Biggest Fears About Anesthesia

Dr. G (00:02):
You are listening to another episode of All the B's with me, Dr. G and my scrub tech Bri. Good morning. And we're back. I'm Dr. Kat Gallus and you're listening to All the B's, unfiltered plastic surgery podcast with me and Bri. And we're back. We've been on a little bit of hiatus where Bri talked to Dr. Chao and then I talked to Ava, and now we're both in town again. So

Bri (00:28):
Yeah, the dynamic duo is back.

Dr. G (00:30):
That's right. Don't call it a comeback. And of course I felt like when I spoke with Ava, there wasn't a lot of good celebrity goss, but today we are blessed with

Bri (00:44):
This week.

Dr. G (00:45):
This week, I know first of all, Starbucks brings back the fall menu on Tuesday, so already winning and then

Bri (00:56):
Yeah, Travis Kelce is about to turn into Travis Swift.

Dr. G (01:01):
That's right. The engagement everyone is talking about, which I think is just good for them and good for them.

Bri (01:10):
And then to top it all off, Meghan Markle sparks season two.

Dr. G (01:16):
Yeah, it's a lot. It's a busy week. I would say the Taylor Swift and Travis Kelce thing cracked me up. She's got some crazy ring that you gave a thumbs down to, I think because like the vintage look.

Bri (01:34):
I didn't, and I know that's very T Swift, love that for her, not for me. Of course, I don't have a diamond that big, so I can't really sit here and harp on it, but I mean, he would've been so dumb not to propose to her. So I know all the memes that are like, oh, we all know who Travis Kelce is. Sorry if there's any men listening, but she put him on the map for females. And I'm not a Taylor Swift fan either, but we all know who he is now.

Dr. G (02:09):
Oh my God.

Bri (02:09):
Unpopular opinion.

Dr. G (02:11):
I just like the tweets and the quotes, how I'm getting more texts about Taylor Swift's engagement than I would ever get about my own.

Bri (02:21):
Yeah, a hundred percent. All our old surgery coordinator was obsessed with Taylor Swift, so all of us had texted her at one time and they're like, oh, just texted her. She loves Taylor Swift. Yeah, definitely got more texts about this than my engagement, that's for sure.

Dr. G (02:41):
And then the other one I like is that pre-nup is about to be longer than any book Travis has ever read, which is also great.

Bri (02:48):
I love that people think he's read a book. I do love him, so don't get me wrong, but the memes are killing it.

Dr. G (02:59):
Well, I mean, I think this will be awesome and I can just tell you, I know somebody not getting invited to the wedding.

Bri (03:09):
Okay.

Dr. G (03:11):
Blake? No, not us. Blake Likely.

Bri (03:12):
I know, I just hated on it a little bit.

Dr. G (03:15):
No, no, no. We were never getting invited. Let's a hundred percent be real. But I think, yeah, she's our royals.

Bri (03:25):
I wonder if Blake, maybe she won't be at the wedding, I don't think. Are we taking bets?

Dr. G (03:31):
Okay. Alright. It would be a massive friendship story arc for them to get back together, I think at this point, but I don't know. We'll see.

Bri (03:45):
No, we're about to have a lot of swifty babies.

Dr. G (03:48):
Oh my gosh. Yeah. We'll see. But yeah, speaking of the other faux royals, I can't say all that together.

Bri (03:59):
Fox, just kidding.

Dr. G (04:00):
Fox Royals, the Meghan Markle second season, which had been filmed pretty much right after the first season and is getting the usual one to two star reviews because it's just so fake.

Bri (04:19):
I think if she wasn't already filming the second season, she would've been canceled right off the bat. They did cancel it, and it's a shame because she is like, I have no hate against her, but it was the most insensitive out of touch, unrealistic, what is it? Inauthentic.

Dr. G (04:41):
Inauthentic.

Bri (04:41):
Show that I have seen. I was just telling her one episode, she's talking about her mornings cooking a four course meal for her kids. I was like, you should have just seen me this morning trying to wash my daughter's hair because it smelled like shit. And then my toaster started on fire, so then I had to put it in the air fryer just to get one piece of avocado toast. You can't relate. You cannot relate. I'm not sitting on my house.

Dr. G (05:06):
We are not making homemade graham cracker s'mores with vanilla bean turmeric marshmallows.

Bri (05:11):
No.

Dr. G (05:11):
Also, if I made that, nobody in my house would eat that. They'd be like, get the turmeric off my damn marshmallows.

Bri (05:17):
They'd be like, absolutely not.

Dr. G (05:19):
So yeah, I mean a little bit of it hearkens back to way back when Martha Stewart would make boiling an egg incredibly complicated and that created a brand for her. But this is just something to be mocked at this point because she just sounds like a really bad Hallmark card all the time, in my opinion. There are easy ways to show up lovingly. What? Easy? It's like you're going to craft necklaces and make persimmon topped sourdough. Are we still doing sourdough? What?

Bri (05:58):
We've had the starter for a week and a half since my sister made me purchase it, and I haven't even made it, so I'm not going to be doing that and crafting necklaces using pressed flowers for your child's individual birth months and setting them with a UV resin. It's easy. Okay, this is what I have to say to that.

Dr. G (06:19):
I'll just say that. Yeah, she's talking about being authentic and she's in a rental property down the road and overly branding everything and it just seems insane.

Bri (06:32):
I think.

Dr. G (06:33):
Yeah.

Bri (06:34):
Yeah. I think she could have made that a great show if she had just really been a little bit more genuine and not been like, oh, this is all so easy. It's not easy. This is not easy for a working mom or a busy mom or even a stay-at-home mom.

Dr. G (06:52):
Yeah, it's over aspirational. And it's funny because at the same time she did an interview where she kind of promoting the show, talking about how when she still was with the royal family, how she felt like having to wear pantyhose, like nude pantyhose for every outing was inauthentic to herself.

Bri (07:15):
And also bowing to the queen. She made this whole mockery of bowing to the queen and they show it was just, she could have done a little bit. Yeah,

Dr. G (07:29):
Everything's like an aesthetic. She's just one giant Pinterest board that's not real. Anyway.

Bri (07:38):
And she sprinkles everything with edible flowers. Right. Nobody will be eating that in my house. Not even me.

Dr. G (07:48):
The article's great. It's just so easy to, easy to mock and all I kept thinking. So in this quote, it says, each episode sees Meghan throw together over the top snack and drink for her guest's arrival before forcing them to participate in mandatory making and baking activity. Painting children's aprons using limes as stamps, feels particularly unhinged. And then she presents them a gift on the way out. These guests are not even people she's ever met. Queer eyes, Tan France, France is on there, or celebrity chef. They aren't people that she actually knows, which is also more bizarre. Anyway, all I kept thinking is now's a good time to have a labiaplasty because you can hate watch this during your three day recovery. And I feel like we had a slow season of nothing to watch.

Bri (08:42):
It went from a Love Island to nothing. So

Dr. G (08:46):
You need something not too compelling because you're not, you just need something to have on. And I feel like this is three days of laying flat and hate watching this nonsense would be great.

Bri (09:01):
So my advice is to put on episode one, take your oxy and hope to God you go to sleep.

Dr. G (09:08):
Wake up after, I don't know, maybe when Chrissy Teagan's on.

Bri (09:13):
Yeah, love her.

Dr. G (09:17):
Alright. Okay. So that's my only way to relate that to anything plastic surgery, which is, it is a good show to watch if you're recovering because you don't need more than 2% of your brain. Just enough to turn it on and fast forward as necessary. All right, so moving on to actual plastic surgery, adjacent celebrity news. We can talk about the ozempic vulva, which is interesting, but I feel like if you just put ozempic in front of a body part, you have a new trend, honestly. So ozempic face, ozempic butt, and now we have ozempic vagina, so we're just adding that to the list. That being said, we did get an inquiry the other day about the puff procedure, which is Ava was like, what is this? I was like, oh, yeah, yeah, yeah. That is injecting fat in the outer lips. So in the vulva area, if they're deflated and or droopy, you can puff them up.

(10:22):
So it's exactly what it sounds like, which oftentimes in plastic surgery is not. So if you have rapid weight loss, you can get visible skin sagging and laxity pretty much anywhere. It can be in your face. It can be in your butt, your boobs and your inner and outer labia, your belly, your pubic mons, otherwise known as the pupa. All of those areas can sag. And one of the options is to add the volume back by putting fat in there. So I think we'll probably see that trend on TikTok for a minute. And then because it's like that BBL smell, people are like, wait, what? And then it dies down. And again, as we know, people lose weight in different areas first faster. Some people lose it in their breasts, some people lose it in their butt. You're always bemoaning the loss of any butt fat. So I think it's not going to be a thing for everybody. Not everyone on a GLP one has to panic, but yeah, it's something that can be addressed. You can use your own fat, you can use filler like a hyaluronic acid filler, and you can use the fake fat, the Aloclae, albeit that's a slightly more expensive option.

(11:50):
I keep calling it fake fat, which is not true, it's fat, fat from somebody else that has been stripped, stripped of any DNA filtered out so that it's really just a space holder until your own fat can come in and build up that area. But it is a volumizer and it does stimulate your own fat to come in there and it's in a syringe so you can just inject it without having to go under any anesthesia or have the fat harvested from somewhere else. It's a small area. You can't go crazy in there. You don't want to overfill. So it might take more than one session. And I feel like it's in that category of people who this is your number one issue or do you have other issues? I feel like if you have significant laxity there, you probably have significant laxity elsewhere and you've either already addressed it or those other areas are going to prioritize your arms, your face, your boobs, any of those things.

Bri (12:55):
I feel like my labia would be the last thing that I would address.

Dr. G (12:59):
On the list. Whatever. But if you have money to set on fire like Kim Kardashian, maybe you consider doing it.

Bri (13:08):
Yeah. Come get your labia fluffed, fluffed and pretty

Dr. G (13:14):
Speaking of fluffy, Kim Kardashian's ex-pal, Larsa Pippen denies plastic surgery rumors after she looks insane. Sorry. You just have to see the face to be like, why are you denying?

Bri (13:29):
You don't have to deny. We are in the era of transparency. I mean.

Dr. G (13:33):
Her face just looks super puffy and I feel like some point she denies it by saying that she just had a bunch of PRP injected in her face and that's why it's puffy.

Bri (13:43):
There's no way.

Dr. G (13:45):
Okay. Well, PRP is still plastic surgery. What are you talking about? So it's just using, because I think she thinks because taken her own blood and reinjecting it and I don't know. I don't know what her logic is there.

Bri (13:59):
Does it make you look that puffy?

Dr. G (14:02):
I mean, if someone injects a couple ccs under your eyes, I can attest to the fact that that can make you look puffy.

Bri (14:08):
But it goes away.

Dr. G (14:10):
I know, but I feel like she said she had done it recently. She's on some show and her face is pretty swollen and I feel like she probably had fat transfer and the swelling, she didn't plan that around her, whatever. Because you see how she's in that dress with a little mic. It's like a recent appearance, and I think in the article she mentions that she had something i.e., not plastic surgery, but okay. Aesthetic enhancement like a week or two earlier and that she was recovering from it. But PRP or fat, either one is your face could be swollen if they layered it in everywhere up to two weeks. So I don't know why, I don't know that it's a shocking transformation. I feel like she just has

Bri (14:59):
I fell like she's always looked like that.

Dr. G (15:01):
A ton of makeup on. I think if we scroll down we can see a before and after.

Bri (15:05):
And enormous lips. Yeah. She's always had so different though.

Dr. G (15:12):
Her face just looks puffy though. I mean.

Bri (15:15):
It's like she had an allergic reaction.

Dr. G (15:17):
Right. That's why I'm telling you she had facial a fat transfer and it just hasn't settled down yet.

Bri (15:24):
Yeah,

Dr. G (15:25):
Because it's everywhere.

Bri (15:26):
She's so pretty though her before picture, she didn't need any of that.

Dr. G (15:32):
No, not at all. But that was also five years ago, so who knows. But again, I mean I had a fat transfer to my face like 10 years ago and I look like a pumpkin for two weeks.

Bri (15:48):
So she looks like she's had a lot of other work done though, so I don't think that now's the time to start denying things.

Dr. G (15:59):
Oh, right. Yeah. You're like, girl, you've had a bunch of stuff. So I think she's just trying to deal with the fact that her face was swollen, and who knows? I mean, when you do these less invasive procedures, there's the patients that you put the topical numbing cream and their face looks like that and you're like, oh yeah, this is going to go well, if you're already going to get swollen with just a numbing cream, then yeah, probably going to take a little while for the puffiness to go down. And maybe you could have done a steroid burst or something to get it down, but you're really kind of stuck. So case in point when I had my face injected with fat almost on a bet, it was kind of bet.

Bri (16:39):
She does the craziest things.

Dr. G (16:41):
They were like, oh yeah, no, no, no, you can do this under local. I'm like, really? And the surgeon I knew was like, yeah, yeah, yeah, I'll do you tomorrow. So anyway, yeah, my face was hella swollen for two weeks and I felt like I looked insane like Larsa looks right now, but

Bri (17:02):
You just have all the time in the world. You're not doing appearances all the time. Just take the two weeks to sit in your bed.

Dr. G (17:09):
Yeah, so I guess she was on a segment of Goodnight New York on Wednesday and people were freaking out. I mean, it's scrutiny.

Bri (17:18):
We hope that settles. That's all I'm going to say if it doesn't,

Dr. G (17:22):
Then maybe go back and ask for a refund. Okay. So Kim Kardashian fans flip over bizarre Korean procedures that include an injection and eyebrow tape. Okay. Her Instagram post, I feel like she just does shit now at this point to

Bri (17:41):
Yeah, yeah.

Dr. G (17:42):
What is doing? What's going on?

Bri (17:44):
She's always posting her random facials like what, vampire?

Dr. G (17:47):
This, I don't know what's going on here. Are they drawing blood? That's a lot of blood. If they're injecting blood, you would never inject blood in a, is that an IV? You are the paramedic. What the actual fuck?

Bri (18:01):
With a purple liquid as she was.

Dr. G (18:04):
It looks like blood.

Bri (18:05):
What would the purple liquid be? A smoothie?

Dr. G (18:09):
What are you injecting into your arm looks like a smoothie. Honestly, I think she's having stem cell treatments, but literally what ghetto medical person is doing this, first of all, let's 10 things wrong with this photo. Go.

Bri (18:26):
She has no gloves on.

Dr. G (18:27):
Number one

Bri (18:29):
A purple, also, they just, I'm just confused on the tape job. It's literally leaking at the hub. Yeah, there's so many things not right with this photo.

Dr. G (18:41):
The gauze?

Bri (18:41):
Is that an IV or are they just shoving a hypo in her arm?

Dr. G (18:45):
With a giant syringe? How are you going to push that through?

Bri (18:52):
They're going to blow the vein.

Dr. G (18:55):
I dunno what's going on.

Bri (18:55):
I'm just confused on where it's even,

Dr. G (18:57):
I feel like it's obviously a staged photo by someone who has no medical. Just hold the syringe up next to my arm and throw some tape on it.

Bri (19:09):
I don't know. I'm very confused.

Dr. G (19:11):
So if anybody wants

Bri (19:12):
What angle is that? What are we doing? No, it's not a smoothie. It's clearly blood, but gross. Gloves. I just have to say the gloves is just a,

(19:22):
I don't think that's how you do a

Dr. G (19:24):
Deal breaker

Bri (19:26):
Blood transfusion.

Dr. G (19:26):
And then does she not have a tourniquet? Are they drawing blood? Are they injecting it? Anyway, article goes on to say she's getting stem cell treatments in Mexico because nobody in America can treat her. Well, let's just say

Bri (19:38):
Oh really?

Dr. G (19:40):
For her back pain or something. It's stem cell therapy to help her overcome various aches and pains. She's not the only celebrity to do that. It's just illegal in the US to promote that. So she's going overseas. They went to South Korea, but I feel like they also are going to, she's getting treatment in Mexico, which as we all know is fraught with issues because they might not wear gloves. And I also don't understand why some of that paste or whatever that's on our face is only on half of it. What's happening?

Bri (20:15):
I have just so many questions. And was that them injecting. that wasn't stem cells that they were injecting?

Dr. G (20:23):
I don't know what they're doing. You've got to spin it down and you wouldn't have a 60 cc syringe up against someone's arm.

Bri (20:30):
And Yeah, once you inject it in her back?

Dr. G (20:32):
Yeah. In the area that needs to be treated.

Bri (20:36):
I'm very confused.

Dr. G (20:38):
Sometimes people do infusions, but even if you do infusions You need an IV

Bri (20:41):
That's not how you do it.

Dr. G (20:43):
Yeah, you don't just inject it.

Bri (20:45):
I you do. I am injection of stem cells. Bring it interosseous like it's an episode of Grey's Anatomy, what is happening? And then to post that and have no comment about what actually is happening. The eyebrow tape for whatever. If you scroll down, you'll see more eyebrow like what she tape. I don't, she probably had to be honest right there, she probably had her brows tattooed and then just put a little tape over it or something. But she's insane. All of this is very confusing. But yeah, she talks about getting stem cell therapy that's not approved in the US, for good reason. It has no medical merit. Oh yeah. She's using the Dezawa Muse cells.

(21:37):
Interesting.

Dr. G (21:39):
I can't. Also, you can get injections in the US, they just can't label it as stem cell therapy. But the Muse, the fact that it's a branded stem cell treatment when it's your own freaking cells is bananas. Yeah. Since Muse stem cells aren't yet accessible in the us I had to travel to Mexico. Great. So disturbing.

Bri (22:08):
We have questions.

Dr. G (22:10):
Yeah.

Bri (22:12):
I don't even know what the Muse treatment is.

Dr. G (22:14):
That's what I'm saying. It's some branded nonsense. I did look it up yesterday because it couldn't bear it. Branded nonsense treatment that you can only get in Mexico, which means it's not what?

Bri (22:24):
You can only get it in Mexico. That should have been your first red flag. But we also know Kim K doesn't like to look at red flags.

Dr. G (22:32):
Yeah. Okay, so let's talk about anesthesia, which is our topic today. The first celebrity adjacent story is Raven Symone recalls suffering a seizure from anesthesia after undergoing her first breast reduction at 15. And then really the story is more about how she got pushed into getting a breast reduction at 15, which is a little on the young side. She said she was influenced by the discretion of adults around her. She went from a triple D all the way around to a B. I'm not sure I know many 15 year olds who are excited to have triple D surgery, but whatever. But then that was a slippery slope. So in an effort to keep the public from shaming her for her weight, she turned a liposuction. I mean, I feel like the era of child actors and child stars continues. It's now maybe YouTube stars, but this is not like when in the whatever age Judy Garland was in, they just put you on pills.

Bri (23:41):
Don't know who that was.

Dr. G (23:42):
Judy Garland. Come on.

Bri (23:46):
Oh, that's right. You weren't allowed to watch the Wizard of Oz. It's Dorothy, man.

(23:49):
 I've never once seen the Wizard of Oz out of respect for my mother. Yes, he did allow me to watch it. So

Dr. G (24:00):
Anyway, okay, so back in the day, they just used to put the actresses on pills to keep 'em from eating so they could stay small. Raven Symone's now 38. So 15, 20 years ago they just said, you know what? Get a breast reduction, get some lipo while you're there so we can just shrink you down, which is, I'm going to say I

Bri (24:25):
At 15?

Dr. G (24:26):
Bananas to do to somebody who's 15.

Bri (24:29):
I understand that breast reduction, I do do feel like we get some younger girls who just, it inhibits a lot their life, their activities, their sports. But getting a lipo, I mean that's just setting you up for,

Dr. G (24:44):
It's terrible.

Bri (24:45):
A lifetime of body dysmorphia somehow. I don't know how, but it is.

Dr. G (24:49):
It is. So, anyway, so I feel like she talks about this, I'm not sure when the seizure, oh my god,

Bri (24:59):
Caesar.

Dr. G (24:59):
Comes into play. She says she suffered a seizure when she awoke due to the anesthesia. And I'm like, could you again, I have questions.

Bri (25:13):
Yeah,

Dr. G (25:14):
What does that mean? Was she shaking? You know how people shake?

Bri (25:17):
I'm just in imagining. I'm just envisioning when you wake up, people shake.

Dr. G (25:24):
Yeah, I think that's what she's talking about. As you clear the anesthetic.

Bri (25:27):
It's not a seizure.

Dr. G (25:28):
Yeah, I thought it was Demerol insufficiency, but Dr. Abrahams hates when I see that because usually people,

Bri (25:37):
We don't even carry Demerol.

Dr. G (25:39):
I know, I know. But in the hospital setting, when people routinely kind of shake and tremble as they're waking up, the anesthesiologist will just give them some demerol and it knocks it down. However, we rarely have patients that do that because of how our anesthesiologists handle things and people wake up pretty smooth, but if they do shake a little bit when they're waking up, you just have to let them clear the gases. Honestly, it's a very short period. It's like, yeah, I mean seizure's a short period, but it is weird that they label it as such. And then she talks about how she still has scars. Of course, they don't

Bri (26:21):
Magically go away.

Dr. G (26:23):
 And then she said she gained weight and had to go back for a second reduction. They were too big for others. I don't know. She doesn't really say when that was. I mean, again, the one thing about having a breast reduction at 15 is that there is potential that you might need it again because you're not potentially done growing. So I feel like all of this is rooted in some fact. It's just sad that someone felt so exploited and didn't have the feeling that they can make decisions for themselves and so much external pressure at that time. That's depressing. But

Bri (27:03):
I feel like it was everyone from that Disney channel era. All I can think of is Hannah Montana. Okay. Miley Cyrus, all those kids that went through that little couple years of the Disney.

Dr. G (27:14):
Ariana Grande. And you go back a little bit, it's like Britney Spears, Justin Timberlake.

Bri (27:21):
Yeah. They're just

Dr. G (27:23):
Christina Aguilera, all of them.

Bri (27:26):
Yeah.

Dr. G (27:26):
It's sad. Anyway, it sounds like she's come out on the other end. She's married, she's moved on and I think she's got a handle on it. So kk, but we can talk about the risks of anesthesia. Seizure is generally not one of 'em, but it's a potential general anesthesia can increase your risk for seizures i.e. it lowers your seizure threshold. So does caffeine just FYI. So does some other things will lower your seizure threshold. I'm not an expert on seizures. You can have a seizure disorder, but we recently had someone that we canceled surgery for because she failed to disclose that she had been hospitalized for seizures within the last two months for unclear reasons. And I won't get more specific than that for patient privacy reasons. And that wasn't the only reason to cancel her surgery. But when I said, Hey, this is important because having a seizure for whatever reason, be it a low sodium being it a withdrawal from a medication or a drug unknown etiology, all of those things have to be worked out and balanced before you undergo elective surgery under a general anesthetic. Because the anesthetics can lower your ability to have a seizure. So

Bri (29:03):
I know I've harped on this so many times, I really don't understand the need to hide things from your doctors when you are going to be put to sleep. I don't think people understand the importance of letting people know your medical history. Like it's no big deal.

Dr. G (29:21):
Right? Well, I'm not currently seizing right now was sort of the attitude I got back. So I feel like there's two kinds of patients, the ones that are like, can you do it under local because I'm absolutely terrified of anesthesia. Those patients are going to be fine because they usually have no medical problems and they're just anxious, which I get. And then there's the patients that know there is a risk of having anesthetic. They're on a medication like FenFen, that also makes it a little risky. You need to come off of that for two weeks before surgery or you're on a GLP one. You need to come off of that for two weeks before surgery. You're actively smoking. Need to stop that before having anesthesia, all of these things, those patients usually pretend none of that exists or don't disclose it because they're like, I'm sure it'll be fine. I'm like, no, no, no. That's what we're looking for. We were trying to assure you that anesthesia is safe, but it's safe in the context of knowing the full story. So I know that our general theme today is that anesthesia is safe, but the asterisk is in the context of your medical health. So don't mess with that man.

Bri (30:39):
Yeah, be transparent.

Dr. G (30:41):
Don't go out drinking with your anesthesiologist the night before your surgeon or whatever that poor girl did in Turkey. Remember the one?

Bri (30:52):
Yeah. She partied with her surgeon the day before and then she died.

Dr. G (30:56):
Yeah. So what are the most common fears that we hear from patients?

Bri (31:03):
Dying, not waking up and being super nauseous.

Dr. G (31:07):
In that order actually. What's the most common? Being super nauseous.

Bri (31:12):
Yeah.

Dr. G (31:13):
I feel like I've, knock on wood, never seen anybody not wake up from anesthetic. I've heard of it, but it's usually been very tragic, extenuating circumstances. But nauseous, high likelihood. And I think we do a lot of things to make patients aware of that and so that they don't wake up nauseous. I feel like our track record's pretty good here. Again, some of it's the magic of what they're giving you for the anesthetic. Our board certified anesthesiologists minimize the amount of narcotic. It's namely fentanyl that you get IV during surgery when your vital signs indicate that you might be having some discomfort your sleep. But we can tell if something's bugging you because your heart rate goes up or your breathing rate goes a little bit faster if you're not paralyzed and some anesthesiologists will give you extra fentanyl and then you wake up and you want to puke your brains out. So try not to do that. Things you can do in advance are drink plenty of water leading up to the days before your surgery. What else? What am I forgetting?

Bri (32:31):
We also prescribe you a scope patch that you put on the night before, which is super effective. I feel like it helps with the nausea so much. but this also goes into qualifications is, and I am not shaming any CRNAs, but I've also had my fair share of surgery and I think just having somebody who is qualified and knows what they're doing and isn't just flooding you with drugs to make you feel like shit to get through the case. My first surgery I had a CRNA and I wish I would've known the difference. And actually my pre-op was two days before my procedure and they're like, oh, you're actually doing twilight sedation. I was like, oh, what is that? I thought I was going under general and they were like if you want to pay a thousand dollars more. And I was like, at the time I was like 21.

(33:21):
I was like, yeah, no, I am. No. And I was puking my entire ride home. I was so sick. It was miserable. It was a terrible experience. And then I've had surgery with an actual anesthesiologist and it really could have just been, I don't know, I was prescribed the proper medications. I woke up and I felt great. I feel like I should be super nauseous right now. And I wasn't, cuz I was petrified the next time I had surgery of being as sick as I was because I couldn't even take my pain meds. I was so sick.

Dr. G (34:02):
Pain meds also, and I was fine, make me hella nauseous. So even with my, I mean had C-sections under epidurals and again, different contexts. I had board certified anesthesiologists doing my epidural for the C-section. They were elective, but when I was in the setting of a place where I actually worked, they're so stressed out about me feeling something they gave me, they just want to cover their bases, give me a little extra, and I'm like, no, no. And even though it was a spinal anesthetic, I still got nauseous. So I get it. And then so some things you can't control. So being young, being female and having breast surgery are known risk factors for having postoperative nausea and vomiting. But the things we can do are make sure you're properly hydrated, do the scope patch before. There is a medication you can take the morning of that also prevents nausea postoperatively, but it's ridiculously expensive. It's called Ament.

Bri (35:11):
Oh yeah. We're just talking about that yesterday. And I looked it up and it was like, if you have no insurance, it was like $900. I was like, Hmm, won't be prescribing that.

Dr. G (35:21):
I keep waiting for the patent to run out because, or whatever they call, you know what I mean? So that you can prescribe a generic version of it. When that happens, it'll be a game changer. Then people can just do that because the scope patch, it's the one you take for motion sickness or seasickness, not everybody does well with it. Most people do, but maybe one in every 30, they're really drowsy with it or their mouth is super dry or they feel like they're slurring. It can hit people a little bit hard. Most of our patients you put in on the night before you do fine. And then minimizing the amount of narcotics you get during the procedure is also helpful. We do that by having them preload with medications like non steroidals Tylenol the morning of, preoperative Tylenol is helpful. We've been trialing the Journavx, which is another non-narcotic.

(36:13):
All of these things onboard and then me doing local anesthetic before we even get started, all of that minimizes the amount of narcotic that Dr. Abraham or our other board certified anesthesiologists are going to give. And then you wake up just so much better. So yeah, not all anesthesia is the same and you really have to be conscientious about giving them enough fluid but not too much fluid and making sure that we do all of these things because honestly, that's the most common side effect is nausea. That's not the most common fear unless you've had anesthesia and you woke up nauseous and you are really stressed about that. Most people are worried about not waking up or having something untoward happen, which is less, less than 1% chance. I mean, it's really low and we have all the proper things here if you have an issue, so crash cart inspections, the really, really rare risk that you get something called malignant hypothermia. So you get your temperatures go up for as a reaction to the anesthetic gases also pretty rare and was more common with the anesthesia used in the past different gases that most people don't use anymore.

Bri (37:33):
And that's a genetic order. Correct? Yeah. That's why we do, we do a lot of pre-anesthesia evaluations before your procedure and we ask if anyone in your family has ever had complications, if you have any history well known, and that's why you have to let us know your medical history because it's important not just for us, but for the anesthesiologists to be able to predict or outcomes of cases because, say you have that and you mark that, but you're like, oh, whatever, it's fine. That is a way that you can die. You know what I mean? It's just small little things.

Dr. G (38:17):
I think. Yeah. So just disclosing your actual history is important and that helps us decide what the best anesthetic is for you or if you're even safe to have surgery in an outpatient setting. So yeah, we face those decisions in the hospital setting all the time. People sometimes need urgent surgery and you have to balance the risks and benefits. Is it a trauma surgery? Did they just eat all of those things? However, we're doing elective outpatient surgery, so we are going to maximize your safety and if it's not safe, then we're going to politely decline. Right?

Bri (38:56):
Right. A hundred percent.

Dr. G (38:58):
Because we're not taking out your appendix here.

Bri (39:02):
I feel like over the years, at least since when I started working here, we've really upped our criteria between getting lab work, medical history. We have certain ages where we require cardiac clearance, going to see your PCP getting just a bunch of things done. So we know that you are safe to have surgery.

Dr. G (39:30):
And it's not just necessarily, although there have been cases where if you tell us you're otherwise healthy and have no medical problems, you think, well, why do I need your primary care doctor to write a note then? Because sometimes people lie about all kinds of things. But also I've seen patients again where I was like, well, if you haven't seen anybody in a while, maybe you should just go get checked. And then they unearth, literally, I had somebody who had a hemoglobin A1C, which is an indicator of diabetes, and it normally is around five, was like, okay, I'll go get some labs. This is back when I was in the hospital setting and it was a breast reconstruction case. Her hemoglobin A1C was 11. What? She walking around ready to go into a diabetic coma just but hadn't seen a doctor. And so you're like, okay, you need to get that checked out.

(40:26):
Or the patient I saw a long time ago who wanted cosmetic surgery had a history of hepatitis C, and I was like, okay, well who's following you for that? And she's like, oh, I'm praying about it.

Bri (40:38):
Not getting care?

Dr. G (40:39):
No, no, they have medication for it. Your liver. I can't you, it's all about priorities. So yeah, so if you're optimized and you're healthy, then your risk of anesthesia is extremely, extremely low. And those are the patients that we're going to do elective cosmetic surgery in certain circumstances in usually in the hospital setting. We make exceptions because people actually need surgery. But I think sometimes we can tweak it and do certain things under local anesthetic if you are maybe not a good candidate for general anesthesia. But that's generally not why we're doing things under local in our office. Right.

(41:26):
Usually we're doing it under local because it's just

Bri (41:30):
You don't need to go under.

Dr. G (41:30):
We had somebody come in for a labiaplasty consult that asked about going under general anesthesia, and I was like, well, why would you? So the downside of doing it if you don't need it is that it does take a little bit of time to recover in terms of the grogginess and waking up. Whereas if you do it under a local anesthetic, you up and out of here, no big deal. Especially if it's something like labiaplasty where you're still numb so you don't feel it's like having a dental procedure. Most people don't need to be under for that. And once the numbing wears off, you need to be in a place where you can recover well, but you don't need to be under a general anesthetic. Eyelid lifts, upper lid blepharoplasty, we do under local anesthesia. I think we're doing one today, correct?

Bri (42:22):
Right.

Dr. G (42:22):
Dr. Chao has one. No reason to go completely asleep for us to remove skin from your upper eyelids. You just don't need to. You're just adding all those medications that are required to put you to sleep and to wake you up for something that could be done with just a little local anesthetic. And then maybe we should break down what local versus general means. Huh?

Bri (42:49):
What'd you say? Hetero?

Dr. G (42:52):
Heteronormative?

Bri (42:54):
Heteronormative. Straight local. So here in our office we do straight local, which is, there is no anesthetic use whatsoever. We do give you an option to have, it's called an MKO melt, which is a very, very light dose of sounds scary, but ketamine, percocet and Zofran, and it's just like having a couple margaritas. We have, I mean you need a ride home from that, but we have the Nioxin office, which is just like laughing gas. And those are all things that can be done in conjunction with the local, which is just injecting local into the site you're having done, you're fully awake for it. We do IV sedation. Dr. Chao is very big on IV sedation and she loves doing facelifts under IV sedation. That is still and carries the same cost as going under general. But for a lot of her patients, she does have an older population who it is probably more health conscious to be awake. They're still getting a good mix of ketamine or fentanyl, but they're able to talk back. They're able to actually make movements during the procedure. You're not fully, fully asleep. You still may remember a little bit, but hopefully the versed does its job and then you can just be knocked out. So

Dr. G (44:19):
That's the general anesthesia.

Bri (44:21):
Yeah.

Dr. G (44:21):
So straight local, we're just injecting, like you went to the dentist and we're going to numb up the area and do our thing. And you're fully present for the whole thing. That's most commonly labiaplasty for us because people will chitchat and whatever kind of hang out. You shouldn't feel anything. You won't feel anything. It's just weird. You might feel some tugging, you might feel some pulling, but you're not going to feel anything sharp. We do that under the local, we do the upper eyelids, we do implant removal. We have four of them coming up in the next couple of weeks. So I will numb your old incision wherever that might be. So inject local anesthetic, make an incision, you won't feel anything, and then you'll feel pulling and tugging as I remove the implant and then I close up the incision. So you can be fully awake for that.

(45:14):
But if you're a little bit anxious or nervous, then like Bri said, you can take the sedative, you can huff on the pronox, you just need a ride home. And then yeah, IV sedation. I think one of the things that the older patients who are getting facial rejuvenation surgery appreciate about that is that you're less groggy. You can have something called a post anesthetic cognitive delay or where you're just a little foggy. And that can be for a few days afterwards. And it's harder hitting for patients who are older, like sixties, seventies. Again, if you think you're prone to that or you are older, again, the anesthesiologist can tweak things so that they're not, they're minimizing the amount of medications you get intraoperatively so that you don't wake up as groggy and having to clear that. But yeah, IV conscious sedation, man, you guys do the facelift, wrap 'em all up and they walk out.

Bri (46:22):
And so we did one not too long ago and the patient, I mean I was in the patient's face the whole time, but she just opened her eyes and be like, wow. She actually offered to hold one of the retractors. She was saying the names a thing. It was hilarious. She was so funny. But they do, people do so well. And I think I was just as surprised because I had never done a facelift under IV sedation and people do great. Would I recommend it for every procedure? Absolutely not.

Dr. G (46:52):
No. And there are definitely certain things that are a little, so one of the things about IV sedation is sometimes patients are interested in it because they think it's going to be cheaper. In our office setting, our anesthesiologist does the sedation so it's not cheaper. You're still paying for the anesthesiologist to be there. So if you're doing, I don't know, if you're doing IV conscious sedation, maybe with a nurse, then maybe it's a little bit less, but we don't offer that. So you want somebody, this is where people get into trouble. You want to make sure somebody certified in sedation who is not the same person as your surgeon is doing the procedure.

Bri (47:37):
They can't do both.

Dr. G (47:39):
You should not be doing both. It's a conflict of interest.

Bri (47:43):
You just scrub out every time you have to push meds

Dr. G (47:48):
Well, so

Bri (47:49):
You can't monitor and watch and do surgery. None of it works.

Dr. G (47:54):
No. So generally speaking, you're not pushing the meds, but you're directing somebody. So you're in charge of the sedation as well as doing the surgery. And I think it's a little bit arrogant to think that you can do both and do it well. So if there's any issues, if you're doing a colonoscopy, sure, you can direct the sedation maybe, but a facelift, maybe you should be focused on the facelift and let somebody else monitor the patient's vital signs, be writing that stuff down every five minutes, assessing whether they're feeling pain, dealing with all of that. And you just focus on doing the surgery and not saying anything inappropriate because the patient's awake. Right. That's already energy.

Bri (48:38):
I made a joke in one of Dr. Chao's facelifts. The patient was awake and I said, sorry, first day. And she was like, oh wait, it's not her first day. I swear. I was like, oh, it's

Dr. G (48:51):
Just a joke we have. Sorry.

Bri (48:52):
It was just a joke and it was something so silly.

Dr. G (48:56):
Yeah,

Bri (48:57):
That's a me and her thing that we say, yeah, so I learned my lesson there, but she does not like my first day jokes.

Dr. G (49:10):
So you do have to be a little bit more cognizant. But I do think if you're going to do it under IV sedation, an actual provider who's responsible only for the sedation should be doing that. And the surgeon can be doing surgeon things. And when you do see horror stories about people having horrible outcomes after having something,

Bri (49:28):
The scrub tech doing the anesthesia.

Dr. G (49:31):
It's happened in San Diego where someone, yeah, they did not have an anesthesiologist. They're doing a breast augmentation under, I don't know what, IV sedation by the scrub tech. No one else is licensed to do anything. And then you have an outcome. It's awful. It's so awful. And it's happened. I remember reading a story about it. We had to, when I was in training about a guy in Manhattan that was doing that, he had built his own little OR, and he was doing twilight anesthesia, facelifts and somebody crashed and died and it's just you and you're doing all of it. It just, it's, it doesn't make sense. It's not worth it.

Bri (50:12):
And how would you manage, I mean, realistically, no offense, but surgeons focus on surgery. They're not managing the airway. They probably haven't done anything airway since they've been in the hospital.

Dr. G (50:25):
I know. We're managing to knock the airway out.

Bri (50:28):
Exactly. There's no way if there was an airway emergency that anybody else would be able to manage that appropriately. There's many different positions that are needed if there was an emergency and having people that aren't qualified to do those positions. You know what I mean? If something were to happen, we all have very strict roles. We have policies, we have procedures on how to transfer patients to hospitals. We have certain things, anesthesia would be on airway, most likely I would probably be on compressions. You're going to be directing meds. You have Azella who's going to be getting the crash card. And everyone has very specific roles. And you can't do that with unqualified people that don't know what they're doing.

Dr. G (51:12):
Horrible.

Bri (51:13):
It just sounds like a bad idea.

Dr. G (51:16):
Yeah. I feel like we take safety pretty seriously, even though we come across as pretty lighthearted. We don't f around with it. And that's why we have other surgeons that operate here. That's why, as much of a pain, Dr. Abraham can be sometimes, I like it where he's like, what? No.

Bri (51:35):
If you're listening.

Dr. G (51:37):
He's not listening to us.

Bri (51:40):
Absolutely not.

Dr. G (51:44):
So there's a lot of safe, we're keeping the patient warm. That's my favorite thing to bug Dr. Abraham about is the patient temperature. Our room is hot. There's just so many little things that you're taking care of as a group collectively. I think we mentioned CRNAs, and I don't want to have CRNAs come at me, but the difference between the two of 'em is as is most things in this country complicated. So a CRNA is a nurse anesthetist, anesthetists say that 10 times fast. So they are someone who went to nursing school, generally did higher level of nursing like ICU in order to get qualified to go to this special school where they do anesthesia. Originally, the idea

Bri (52:33):
The master's program that is about 22 months,

Dr. G (52:37):
Two years. So not medical school and an anesthesia residency, which is like five years or specialty, you know what I mean? So not nine years, but two years or a little less than two years. Ostensibly they were supposed to be extenders, so they should be practicing under an anesthesiologist, but it gets muddled from state to state, just like a nurse practitioner. So in some states they can practice, well, not technically, independently, but they're practicing under the auspices of the surgeon. And in other states they have to be under an anesthesiologist. And an anesthesiologist is then responsible for three or four CRNAs. So it's like a pyramid scheme. You can run three or four rooms because the anesthesiologist is monitoring all three or four, three or four CRNAs. That was the original game plan. But now they can do anesthesia on their own in an outpatient setting, and the person responsible for them is the surgeon. Which again, brings me back to the whole, sure: Have I worked with CRNAs in the past in hospital settings that were amazing? Yes. That I thought could rise up to the level of the anesthesiologist. Sure. But do you know if you're getting the CRNA that just graduated last year, or the Navy guy that got kicked out to Afghanistan and had to function as an anesthesiologist under some really crazy conditions and is not phased by anything and is going to practice safe medicine? Impossible to know. I will say in San Diego, there are some retired navy CRNAs floating around that do outpatient surgery and they're good.

Bri (54:14):
Yeah, I know some phenomenal CRNA's, but like you said, you just don't know who you're getting.

Dr. G (54:20):
Are you going to screen 'em? Yeah.

Bri (54:22):
Right. It's like going to, here's my analogy for the day. I'm thinking about the Amazon Prime trucks, but it's like going to a med spa and you have these nurses who are injecting under a doctor. You know what I mean? You can go to a really crappy med spa and get a crappy nurse who doesn't know how to inject where they're injecting. Or you can go to a phenomenal one and get a really great injector. You just don't know. And you don't want to learn that by

Dr. G (54:48):
The hard way.

Bri (54:48):
The hard way. But there are some phenomenal CRNAs and I worked with a bunch of 'em, CRNAs at Camp Pendleton Hospital who did a great job, who actually anesthesiologist called when they had a problem or a heart stick or something, you know what I mean? But

Dr. G (55:04):
I will say the Navy CRNAs are solid. So if you can find one of those, because they are put in positions where they almost have to practice independently and are really good.

Bri (55:17):
So no shame. It's just education differences.

Dr. G (55:20):
Yes. Just make sure you're educating, just learn about things before you take the plunge or again, disclose everything before you allow us to make those decisions for you. Yeah, and I think is there a big anesthesia myth we wish would disappear?

Bri (55:40):
I don't know. I feel like people, I really don't know.

Dr. G (55:46):
No, I think it's the risk of dying, I think is, and it happens to be our population is usually women who have children and are worried about relinquishing control of their breathing and everything to somebody for several hours and worried about how that's going to go. And I get it. I too have been under anesthesia and a little stressed about it. And I think it's interesting that my male colleagues who were also surgeons were like, why are you worried? You just get a nap. I was like, okay, someone, someone's breathing for you. Awesome.

Bri (56:21):
Close your eyes. And then you wake up literally one second later. I'm always like, my skin looks so great. I feel like that's the most hydrated I've been during surgery. Dr. Abraham did not like that answer when I said it, but we like safe surgery. He is conservative, he does love safe surgery. He will go through your background, your charts. He just wants to make sure all his bases are covered. Like we said, this is an elective office where we want happy surgery, we want good outcomes. So there's no reason you should be coming in to get an emergency breast aug if you have poor medical history. It is not worth it. It is not worth the risks of something happening during surgery. It's just not. So you go through a whole bunch of different people to make sure that you are a good candidate and yeah.

Dr. G (57:19):
I feel like you should listen to this episode and then follow it with what makes good recovery. Because those two things are important parts of having surgery, making sure your ducks are lined up, you're getting the right anesthetic for the right procedure and it's safe. And then making sure you've given yourself the appropriate time and resources to recover so that everything goes as well as expected.

Bri (57:43):
Wherever you go, I just have to say, ask a lot of questions. Something I never did before I started working here. Ask what kind of providers doing your anesthesia, ask what kind of anesthesias best, just ask all the questions. Make sure, yeah, their accreditation. It's really important to make sure, like I said, we have a fully accredited OR, we have everything that we need here for pretty much all if things were to go wrong. So

Dr. G (58:11):
That's

(58:11):
How we ward off evil spirits.

Bri (58:13):
Yeah, good Juju. Gotten some sage. We saged the office the other day and it just smelled like we were just smoking. We were getting high as a kite in here. I was like, it was, my gosh.

Dr. G (58:27):
It was strong.

Bri (58:27):
I came home and I smelled like it and they were like, did you smoke? I was like,

Dr. G (58:35):
We needed a cleansing. Okay.

Bri (58:37):
Yeah, good juju.

Dr. G (58:40):
Okay, so I think we've covered most of the basics about anesthesia and elective surgery, but if you have questions or want more information like and subscribe and put your questions in the comments because we want to know what you're thinking and what we missed.

Bri (58:59):
Yeah, lock in. I've been waiting to say that.

Dr. G (59:03):
Lock in. Alright, we're going to scrub in.

Bri (59:06):
And scrub out.

Dr. G (59:09):
If you're listening today and have questions, need info about scheduling, financing, reviews, or photos, check out the show notes for links. Restore SD Plastic Surgery is located in La Jolla, California. To learn more about us, go to restoresdplasticsurgery.com or follow us on Instagram @restoreSDplasticsurgery. If you enjoyed this episode, please share it and subscribe to All the B's on YouTube, apple Podcasts, Spotify, or wherever you like to listen to podcast.