INTRODUCTION

Anesthesiologists are trained to administer anesthesia for surgery. Elective cosmetic surgery is commonly performed in an office-based facility with patients discharged to home. However, elective cosmetic surgery differs from elective or emergency surgery in many substantial aspects (see Tables 1–1 and 1–2).

“Cosmetic surgery is almost always elective, and patients are almost always in good health. The patient, however, is willing to risk this good health (at least to a limited extent) in order to experience improvements in physical appearance, and perhaps more importantly, self-esteem, body image, and quality of life.”

There is no medical indication for elective cosmetic procedures, excluding breast reconstruction post-mastectomy. One may consider risk-benefit ratios of differing anesthetic regimens in medically indicated surgery. However, surgery without medical indication should not accept any avoidable risk. Halogenated inhalation anesthetics are triggering agents for malignant hyperthermia (MH), carry an increased risk of deep venous thrombosis with potential pulmonary embolism, and are emetogenic. If the patient is interested and the surgeon is willing, all cosmetic procedures can be performed under local only anesthesia. Therefore, any additional anesthetic agents should be subject to the highest justification.

Most patients desire some alteration of their level of consciousness from fully awake through completely asleep. Given that all known risks should be avoided, when possible, then which agents are best suited to the task, what monitors should be employed, and to what level of anesthesia should be administered (i.e., minimal sedation [“anxiolyis”], moderate [“conscious”] sedation, deep sedation, or general anesthesia [GA])? (See Appendix 1–1, Defining Anesthesia Levels).