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CosmeticSurg Blog

Dr. Rodriguez discusses Plastic Surgery, Medicine, and Stem Cell Research

Breast augmentation with IV Anesthesia – a safer choice

I often hear from patients who want to have a breast augmentation, but are afraid of anesthesia, or “going under.” They are concerned about the postoperative nausea,  and feeling rotten for a couple of days after anesthesia. It doesn’t have to be so. There are well described techniques for doing breast augmentation with another type of anesthesia — twilight anesthesia. With this type of IV anesthesia the recovery is very quick, less nausea, and no lousy feeling the days after surgery.


There are two keys to successful breast augmentation with twilight anesthesia. The first is using the newer combinations of intravenous anesthetics. A short acting barbiturate, such as propofol, is used with a dissociative anesthetic, which as the name implies, dissociates painful stimuli from higher levels of brain activity. The patient is then not as heavily sedated and can breathe on her own. Another drug used is an amnesic, which prevents formation of memory of the event. More importantly, using this combination, there is very little need ,if any, for narcotics. Narcotics are a major source of postoperative nausea and vomiting.

IV anesthesia allows a patient to have a surgery where she is awake enough to be breathing on her own, will not experience pain, and will not remember the event.  With IV anesthesia there is no risk of malignant hyperthermia or blot clot to the legs or lungs, as those risks are only associated with general anesthesia. Thus, properly monitored IV anesthesia is a safer choice than general anesthesia for breast augmentation.


The second key is blocking the nerves before starting the breast augmentation surgery. It is well known that blocking a nerve before stimulating it will diminish the total experience of pain from that nerve. In the chest cage the nerves emerge from the intercostal (between the ribs) spaces along the mid-axillary line, and intercostal spaces along the sternal borders as shown in the illustration. They provide sensation to the tissues of the breast along parallel tracks that are called dermatomes.


If you can block the nerves close to where they come out from between the ribs you can numb the entire breast without having to inject the whole breast with local anesthetics. Once the nerves are blocked, there are very few pain signals reaching the brain.

Local anesthetic is injected to areas where the nerves are emerging from the chest wall

Local anesthetic is injected to areas where the nerves are emerging from the chest wall Shown in pink are the areas we inject with the local anesthetic. We use a long acting anesthetic (marcaine) before even starting surgery. The anesthetic numbs the nerves for 12 to 18 hours. The patient will wake from anesthesia with little if any pain.


The final part of the experience is to reduce pain during the recovery period. At the end of the surgery I insert a pain pump which delivers a local anesthetic to the implant pocket for the first few days after surgery. The end result is that you should experience much less pain after surgery.

The recovery room experience is much improved with twilight anesthesia. First of all, the patient wakes up much quicker. Secondly, there is hardly any nausea. When I used general anesthesia in the past, I used to prescribe Zofran (anti nausea drug) routinely. Since I have been using monitored IV Anesthesia  I have only prescribed it once or twice in the past year. The recovery room stays are now so short, that the patient is fully awake, walking and ready to go home within an hours time.


Two days after breast augmentation surgery, I usually see patients to remove the drains. At this appointment, I see a remarkable improvement in their recovery from using twilight anesthesia. With general anesthesia the patients used to show up in pajamas, or sweat suits, hair undone,  and walked in by the person that drove them in. The most often asked questions are how long the pain is going to last, and can I refill the pain medication prescription.

Patients who have had twilight anesthesia recover quicker.The patients that had IV anesthesia and a pain pump come dressed to the two day post op appointment with normal clothes. They are usually chattier and asking questions about activity levels. Since they are having less pain, they are breathing better, since they are hardly taking any pain medication (narcotics)  they are not nauseated or constipated.

Undoubtedly, breast augmentation with  IV anesthesia has been a great advance in patient care for my patients and I highly  recommend it to any one contemplating Breast Augmentation.

Posted in Breast

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  • wrote
    October 18, 2009 at 2:02 pm

    We are well aware of this.
    Our site is staffed only by MD anesthesiologists.
    Our technique for induction is not a loading dose, which can in rare instances lead to events you describe, or lead to situations like Michael Jackson’s. ANY medication used for anesthesia can cause problems when not properly administered.
    Our technique is a slow drip regulated by automated pump so there is no chance of overdosing.
    After the patient is sedated we add a small dose of Ketamine and Versed, enough to tolerate the injection of the tumescent anesthetic. We do not depend on propofol levels for anesthesia, only for light sedation.

  • wrote
    October 11, 2009 at 5:02 pm

    Be aware off extreme bradycardia, even asystolie in awake or almost awake patients (propofol).

  • wrote
    August 8, 2009 at 5:27 pm

    Thanks for the backup.
    For me the most difficult part was finding anesthesiologists who would go along with it.
    The best part is the postoperative recovery for patients. Many many less headaches for them and me!
    Will look you up in Seattle.

  • wrote
    August 7, 2009 at 10:50 pm

    Nice post Dr. Rodriguez. That is actually very similar to my technique. I use propofol without general anesthesia and a lot of local anesthetic. I find in my hands that infiltrating the local directly under the pectoral muscle helps with pain control and particularly hemostasis. I rarely have to use any cautery.

    Pain pumps are a good idea. I use Marcaine in the implant pocket after closure for long lasting pain control without the expense or hassle of the pain pumps but have certainly considered the pain pumps.

    I had done general anesthesia for the first half of my career and now wouldn’t consider going back. Much easier on the patient and in my practice means it becomes an office procedure at significant cost savings to the patient. We do full abdominoplasty, breast reduction, and breast lift with similar anesthetic techniques.

  • wrote
    July 22, 2009 at 8:19 am

    Yes, we do all surgery under twilight.
    Patients recover much better. Less nausea, less tiredness after, etc.
    Highly recommend it!

  • wrote
    July 21, 2009 at 4:58 am

    Would this be the same also for breast lift? as in ok to have twilight intead of general?

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  1. […] monitor Some of you may have read my posts on why I like to do breast augmentation under IV sedation. I also do IV sedation for all major and combined procedures. Naturally, some patients are anxious […]