PODCAST: Who Shouldn’t Have Surgery Under Local Anesthesia?

Some people avoid general anesthesia procedures because they don’t want to commit to the downtime, while others have a fear of not being in control of their own body.

If you’re one of these people, the good news is you can have procedures like face and neck lifts, blepharoplasty, and even liposuction under local anesthesia. But if you have a low pain tolerance and can’t handle needles, you probably shouldn’t rely on local for your cosmetic procedures.

Drs. Bharti and Kortesis outline the procedures which can easily be done under local, the benefits of choosing local over general anesthesia, and the limitations of local.


Speaker 1 (00:03):
You’re listening to Dr. Bill Kortesis and Dr. Gaurav Bharti on It’s Complicated, the podcast that uncomplicates the mental and physical aspects of life and the aesthetic surgery to help anyone committed to achieving their personal best.

Dr. Bharti (00:19):
All right, everybody, uh, G here. And we’re gonna talk about having surgery under local and what procedures you can do easily under local that you can do and you can just move forward, top procedure for under local.

Dr. Kortesis (00:30):
I didn’t realize how many people were, are nervous and scared about general anesthesia and they just do not want to go under general anesthesia. And I’m one of these people, I’m, I’m a little bit of a control freak. Shocking if you didn’t know who I am. But part of that is like, I don’t like not being in control of my body. And so for me, doing things on our local would be absolutely fantastic. So yeah, I think it’s a growing part of our field and I think people want to have procedures done under local anesthesia. So to your question, what things can you do? Any facial procedure, any facial procedure you want can be done very easily under local anesthesia.

Dr. Bharti (01:07):
So then perks though. So I’m the patient and I’m like, well, should I do it under local or should I do it under general? What do you recommend?

Dr. Kortesis (01:14):
I, I would say whatever the patient ultimately wants. And the, and the reason for that, you, you give them the option. Again, if you’re me and you’re a control freak, heck yeah, local anesthesia all day long. But it’s also your pain tolerance level. If you’re one of these individuals or squirmy and you can’t do deal with needles or the one little ounce of pain’s gonna, you’re not a candidate for local anesthesia. But if you can tolerate it and you don’t want to go asleep, local’s the bomb, and like I said, you can do eyes facelifts, neck lifts, liposuction can be done under local anesthesia. You can do some small excisional procedures under local anesthesia, hair transplantation under local anesthesia.

Dr. Bharti (01:57):

Dr. Kortesis (01:58):
So it, it’s a pretty remarkable thing we do. I mean, how about you? I mean, I’ve talked a little bit. I mean, would what would you want?

Dr. Bharti (02:05):
Here’s my deal. Like I don’t want to feel like shit afterwards. So I have a phobia of getting anesthesia that I’m gonna feel bad cuz I’m worried about throwing up. Like if I throw up, I’m dying. So I have

Dr. Kortesis (02:15):
Like you’re on a boat.

Dr. Bharti (02:16):
Yeah. Oh I get so sick on boats and like I don’t want to have that feeling after. So that’s my fear. And so typically that’s an important thing about local. With local you have less incidents of postoperative nausea and vomiting cuz you’re getting less volatile anesthetics. Now I just wanted to say something. We, we don’t poo poo anesthesia cuz we’re able to do anesthesia in an incredible way and have very low incidents. But there’s no doubt if you get local anesthesia you can rebound and you have essentially no real hangover like anesthesia hangover.

Dr. Kortesis (02:44):
The other part is a caretaker. You know, if you have general anesthesia, you need somebody with you for 24 full hours by your side. And that’s a little known fact that, you know, patients don’t necessarily know. And so with local, you don’t have to have somebody with you for those first 24. And so if you live alone or you know, you don’t have a significant other local may be a better option for you.

Dr. Bharti (03:05):
No doubt. And, and I think patients need to understand what it means to get local. What does local mean? Local means that you use something called an anesthetic. An anesthetic like lidocaine. Most people heard the word lidocaine or Marcaine or bupivacaine or ropivacaine. There’s a bunch of these and that local anesthesia often will have something called epinephrine in it. And so when you do go to get local, no matter what, there has to be a stick. And that stick obviously can cause pain. But what we can do with that local is we can add something called buffer to it so that actually, cuz usually when you use just local by itself, it burns while they’re injecting it. But we can add buffer to it so that it’s more isotonic or the pH is more balanced to your body. So it hurts a little less.

And so that can make it better. What we’ll do in our practice is we’ll also give them potentially a little oral relaxation medicine like a Valium et cetera, which is an anxiolytic which kind of lowers that anxiety level. And I, when I say the word anxiety, it’s an important cause it’s a little segue. If a patient, I’m looking at her or him anxious as hell freaking out about having this surgery and, and think, yeah, I wanna do under local, I wanna do it learned local. And you’re like, hold on. How do you normally do with pain? Or do you like the idea of us, you know, making incisions or using a needle in a knife somewhere close to your eye and you can just, and quickly you realize, mm, this person is probably not the best candidate cuz we’ve all been there where you have a situation where you’re doing something under local and they’re just not a good match. Cuz what you don’t wanna do is be caught with your pants down during an intervention. So sometimes you a patient,

Dr. Kortesis (04:30):
You gotta keep your pants up, G.

Dr. Bharti (04:31):
Always keep your pants on. No. So and so I think that’s an important thing, right? Don’t walk around with your pants off, it’s just gonna get you into trouble. Right. And so same with with surgical intervention, but most people do phenomenal with it. And we have other tools now where we can use something like prox, which is inhaled nitrous essentially, that will again take the edge off. And so there are lots of things that we can do under local that do phenomen.

Dr. Kortesis (04:53):
I always tell them it’s like one or two glasses of wine.

Dr. Bharti (04:55):

Dr. Kortesis (04:55):
You know, it just inhibits them ever so slightly so you can do what you need to do your practice. What are the top three procedures you perform currently under local anesthesia?

Dr. Bharti (05:05):
Number one is for sure upper lid blepharoplasty, which is an eyelid lift where you remove that extra skin and close it. And the idea for that is to get rid of the hooding around the eyes just so people look more alert.

Dr. Kortesis (05:16):
Such an amazing operation. 20 minutes, refreshed.

Dr. Bharti (05:20):

Dr. Kortesis (05:20):
Really no downtime. Pretty remarkable.

Dr. Bharti (05:22):
Next, next one is, uh, central lip lift. Upper lip lift is probably two now. And some of these are, are are changing, you know, cuz there’s different, um, things that are hot and that are not. And then the next one is probably under your chin contouring. Like either a neck lift or, or um, liposuction under the chin. But I will, I will say though, there’s some other ones that have become a little bit more popular too.

Dr. Kortesis (05:43):
I always walk in the room and see G doing dimple creation dimples. I think he creates like 1 million dimples in Charlotte.

Dr. Bharti (05:49):
Listen, I I’m gonna tell you like, that procedure is incredible and the results are remarkable. And I think people are just amazing. They’re beautiful in their own right. But when you add dimples to some to patients and they’re actually dynamic, so you, you’ll you’ll create a little indentation and then when they smile you can see it. It’s, it’s pretty awesome. But the patients born in anything are are thrilled with it. They’re thrilled. And it takes like literally 15 to 30 minutes, no external incision at all. Buckle fat’s. Another one we do under local always.

Dr. Kortesis (06:16):
You know, I do a ton of implant removals under local anesthesia or potential even implant exchanges

Dr. Bharti (06:23):
A hundred percent.

Dr. Kortesis (06:23):
If it’s just for size discrepancies.

Dr. Bharti (06:25):
Yeah. And I think the crazy thing is the area that you’re actually working at and having to make an incision is extremely small. And the best thing about it though, like you, the patients walk themselves out and they can carry on with their day. So I think there is something that we have to pay respect to as surgeons. We sometimes are just like, we just don’t want ’em to be, you know, moving. We want them to be calm and collected. But I think that a lot more things that we do actually can be done under local.

Dr. Kortesis (06:52):
If you’re a patient, how do you bring this up to your surgeon?

Dr. Bharti (06:56):
Well I think that ask them, I think you need to

Dr. Kortesis (06:59):
Am I a candidate for local anesthesia?

Dr. Bharti (07:00):
Yeah. And so sometimes here’s the conversation, then the patient’s like, well it’s local, so good, I want you to do my tummy tuck and liposuction and fat grafting under local.

Dr. Kortesis (07:09):
Yeah. So there, there is some limitations with local, you know, to that some of those medicines you were naming, they have maximums that you could actually give somebody because if you give more than that, they can be detrimental. And so in those cases where you’re doing larger surface areas, those cannot be done under local anesthesia just because of the fact that you’re having to give too much of that medication.

Dr. Bharti (07:31):
Yep. And I will say cuz we like to really just always be accurate, um, versus just, you know, saying something or somebody says, oh, we need to fact check that podcast. Is that there are ways to do those things under local. We have some colleagues like, uh, Gruber down in Florida who’s a pioneer in local and local procedures and doing practically everything under local. But the key is you do have to segment them off and you can do things more compartmentalized and then you can use different, uh, concoctions or different type of formulations in that local. So, uh, sometimes you really can do that. There are situations where I do a better job with a patient getting anesthesia and that’s me and you. And so I think that we have to be very poignant about that. At the end of the day, the patient typically wants the best outcome. You as a surgeon want the best outcome. So I think at times we have to modify that. But anytime that I think we can do something under the local, I think it makes sense.

Dr. Kortesis (08:22):
But, this is a really good follow up to this. Say anesthesia question. What is really considered general anesthesia? And is general anesthesia all the same or is it not?

Dr. Bharti (08:31):
That’s a great point. And I think you’re right because if you did local for example, and you give two agents, you’re kind of, it is almost in a state of like conscious sedation. And what does that mean?

Dr. Kortesis (08:43):
So I, you know, I tell everybody that anesthesia is a gradient. You can go really light or you can go as aggressive to the point where you’re not breathing on your own.

Dr. Bharti (08:52):

Dr. Kortesis (08:53):
And you need a breathing tube to help you breathe. Yeah. Or you can go really light where you’re, you’re not cognizant of what’s happening, but you’re still breathing on your own and there’s different levels of, of what that ultimately means. But if you’re giving a couple of material drugs, that’s considered general anesthesia.

Dr. Bharti (09:10):
That’s, it’s very interesting. And then the other thing is, so let’s just say that someone wants to do something under the local, but really what they’re getting is kind of a, a deeper sedation or if someone’s doing something under Tiva. So the idea of Tiva means all the anesthesia’s being given through your iv, there’s nothing going through your mouth. Now an example to like that is, uh, like when you get your colonoscopy, right, using propofol, et cetera. But there are instances where even though you can do that, and we talk to our anesthesia providers, their thing is like, listen, uh, we can run TIVA, but we just need to protect the airway. And I think patients need to understand what that means. Protect the airway means that sometimes if you get a little bit too much anesthesia or you, there could be a choke event or a little aspiration and then that some fluid can go down the wrong tube, meaning not your esophagus, but it can go down into your windpipe.

You can get something called aspiration pneumonitis and a bag of issues. So sometimes we actually need to just protect the airway and you can actually run them on a very low level anesthesia and the patient’s not paralyzed is breathing on their own. So I think, um, we just have to be careful. Cause sometimes being a, a cavalier or being like, oh, we can do all of this under local is no problem. And then we found that some of our colleagues are giving these huge whopping doses of oral agents so you can get a respiratory depression, um, and you can get a potential issue. So it’s like, just because you can doesn’t mean you should. And you just gotta always think and be ready for the worst.

Dr. Kortesis (10:29):
And don’t be caught with your pants down.

Dr. Bharti (10:31):
Don’t be caught with your pants down.

Speaker 1 (10:35):
Links to learn more about anything mentioned on today’s show are available in the show notes. To learn more about Dr. Bill Kortesis and Dr. Gaurav Bharti and the entire team of HKB cosmetic surgery, just go to hkb or follow HKB on Instagram at hkb cosmetic surgery. Subscribe to our newsletter for key takeaways from each episode, links to any resources we discuss and promo codes or giveaways from HKB and our partners. If this show has helped you in any way, if you learn something, write a review on Apple Podcast and share the podcast with a friend. Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment. Or mention the promo code PODCAST to receive $25 off any service or product of $50 or more. It’s Complicated as a production of The Axis, t h e

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