timberland laptop bag Experts warn about ‘awake’ plastic surgery
Paulette Hacker couldn’t stop screaming. Lying on her side on a gurney, wearing only a bra and panties, she felt as if she were being stabbed again and again. In a way, she was. Through incisions in her upper back, a stainless steel tube called a cannula was suctioning out her excess fat.
“Please stop! You’re hurting me!” she cried to her doctor. Because although Hacker’s body was limp and her mind bleary from an unknown combination of drugs she’d been given through pills and a gas mask, the 38 year old was awake partway through the second day of liposuction on her back, underarms, abdomen, hips and neck. That was the whole point: She was undergoing the new and aggressively marketed Awake cosmetic surgery, which is performed under local anesthesia.
“You can’t scream, Paulette,” a gruff voice answered her. Hacker hazily realized that the voice did not belong to her doctor; the man performing her operation was a stranger whom Hacker would later discover was a physician’s assistant. (Through his attorney, Dr. Bittner strongly denies all of Hacker’s allegations.)
“Move her into the TV room she’s making too much noise,” a confused and terrified Hacker heard another voice say. Her gurney was rolled down the hall and into a second room, where she could see the assistant jab her while he watched a basketball game playing in the background on a wall mounted television. The volume was cranked up loud enough to drown out her cries.
After the five hour operation, Hacker says the assistant and an office clerk yanked her to her feet and squeezed her into compression garments. Dazed and sobbing, she struggled into her clothes and found herself face to face with a beaming Dr. Bittner. The doctor gently asked why she was crying, she says. Then he maneuvered her beside him and told her to smile for a photo.
Marketed as cheaper, more medically advanced
Hacker had been excited to fly down two days earlier from Sacramento, California. The stay at home mom weighed 233 pounds and was trying to slim down; she’d lost 22 pounds on her own through diet and exercise mostly jogging and now felt she could use some help. But she’d never had elective surgery before and feared having general anesthesia.
Surfing the Web, Hacker had discovered the Awake procedure, which was advertised as a cheaper and more medically advanced alternative to lipo and, for those inclined, to abdominoplasty and breast enhancement, too. The price was right: Awake lipo with Dr. Bittner would cost only about $700 for each body part, versus about $3,000 if she had regular plastic surgery. She found it comforting that the lipo would be performed in a doctor’s cozy office, not in an intimidating outpatient surgical center or hospital. Best of all to Hacker, Awake ads promised that patients would remain lucid throughout the operation and even be able to interact with their doctor. “I liked the idea that I’d be awake and in control,” Hacker remembers. “The surgery really looked like it was for me.”
Unfortunately, the procedure may not have been designed to meet her needs, but rather the doctors’. “The reason for the ‘awake’ portion of it has nothing to do with improving patient comfort,” says Joseph M. “It has to do with doctors not needing to involve an anesthesiologist.” General anesthesia is expensive, and the specialists who provide it prefer to work in hospitals or clinics that have met high safety standards. Awake surgery has become a way for doctors who lack hospital privileges but who want to cash in on the plastic surgery market to exploit a loophole by performing the operations in the privacy of their offices. “This is just a gimmick by people who can’t operate their way out of a wet paper bag,” Dr. Gryskiewicz argues.
Free! Create a Fun Customized Workout Video
Hacker had chosen Dr. Bittner’s medi spa after studying his website, which showcased his Johns Hopkins education, testimonials and pictures of smiling patients beside the tall, tan doctor. Hacker checked to make sure Dr. Bittner was qualified, and there it was: “board certified.” She didn’t realize that he was a board certified radiologist. A non plastic surgery background is the norm for Awake practitioners, who tend to be family physicians, OBs, ophthalmologists, pathologists any doctor willing to shell out up to $7,000 for two day training courses held around 30 times a year by a group of recently formed professional associations.
It’s all emblematic of a growing problem of amateurism in the plastic surgery field, warns Michael F. In Southern California, 40 percent of liposuction practitioners had no training in the procedure before entering practice, according to a 2010 study in Plastic and Reconstructive Surgery by surgeons at Loma Linda University Medical Center in California. The study found that the most numerous providers of lipo after plastic surgeons were otolaryngologists ear, nose and throat doctors. And a 2008 review of liposuction related fatalities in Germany concluded that in cases in which patients died, “lack of surgical experience was a notorious contributing factor,” especially when it came to doctors’ failing to identify complications.
Breast augmentation takes that risk to an even higher level, Dr. McGuire says, because of the host of emergencies that could arise, including blocked airways, blood pressure changes or collapsed lungs. And full tummy tucks are the most invasive of all, risking pulmonary embolism and abdominal perforation; Dr. McGuire calls it “inconceivable that anyone would do such a major procedure under anything less than a light general anesthesia.” He cites Awake surgery as part of a disturbing trend of non plastic surgeons attempting procedures that have not been thoroughly tested such as the not yet FDA approved “stem cell face lift,” and Macrolane injectable breast enhancement and unabashedly touting them to the public as the Next Big Thing. “Awake surgery is a carnival sideshow event,” Dr. McGuire says. “Your life could be at stake with some of these kooks.”
Patients alert and have input, but also agony
An Awake breast implant surgery in the Plano, Texas, office of Jeffrey C. “If they take too much sedative, they’re going to have trouble picking out a size,” says Dr. Caruth, a board certified ob/gyn who has performed more than 200 Awake breast jobs since his training course in May 2008 (as well as 1,000 Awake liposuctions, charging up to $5,000 per surgery). Using a thin needle, Dr. Caruth injects each breast with a small amount of the anesthetic fluid lidocaine. When the area numbs, he makes his first incision. There’s no anesthesiologist and, unlike with IV administered “twilight sedation,” no drip that can be adjusted to render a patient unconscious if she’s in pain.
“They’re totally alert,” Dr. Caruth says. “It’s actually a lot of fun; we play music and talk.” He says his patients feel nothing as he uses a cannula to infiltrate both breasts with tumescent fluid a solution of saline, lidocaine and epinephrine and makes more incisions. Next, they feel pressure and pulling as he stretches the skin and muscle to create a pocket under the muscle large enough for the implants. Then comes the climactic moment: The patient’s gurney is ratcheted upright so she can face a mirror and see her chest inflated with temporary sizers. The doctor ushers in her partner, family or friends to help her decide if she’s happy with her new silhouette before proceeding with the implants.
This is the driving reason women choose Awake breast surgery, according to Dr. Caruth. “They want to have input. When you go shopping, you don’t take something off the rack, throw it in the sack and go home. You try it on first,” he points out. “Women are picky. It’s like shopping for a new dress or a pair of shoes.” He consults with patients before surgery about what’s feasible, but the ultimate decision comes while they’re under the knife.
Get In The Best Shape Of Your Life With Jillian Michaels!
A patient’s autonomy her ability to exert control over her own body is a huge selling point, emphasized again and again on the websites of Awake practitioners. “A woman lying there is not in any position to be giving advice to the surgeon,” she exclaims. Louis who has researched the safety and design of breast implants. Dr. Lund watched a video of an Awake breast surgery at an ASAPS conference and says the roomful of doctors was aghast. “The patient looked as if she’d had about 10 stiff margaritas” as she contemplated her reflection and at her doctor’s urging agreed to go up a size, he recounts.
Dr. Caruth says his patients are completely lucid because of his insistence upon minimal sedation about half of his patients take no
Valium at all and that he’s had only two patients who wanted do overs, both to go bigger. “I know people who say they do Awake breast augmentation and then slam the patient with narcotics,” he says. “That’s not the case here.” But even among patients who aren’t sedated, the time to make reasoned decisions is before surgery, Dr. Lund argues. The operating room is not a shopping mall, after all; if you regret your impulse purchase, you can’t easily go back and return it. “In the consultation room, the C cup might have made more sense for your body and your life, but in the operating room, you might say, ‘Give me the D!'” Dr. Lund says, adding, “Later, if you’re not happy, the doctor can say, ‘Well, I gave you what you wanted.'”
Another Awake premise is that patients are smart to avoid general anesthesia, which causes one death per 200,000 to 300,000 anesthetics given, the Institute of Medicine estimated in 2000. But the large volume of lidocaine used during an Awake surgery poses its own risks. “The amount of local anesthesia needed to anesthetize both breasts comes close to the toxic level,” says Dr. McGuire, who is also immediate past president of the American Society of Plastic Surgeons (ASPS). Lidocaine has not been extensively studied for breast augmentation, but plastic surgeons say a limit of 35 mg to 50 mg per kilo is wise. Dr. Caruth says he uses about half this amount. But in reviewing more than a dozen cases of Awake surgery gone wrong, Dr. McGuire says patients got more than the limit and warns that a lidocaine overdose can kill. The idea is that a high dose is safe in Awake surgery because it’s injected into fat, which, having fewer blood vessels than muscle does, is slower to absorb anesthetic. On the other hand, “that slow absorption could mean you’re just delaying peak toxicity,” says Keith J. “So theoretically, you could have someone on her way home from surgery, and complications like seizures and heart arrhythmias could arise.”
Without an anesthesiologist present, patients can also end up in agony. Dr. Caruth says he’s able to resolve discomfort with an extra squirt of tumescent fluid. But “you don’t want people with a low threshold for pain,” he adds. If a patient remains uncomfortable after a doctor has already maxed her out on lidocaine, an Awake practitioner is left with only two options: Halt the surgery, or grimace and carry on. Responsible doctors would do the former; Dr. Caruth says he’s only once had to cut a surgery short. But not all surgeons act responsibly, Dr. McGuire says, and if patients were to writhe in pain at the wrong time, it could spell disaster. “The stories are just hair raising,” he says. “As a surgeon, I don’t want to be operating on screaming people.”
Awake doctors aren’t trained in plastic surgery
After her painful procedures, Hacker returned home bandaged, swollen and sore. “I hurt so much, I couldn’t function,” she says. Her entire body swelled out of control despite her wearing a pressurized garment for eight weeks, and she had neck and back pain so wrenching that she couldn’t lift her young daughter for the next year and a half.
Free! Give Yourself a Virtual Makeover
The more facts Hacker learned about her physician, the more disturbed she became. Three other patients had come forward, alleging their Awake liposuction was performed not by Dr. Bittner but by his office manager a woman with no medical license who was also his girlfriend and that they emerged injured and disfigured. Those suits were settled or withdrawn. But Dr. Bittner still faces a felony charge for aiding and abetting the practice of medicine without certification, as well as a civil suit brought by Hacker. His lawyer, Benjamin Gluck of Los Angeles, notes that his client has “hundreds and hundreds of satisfied patients” versus “a few unhappy patients who have retracted their more colorful accusations under oath.” Given this, Gluck says he strongly believes the criminal case will resolve in the doctor’s favor.
Hacker also discovered that no doctor should have given her lipo in the first place. It is inappropriate for obese patients because of their higher risk for complications and because surgeons can safely remove only about 5 pounds of fat, Dr. McGuire says. Worse, experts say, doing multiple sessions of lipo on many body parts over sequential days common among Awake surgeons is far outside the norm and vastly increases the dangers. When she shared post op reports from Dr. Bittner’s office with another physician, Hacker learned her blood pressure went so high during the procedure she could have had a stroke. “This was all about greed, not about taking care of patients,” she says.