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Background: Intravenous sedation, supplemented by local and regional anesthesia, is becoming increasingly established as the anesthetic method of choice for a wide variety of aesthetic surgical procedures. It offers such advantages over general anesthesia as obviation of risk associated with intubation, reduction of post-operative nausea and vomiting (PONV), and containment of cost.  Additionally, it allows a multitude of procedures to be performed in the office or outpatient setting, granting greater convenience and flexibility to both patient and surgeon. While several prior reports exist regarding either abdominoplasty or breast procedures performed under sedation, it had previously not been considered feasible to undertake simultaneous major aesthetic operations of both abdomen and breast without the employment of general anesthesia. We demonstrate a technique employing intercostal blocks and regional anesthetic, supplemented by propofol/ketamine for intravenous sedation.
Objective: To demonstrate the safety and effectiveness of intravenous sedation, with local and regional anesthetic blockade, for concurrently-performed major breast and abdominal aesthetic procedures, through a review of experience at the authors' institution.

Patients and Methods: Over a five-year period from 2002-2007, 66 patients were operated on by a single surgeon/anesthesiologist team in one hospital-based ambulatory surgery center. All were ASA class I or II. All patients underwent abdominoplasty, concurrently performed with breast augmentation and/or mastopexy, under intravenous sedation with propofol infusion, ketamine, midazolam, fentanyl, and meperidine. Of these, 32 patients (48%) underwent additional procedures, including suction-assisted lipectomy (SAL), brachioplasty, and hernia repair. In all cases, supplemental local anesthesia was given in the form of lidocaine and bupivacaine instilled along incision lines, as well as field blocks for breast procedures. All patients underwent bilateral anterior intercostal blocks with bupivacaine and epinephrine, along the mid-axillary line. Additionally, 56 patients (85%) received bilateral posterior intercostal blocks with bupivacaine and epinephrine. SAL, where performed, was done so with tumescent lidocaine and epinephrine. PONV prophylaxis was given in the form of  dexamethasone, in addition to ondansetron, metoclopromide, and/or dolasetron. A retrospective chart review was performed, evaluating operative and recovery room time, maximum O2 requirement in the post-anesthesia care unit (PACU), maximum PACU analog pain scale (0-10), operative complications, and need for hospital admission.

Results: Mean operative time was 224 min. (SD 111 min.). Mean time from end of surgery to transfer to PACU, representing emergence from anesthesia, was 7 min. (SD 5 min.). Mean time spent in the PACU prior to discharge was 111 min. (SD 53 min.). Mean PACU pain scale was 2.1 (SD 3.0). Maximum O2 requirement in the PACU averaged 2.3 L/min (SD 1.6 L/min). 4 patients (6%) required subsequent overnight admission to the hospital, for post-operative pain control. All the rest were weaned off O2 and discharged home on oral narcotic medications. There were no intraoperative complications, and no patients required conversion to general anesthesia. None of the discharged patients required readmission for pain control or nausea.

Conclusions: These results demonstrate that simultaneous major abdominal and breast aesthetic procedures can both safely and effectively be performed under intravenous sedation. The technique requires the patient to begin in the prone position for posterior intercostal blocks (if needed) and additional anterior intercostal blocks and infiltration of local anesthetic. Intravenous sedation is administered utilizing a propofol and ketamine infusion. We show that these patients tolerated the procedures with a high level of patient comfort, and exhibit a low incidence of complication.