The Truth About Awake Liposuction

Monique Ramsey (00:03):
Welcome everyone to The La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey. Today we're going to talk about something that you might've heard of out there. It's called Awake liposuction, and it's one of the biggest trends in cosmetic surgery right now. So if you're thinking about getting it from a clinic, who's promoting the benefits of staying awake during the procedure, I think it's smart to dig a little deeper. So at first glance, it might seem harmless because you're thinking, okay, surgery is risky, maybe general anesthesia is more risky than being awake, but to help us understand whether this sort of low cost option that sounds so sexy and great, what are the potential dangers? And so Dr. Luke Swistun is here. He's back here to talk about this topic of awake liposuction. So welcome back Dr. Swistun.

Dr. Swistun (00:53):
Thank you for having me on. Thank you.

Monique Ramsey (00:55):
Now you do a lot of body contouring. That's one of your specialties. People come from far and wide to have you do the 360 lipo and really shape their whole body and help make their proportions beautiful or handsome or rugged, depending on who's on the table. So tell us a little bit about what is awake lipo and why is it sort of becoming a hot topic?

Dr. Swistun (01:22):
Well, awake lipo is basically just that, is that you're having the procedure of liposuction, but you're not under general anesthesia. You're actually in some sort of a twilight state usually. And depending on the extent of the liposuction, the twilight state can vary and can be adjusted to that. But that's the big distinction is that it does not involve general anesthesia.

Monique Ramsey (01:41):
Let's talk about what are the risks of an awake liposuction and what does that mean? If I were on the table right now having awake liposuction, am I awake, awake or awake kind of asleep?

Dr. Swistun (01:54):
Typically not. Now, again, it can vary based on the extent of our liposuction. So for instance, I've had some patients where we did a full body liposuction and then maybe after six months after they healed, there was one tiny little area, maybe somewhere on their buttock or around their hip where it's like, Hey, you know what? We got 99% of the result, but that one little tiny spot could make it a hundred percent could make it beautiful. That one little tiny spot is so small that we can just put enough local anesthesia just like numbing medication around that spot that the patient really does not need any other sedation. They tolerate that just fine. However, if we're doing a little bit more liposuction, let's say somebody comes in and says, well, I'm happy with my contours except for my abdomen right here. I've always had a problem with my abdomen.

(02:37):
If I just have a little bit more fat than I like right in this abdominal area, basically extends from my chest all the way down to the pubic area. That's a much bigger surface area. And while we would still use numbing medication in order to numb that area up, that patient may be kind of anxious about feeling the liposuction cannula under the skin when we are doing the actual procedure because it's a little bit of a bigger area. So that patient may benefit from something more to calm them down. That's where we have a range of options available. Sometimes it could be something as simple as a Xanax or Valium, just that they take up by mouth, just one pill to calm them down and make 'em comfortable with the concept of what's going on. Sometimes if the surgery is even more extensive and maybe takes a little bit more time, some people actually use nitrous oxide, basically the equivalent of laughing gas that makes patients kind of zone out a little bit.

(03:30):
The benefit of that is that they can actually control how much nitrous oxide they use. They have a mask that they just put on their face and if they get too sleepy, the mask just comes off. And then when they feel like they need a little bit more, then they can put their own mask back on. So they are in control of their airway and their own sort of mental state and sort of mental comfort, so to speak, while everything else is going on. And that will be for a little bit more of a large extensive awake liposuction. So those are the ranges of liposuction, but notice each one of those instances basically gives us some level of mental sedation, so to speak, to be comfortable with the procedure that's going on. And it also gives us some level of local anesthesia, as in we put numbing medication in the area that we're going to work on in order for the patient to be comfortable and not feel any pain.

(04:17):
But when we talk about limitations of awake liposuction, that's literally the same concept is that at some point the liposuction procedure is going to be too big for us to be able to use the local medications available to us. We're just going to run out of room. Basically the procedure requires more than that and the patient's just not going to be comfortable. So the biggest danger to me of doing awake liposuction for somebody who's committing to awake liposuction and wants a very extensive result is that we're not going to be able to finish the surgery because they may get uncomfortable or we may run out of the amount of medication we can give the patients to keep them comfortable. That's actually kind of the biggest obstacle for me. Some patients do come in and ask for a lot of liposuction and they ask, can we do it awake?

(05:08):
And if you ask for a lot of liposuction, obviously we use numbing medication in the tumescent and the fluid that we inject under the skin in order to do the liposuction, and there's a maximum dose that's calculated based on their weight. And we can't go past that because we use lidocaine. Lidocaine is the numbing medication. But if you look at what lidocaine does, it's actually a medicine used in cardio thoracic surgery and then heart medicine to slow down the rate of the heart. So if we overdose a patient on lidocaine, the ultimate side effect is it's a heart blocker. Your heartbeat slows down and eventually stops. So obviously we have to be very careful how much lidocaine we use and we can't overdose patients on that. So if the patient's still uncomfortable and we ran out of lidocaine, the patient can get no more, then we're basically done with the procedure whether or not I finished or not.

Monique Ramsey (05:57):
And this goes back to the mid nineties. So we moved into the Ximed building that space we're in in 1996. And within a couple years there was a really bad situation that happened at another doctor's office who's no longer there, a few floors up, and she was not trained to do liposuction, she wasn't a surgeon and she was doing an awake procedure and she gave so much local that the patient died and it was horrible. It was so tragic and it didn't need to happen. And so it was one of those things like even back then, I mean that's 30 years ago, people were still people. Oh, I don't want general. They're scared of it for some reason. And maybe Dr. Swistun, you can help our audience understand why kind of the difference between local and general and why general isn't necessarily riskier, it's actually safer.

Dr. Swistun (06:57):
Correct, correct. And this is actually a topic that I come across, but pretty much anybody that gets surgery with me, because I do elective plastic surgery, obviously I do body sculpting, I also do a lot of breast surgery, breast and body surgery. And the vast, vast majority of what I do goes under general anesthesia is done under general anesthesia. And literally every patient that I come across, their biggest concern about the procedure isn't the procedure itself. Most patients' biggest concern is, oh, do I have to go under general anesthesia? Am I going to wake up? Statistically speaking, let's look at statistics. Statistically speaking, it is safer for you to get on an airplane than to drive somewhere, right? So if you look at statistics on the highway, highway accidents happen much more frequently than plane crashes have, yet. Everybody's a plane. A lot of people are getting are afraid of getting on a plane because they give up control to the pilot.

(07:47):
They have no control over what's going on, and it just feels like it's a risk. It's a bigger risk than driving yourself, even though statistics don't pan that out, the operating room is the next level of flying on a plane. As far as statistics, especially for an elective case, think about it this way. Basically I always call it the safest place in the world because think about it this way. Let's say you were driving home, let's say you got into a car accident and you needed some sort of an intervention, surgical intervention, they would bring you to a place like the operating room in order to save your life because that's where we have everything. We have all the medications necessary to keep your blood pressure up or bring it down, your heart rate up or bring it down. We have a board certified anesthesiologist to monitor your airway and we can call in reinforcements for pretty much anything.

(08:29):
And that's in a trauma situation where things are unpredictable. So imagine going into that room except you're not a trauma, you're a perfectly healthy patient and we know that because we've checked you, we've examined you. Maybe we ran some labs just to be sure. Obviously this is elective surgery. So we take no risks and we dot our i's and cross our t's and make sure that everything is in place before we take you to the operating room. So you're really in the best case scenario and then you're going into the most controlled sort of environment in the world to have your procedure done. So in that sense, this is the safest place, except conceptually speaking, everybody thinks about it and they're like, well, I'm completely giving up control and am I going to wake up? So it is a leap of faith. It is a trust factor. You're giving out control to the anesthesiologist and to a surgeon, but statistically speaking, it's literally the safe, one of the safest places in the world.

Monique Ramsey (09:20):
And let's talk about, you were talking about the anesthesiologists. So all of our anesthesiologists at La Jolla Cosmetic are board certified anesthesiologists, and so there are the most highly trained in that sphere. Let's talk about general, what does that look like, I guess for the patient?

Dr. Swistun (09:40):
Obviously they meet their anesthesiologist before the surgery, before that even happens, the anesthesiologist review everybody's case just to make sure that from the anes standpoint, this patient is a good candidate. So obviously I do my job as a surgeon, but they do their job before the patient shows up as the anesthesiologist. And once everything gets cleared on paper, then they meet the patient, they talk to them, they talk about their preferences. They always ask, did you have anesthesia before? What do you remember as the biggest problem? Oh, nausea. Well, we can treat that more aggressively this time. We can make you a lot more comfortable than last time, and so on and so forth. So they're very astute to tailoring the approach. Some patients just kind of want to zone out sooner. So those are patients that may get a little bit of medication, sedative medication to help them be comfortable and calm and their mind before they walk to the operating room.

(10:28):
There are some patients that insist on remembering everything, their concept of just not having a memory of what's going on, they're very not comfortable with that. So that can be accommodated as well to some extent. But ultimately, as the patient is walked back to the operating room, they lay down on the table, make sure that they're comfortable. And yes, we start an IV and we start applying oxygen. There's some sedation medication that actually comes in that is injected prior to the immediately before anesthesia, just so the patient is fully comfortable and oxygenated and after they're completely asleep and not feeling anything, not remembering anything, that's when the anesthesiologist would secure their airway. There's different ways to do that and then make sure that they're comfortable before you do anything else.

Monique Ramsey (11:12):
And why is a secure airway important?

Dr. Swistun (11:16):
That's basically the anesthesiologist's entire job is to make sure that the airway is secure so that they can oxygenate the patient throughout the case. If it's a simple short case where the patient isn't moved around at all, then we don't necessarily need to use a tube that goes all the way down to the throat. That's another question that a lot of patients ask. We use something called an LMA is an laryngeal mask. It's basically a mask that goes kind of like right in the mouth but does not go into the throat, and that's enough to secure the airway. For the cases that involve 360 liposuction, that involve a lot of repositioning the patient maybe from side to side or from front to back. Then we want the airway to be a little bit more secure. So we do use a tube that goes a little bit deeper and gets secured down there that way, but that's obviously the anesthesiologist way of making sure that the oxygen is flowing correctly and they get a lot of parameters from that as well.

Monique Ramsey (12:07):
So I would think the reason, and you can correct me if I'm wrong, I would think the reason that it's cheaper when you go compare prices because we all shop, it's okay to do your shopping, do your homework, that the wake would maybe be cheaper because you're not having a board certified anesthesiologist. It might just be a nurse anesthetist. It might be the doctor, him or herself doing that. Correct. So is that kind of where the difference is in terms of people comparing prices? If you're just saying yes, absolutely. Over here it was 15,000. Over here it was 12. Why?

Dr. Swistun (12:47):
Yeah, absolutely. So if we take the anesthesia fees out of the factor, then yes, then that becomes a lot less expensive because the patient is paying for the surgeon and maybe for the facility but not for anesthesia. So that is a significant savings, but again, it comes with a significant limitation. And for some surgeries, for some liposuction that is small enough in a surface area and stuff that may be a perfectly appropriate choice for that patient. But in others that are big, then it may not be a perfectly appropriate choice. Or it may lead to disappointment because well, we tried. We thought we could get away with it, but the patient became uncomfortable way too fast and we just didn't finish the surgery and now the patient has half a result.

Monique Ramsey (13:25):
Speaking of that, some people now I've been in the OR to watch surgery and to film surgery, and I think in concepts like, oh yeah, it's lipo, it's no big deal, but they might be clueless as to sort of, it's a little bit of an aggressive procedure to get that fat out and how uncomfortable can it really be? And let's maybe ask you, looking back at when you've done it under local in a small area, what are the patients saying in terms of what they feel?

Dr. Swistun (13:57):
Again, it all depends on the patient. It all depends on the area where liposuctioning, I mean fat in and of itself is not very innervated. So that's sort of the easy part. And if you have a patient that has a lot of fat in a specific area and that's our target, then all we need to do really is numb them up at the skin where we make the small incision to get under the skin, and then we numb up that fat that we're going after. We wait 20 minutes for the numbing medication to really kick in. And then we test the patient's comfort level. And if the patient tells you, yeah, they're uncomfortable, I'm not really feeling anything, then we can proceed and start getting some fat out. It becomes more tricky if we're doing a large surface area because now that cannula has to reach to much more places, so there is more potential for nerves being irritated and stuff.

(14:45):
And it also becomes a little bit more challenging when the patients are thinner. And that's actually a very common situation for me. I do a lot of what we call skinny BBLs or patients who have a great BMI already, their height and weight are very appropriate. They may be a BMI of 22, 23. It's just that their problem is that they have a little bit too much flank fat and not enough maybe fat in the products, and they just want to shift their proportions just a little bit. But thinner patients are a lot more challenging to keep comfortable because the nerves are so much closer together to that fat. Basically, if you think about what we're doing, we're removing fat from in between the muscle layer and the skin layer. The muscles are to some extent innervated, and the skin is certainly innervated. That's where all the sensory nerves are. So the fat pad is big, and I'm in the middle of it just getting some fat out and de-bulking that fat pad that's usually well tolerated. But if the fat pad is already small, then I have to sort of be very close to the skin in order to give that patient the great result that she wants. And now I'm irritating those nerves a lot more.

Monique Ramsey (15:46):
Yeah, I don't think personally, no, thank you.

Dr. Swistun (15:51):
That's why we limited it to very small areas basically.

Monique Ramsey (15:53):
I mean, if anybody's been, okay, this may be not a good comparison, but here I'm going to go with it anyway. If anybody's been in the med spa and had all therapy things that are not invasive, but they're there to, things like that hurt a little bit and your nerves almost get more fired up, or at least in my experience, it got harder the longer we went because my nerves were angry. And so finally they were taking breaks and the experience was crazy because it took too long because I was in so much pain, and then they're trying to give me more medicine, and then I needed a ride home. This thing sort of snowballed and because I thought, oh yeah, I'll be fine. So now in terms of who out there in the community might be doing a awake lipo, is it board certified plastic surgeons or is it people who were maybe not a board certified plastic surgeon?

Dr. Swistun (16:55):
Well, going back to the example we gave at the very beginning of this podcast, I don't know who that person was. This happened way before my time here. But was that person a board certified plastic surgeon?

Monique Ramsey (17:06):
She was not.

Dr. Swistun (17:08):
So that's the problem with lipo in general is because think of what the procedure is, on paper, technically any doctor can do it, legally speaking. Why do I say that? Because what liposuction involves is you're making a small incision in the skin and then you're putting an instrument underneath the skin to do some sort of an intervention, and then you're closing that incision potentially. So that is something that's the equivalent of lancing, a boil in an emergency room, or that's the equivalent of going to a family doctor's office to do a small tiny mole removal or something like that. So a lot of doctors, a lot of MDs technically have the experience, the expertise and the license to perform a small, tiny invasive, locally invasive procedure, lancing a boil, for instance. Now liposuction on paper, the definition of that is doesn't vary that much from lancing a boil, right? You're still making a very small incision. You're putting an instrument underneath the skin in order to do some sort of an intervention, and then you're going to take the instrument out and close the incision. So on paper, it's about the same as lancing a boil. In reality, it's absolutely not. I mean, the extent of your intervention is way bigger. You're under the skin from the abdomen to the chest, from the back to the flanks, so on and so forth. Much more extensive area, much bigger risk because that cannula under the skin can also go under the ribs and puncture the diaphragm. It can go into the abdomen, puncture the bowel, all these different things. So it's a completely different procedure, but legally on paper, it's defined as almost the same thing. My rule in life was always like, don't do any surgery that you can't deal with the complications and the complications of lancing, a boil are not very big.

(18:53):
The complication of doing liposuction can be devastating, can be huge. I mean, if you puncture the diaphragm and give somebody a punctured lung or if you puncture the bowel, that patient needs additional surgery and a huge operation and people die from mistakes like this. So you really should have a surgeon doing surgery, not an internal medicine doctor or a family physician doing that. And then the other thing is a lot of those doctors actually advertise themselves as cosmetic surgeons. Notice the distinction here, not plastic surgeons or board certified plastic surgeons, but cosmetic surgeons. So you have plenty of doctors around this country who are, let's say family practice or internal medicine or ob-gyn, who then go to Las Vegas and they get a crash course in liposuction, which lasts a weekend, and then they get a little diploma that says aesthetic surgeon or liposuction trained or something like that.

(19:49):
And then they post that in their office, but they advertise that themselves as a cosmetic surgeon, even though they are not a surgeon. They are an internal medicine doctor with this little diploma that they got in Vegas over the weekend. So what's wrong with that? Their training was a weekend. My training was six years in order to basically do the same procedure so I can deal with the complications of whatever happens to my patient, and I know how to avoid those complications. And I have the experience because I've done surgery way more extensive than liposuction, so I know exactly what's going on in there and how to limit my intervention to keep it safe.

Monique Ramsey (20:27):
And I think for the audience, I'll have Hannah, our producer, put in the show notes a link to check how do you check if your doctor is board certified? Because if it says on their website board certified cosmetic surgeon, that's not one of the 26, that's not a thing. It's not one of the ones that are recognized by the American Board of Medical Specialties. And you can go on that website and you can look up your doctor and see what they're board certified in. And I remember meeting at a cosmetic surgery meeting where there was some plastic surgeons. There was, I met a doctor who he was an ER doctor, and that's fine, but does that train him to do blepharoplasty, to do eyelid lifts, to do some of these things that are just different? They're different.

Dr. Swistun (21:20):
That's a great example, actually. ER doctors are definitely trained to lance abscesses, so they are fully allowed to make a small incision in the skin and lance pus and then maybe close it or maybe pack that. They are also licensed to do conscious sedation. I mean, ER doctors do a lot of local procedures in the emergency room that require a little bit of sedation. So they're trained in those things and they're technically not, legally speaking, not stepping outside of their license. However, they are doing procedures that they were never trained in their residency.

Monique Ramsey (21:55):
So one other question I have is about recovery. Would the recovery be any different after awake lipo or with a general anesthesia? Is there going to be a difference or would it be not very observable?

Dr. Swistun (22:08):
The recovery has everything to do with the extent of the intervention.So typically under awake liposuction, the intervention is going to be a lot smaller for all the reasons we talked about. So I think the recovery should be probably a lot easier if somebody is going under general anesthesia and they're asking me to do 360 lipo and fat transfer, and then let's say they start off really thin, then those are the patients that are going to have a lot more of an extensive recovery because we're their body from their neck down to past their thighs. So the area of intervention is a lot bigger and maybe the head liposuction in certain areas and fat grafting in other areas. So all of those factors will play into their recovery. They even have drains a lot of times after that, but the result is going to be stunningly different than any result that I can get under awake.

Monique Ramsey (22:55):
What is your advice to somebody who's interested in body contouring, and as they go out and speak with other doctors out there, other surgeons, hopefully plastic surgeons, what do you want them to maybe be asking about if they're thinking about this awake lipo versus general?

Dr. Swistun (23:16):
Well, first of all, make sure who's doing your surgery. And we talked about that, sort of ad nauseam, but ask about the credentials. Where did you train? What is your actual board certification in? The price shopping is always tricky because that's how they get your attention. But then what comes with that? I think the old adage of you get what you pay for really applies. I mean, if somebody is advertising like a BBL for half of the price that everybody else is advertising it for, then there's got to be something going on.

Monique Ramsey (23:48):
And I think, okay, let's just give an example. If you're looking online and you see a Kate Spade purse and the Kate Spade purse is on katespade.com and it's $300 and you go to Nordstrom Rack or you go on Nordstrom or Macy's or Bloomingdale's and the purse is $249, it's the same thing. And your price shopping makes sense in that way. Why would you spend 50 extra dollars if you don't have to for the same thing? But surgery is very different, and so you're not comparing that same exact experience or that same exact safety situation, the training of the surgeon. There's a lot more to it. So yeah, we all want to be price savvy and conscious and make the most of the money we're spending, but to your point, it's not the same thing.

Dr. Swistun (24:46):
Correct. You're not getting the same thing, I could assure you. If we take every single one of those cases, there's a catch. It's not the same product, probably not the same result, and a little bit more risk. And ultimately, that's the most important part is I think the patient is taking on a risk onto themselves that is maybe unnecessary for a purely elective procedure because they're trying to cut corners or because they're trying to shave down the cost.

Monique Ramsey (25:12):
Yeah. Anything else Dr. Swistun? This has been super informative, but I want to make sure, did we kind address all the points that you wanted to talk about?

Dr. Swistun (25:21):
I mean, I'm just going to say a couple things that may serve as soundbites or not, but I guess the biggest advantage of traditional lipo under general anesthesia over awake lipo is that the patient comfort is not the limiting factor of your end result that the surgeon can actually do as much as they feel they need to do in order to give you the best result possible if your comfort level is out of the equation, if you're fully asleep, if you're under general anesthesia.

Monique Ramsey (25:46):
And the last thing I wanted to bring up earlier, and I forgot, but I want to have in the show notes, we did, I think two different episodes on anesthesia with our board certified anesthesiologists, where they're talking from A to Z the whole time about anesthesia, about the drugs that are used, about the safety of it. That would, I think, really be a worthwhile listen to hear them talk about it from their point of view and give you some things to consider, because if we all go to Dr. Google, we may not be getting all the right information.

Dr. Swistun (26:27):
You're going to get 10 results on all the plane crashes and no results on the millions of planes that landed safely that day. Again, that's another example I like to use is that it's statistics, and even though it's one of those concepts where you sort of mentally speaking, give up control, and that's the scary part. It's actually safer than anything else you can do.

Monique Ramsey (26:47):
Well, thank you, Dr. Swistun. This was really educational and exciting to get to talk to you again. I haven't seen you in the studio in a while, so it's fun to have you back, and thanks for enlightening the audience on the differences between awake lipo and a traditional lipo with general anesthesia.

Dr. Swistun (27:05):
Thank you for making this happen. Thank you for your time.

Monique Ramsey (27:07):
Okay, have a great day.

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