such as diabetes or high blood pressure will also need to be closely monitored and treated.
Awareness is becoming conscious during some part of an operation under general anaesthetic. It happens because you are not receiving enough anaesthetic to keep you unconscious This is a rare complication. Monitors are used during the operation to record how much anaesthetic is in your body and how your body is responding to it. These normally allow your anaesthetist to judge how much anaesthetic you need to keep you unconscious.
RARE OR VERY RARE COMPLICATIONS
Damage to the eyes
Anaesthetists take great care to protect your eyes. Your eyelids may be held closed with adhesive tape, which is removed before you wake up. However, sterilising fluids could leak past the tapes, sheets or drapes or you may rub your eye as you wake up after the tapes have been removed. These could cause damage to the surface of your eye, which is usually temporary and responds to drops. Serious and permanent loss of vision can happen, but it is very rare.
Serious allergy to drugs used
Allergic reactions will be noticed and treated very quickly. Very rarely, these reactions lead to death even in healthy people. Your anaesthetist will want to know about any allergies in yourself or your family.
Nerve damage :
Nerve damage (paralysis or numbness) can be caused by a needle when performing a regional anaesthetic or can be due to pressure on a nerve during an operation. It varies with the type of anaesthetic you have, but is generally rare or very rare. Most nerve damage is temporary, but in some cases damage is permanent. Brain damages as a consequence of a lack of oxygen supply may result in paraplegic hemiplegic or tetraplegia.
Deaths caused by anaesthesia are very rare. Regardless of the type of anesthesia, equipment is used during surgery to monitor your heart rate, circulation, temperature, blood flow, body fluids, oxidation and adequate ventilation. The monitoring is designed to reduce the risk of complications. Advances in the field and in the technology have paid off. In fact, deaths due to anesthesia fell to only one in 250,000
Vital equipment that could fail includes the anaesthetic gas supply or the ventilator. Monitors give an immediate warning of problems, and anaesthetists have immediate access to back-up equipment.
All the complications that could occur due to Anaesthesia and not to surgery itself are under
the Anaesthetist responsibility solely.
What should you remember from this information?
Most often an anaesthesia properly performed will have no complications and no or little side effects either, especially for cosmetic surgery. That the type of anaesthesia used for cosmetic surgery, and cosmetic surgery procedure itself is not as invasive as the one used for deep organs surgery. The side effect are not compulsory and can be prevented (i.e. feeling sick can be prevented by specific anti-emetic drugs.
Many cosmetic surgery procedures can be done without a general anaesthetic, under an intravenous sedation as a day case, such as mini facelift, model temporal lift, upper blepharoplasty to the upper eyelids, ear pinning back, liposuction to one or two small areas…
Remember that you are in the hands of professionals who are use to help people going through this safely as a routine.