Advances in Plastic Surgery: Awake Plastic Surgery

By Kenneth Kim, MD

Anesthesia has been a central component of the surgical process for nearly 200 years. Its discovery transformed the entire surgical field, giving doctors a tool that allowed them to conduct longer, more complex, and more invasive procedures.

Using anesthesia, however, introduces considerable risk to the surgical process. In an effort to reduce that risk, doctors specializing in cosmetic surgery have recently started offering their patients an option known as “awake plastic surgery.” Just as the name implies, the procedure allows patients to undergo many surgical procedures, including facelifts, eyelifts, rhinoplasty, and breast augmentation, without going under general anesthesia.

“Surgery hasn’t progressed significantly for nearly a century,” says Dr. Kenneth Kim, a board-certified plastic and reconstructive surgeon and a partner of Dream Medical Group in Los Angeles. “At this point, one of the major advancements that must be made involves surgical safety. With any surgery, there are two types of risk: surgical risk and anesthetic risk. Awake plastic surgery completely does away with anesthetic risk.”

Dr. Kim is a pioneer and leading expert in awake plastic surgery, as well as a clinical professor at UCLA School of Medicine and a clinical faculty member at Seoul National University. He is also a sought-after speaker who lectures internationally on the dangers of general anesthesia.

“Surgical risk involves the possibility that the surgeon could make a mistake,” Dr. Kim explains. “For example, the surgeon may cut something that shouldn’t be cut. Anesthetic risk, on the other hand, is much more of a concern because it has the potential to cause considerable complications for patients both during and after surgery.”

The risks associated with anesthesia

Dr. Kim points to blood clots as one of the major complications that can occur due to anesthesia by triggering vasodilation, or the widening of blood vessels. When this occurs, blood flow slows down, making it easier for clots to form. Blood clots that form in deep veins — a condition known as deep vein thrombosis — can loosen and lodge in the lungs, threatening the patient’s ability to breathe.

Dr. Kim also warns that patients who undergo IV sedation — another form of anesthesia — for surgical procedures, can easily be oversedated. There are a number of risks associated with oversedation, including respiratory depression, during which a combination of low oxygen levels and high carbon dioxide levels leads to respiratory arrest. Because sedation impairs airway reflexes, it also poses a risk of aspiration. Tech innovations have made it easier for medical professionals to monitor patients and reduce the risks associated with sedation. Clinics often use a temperature monitoring sensor that helps track a patient’s vital signs in real time, ensuring early detection of any irregularities. These advancements provide an added layer of safety, allowing healthcare providers to respond quickly if a patient’s condition changes. Continuous monitoring is crucial in preventing complications and improving overall patient outcomes during surgical procedures.

Understanding the threat of memory loss

Memory loss is another risk that Dr. Kim believes patients must carefully consider before opting for procedures that require anesthesia.

“Both general anesthesia and IV sedation can cause patients to experience memory loss,” he says. “Anesthesia kills neurons in the hippocampus, which is the area of the brain where memories are formed. Any surgery that requires the patient to be under anesthesia for more than two hours can have a significant impact on the brain.”

The memory loss that can result from general anesthesia and IV sedation is especially concerning to older patients, who may already be dealing with memory issues. In addition, neurogenesis — the process by which the brain generates new neurons to replace those damaged by anesthesia — slows with age.

“Patients who choose elective cosmetic surgery to improve the quality of their life should not do so at the risk of serious complications,” Dr. Kim says. “The memory loss that can result from anesthesia is a complication that would decrease their quality of life. Patients who are 60 and older will be more affected by anesthesia-induced memory loss because they have a small reserve of brain cells in the hippocampus at that age. But even if you are in your 20s, you don’t want to negatively impact the brain cell reserve that you will be relying on for the rest of your life. That is one of the primary reasons that I advocate for awake plastic surgery.”

The best option for elective cosmetic surgery

Dr. Kim acknowledges that there are cases in which awake surgery is not the best option. These scenarios normally involve patients who were the victim of trauma or other situations in which the surgery is not elective.

With most elective surgeries, however, the surgeon can map out exactly how the procedure needs to go, meaning they can achieve a high degree of precision. In such cases, awake surgery allows for success with less risk.

“Elective procedures provide a great opportunity for awake surgery because the surgeon can plan exactly what he or she will be doing,” Dr. Kim explains. “Whether the patient is undergoing a facelift, forehead lift, rhinoplasty, breast augmentation, or tummy tuck, if the surgeon is ultra-precise and extremely meticulous, awake surgery is the best option.”

Overcoming the fear of the unknown

Dr. Kim believes the biggest barrier to widespread acceptance of awake surgery is simply the fear of the unknown. “Because this type of surgery is still relatively uncommon, people tend to be anxious and resistant to the idea,” he says, “but they are usually anxious about things that are novel to them.”

As people come to truly understand the risks associated with anesthesia, he believes they will understand the value of choosing an awake procedure for elective cosmetic surgeries. “What I would be anxious about if I was having surgery would be the memory loss I might experience from anesthesia,” Dr. Kim says. “I’d also be worried about developing a blood clot that’s going to prevent me from oxygenating properly.”Surgical procedures that involve elective cosmetic surgery are extremely common and on the rise. The innovations in awake surgery that Dr. Kim is promoting will allow patients to pursue those procedures in a way that dramatically decreases their risk of serious complications.