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Depending on the individual patient's requirements, the breast implants (saline or silicone filled), are either placed under or above the breast muscle (pectoralis). Anesthetic approaches may vary from intravenous (IV) sedation, to thoracic epidural, to intercostal nerve block, or general inhalational anesthesia (GIA). It is possible to perform this procedure on a fully awake patient, but very uncommon.

The use of intercostal nerve block has been reported to produce the highest blood levels of local anesthetic in patient's bloodstream, exposing them to toxicity risk. Thoracic epidurals sometimes result in patients' complaints, including soreness at the site of injection in the back, delayed ability to urinate without assistance, and delayed discharge - since the patient has to wait for the block to wear off. For the preceding reasons, Dr. Friedberg does not offer either alternative to his patients.

Drugs like desflurane, sevoflurane, and isoflurane for general inhalation anesthesia (GIA) are triggering agents for the very rare, often fatal syndrome of malignant hyperthermia (www.mhaus.org). Although the risk is low, Dr. Friedberg feels it is unacceptable when the PK technique is a proven alternative.

Many anesthesiologists favor the combination of propofol and alfentanil (a short acting, synthetic opioid) for IV sedation. A growing number of anesthesiologists in the US, UK, Canada, Australia, and Japan have embraced Dr. Friedberg's PK technique for better results. Improved postoperative pain relief is obtained by placing 10 to 20 cc's of 0.25 percent bupivacaine (a long acting local anesthetic) in each of the "pockets" before placing the breast implant.

The PK technique has been greatly simplified by the addition of the Bispectral Index® (BIS®) monitor (Aspect Medical System, Inc., Newton, MA - www.aspectms.com). With the monitor's measurement aid, the anesthesiologist knows just the right amount of anesthetic needed by the patient so that the patient receives no more anesthetic than absolutely necessary. In more medical terms, the monitor permits quantification of the safe range of propofol. This is important in helping to prevent the rare occurrence of hallucinations from ketamine; arguably, the safest anesthetic drug in the anesthesiologist's toolbox. The dissociative state ketamine produces allows the injection of the local anesthetic into a motionless patient. In this way, the injection and the subsequent surgery provide no perceived pain stimulus to the patient. When the propofol infusion is turned off, patients awaken quickly with little discomfort and no PONV. With a rapid return to their pre-anesthetic mental state, patients are able to return home soon after their surgery is completed, with their surgeon's approval.

Bispectral Index® (BIS®) monitor   www.aspectms.com

Details of Dr. Friedberg's innovative PK technique, which provides narcotic-free pain relief, were published in Aesthetic Plastic Surgery 1993;17:297-300. (No patient's identities were revealed.) The technique is designed to maximize patient safety while creating the illusion of general inhalation anesthesia, i.e. "no hear, no feel." The article has been subsequently cited in twelve peer-reviewed journal articles, and one surgery and four anesthesia textbooks. This is noteworthy because half of all journal articles in print are never referred to in subsequent articles. Several subsequent articles by Dr. Friedberg have also been published.

In the past decade, Dr. Friedberg has successfully performed his PK technique for breast augmentation with more than 20 different surgeons on more than 350 patients. Results of many of these procedures were described in his five-year review article published in Aesthetic Plastic Surgery 1999; 23:70-75. (Patient's identities were not revealed.) No patients were admitted to the hospital for uncontrolled pain or PONV, the two most common causes of post-operative hospital admissions after a day surgery.

  
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