Paulette Hacker couldn’t stop screaming. Lying on her side on a gurney, wearing only a bra and briefs, she felt as if she was 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. although Hacker’s body was limp and her mind bleary from an unknown combination of drugs she’d been given orally and via a gas mask, the 38 year old was awake part way through the second day of liposuction on her back, underarms, abdomen, hips and neck. that was the whole point. she was undergoing a new and aggressively marketed procedure called Awake cosmetic surgery, which, as the name suggests, is performed under local anaesthetic.
“You can’t scream, Paulette,” a gruff voice answered. The voice did not belong to her doctor; the man performing her operation was a stranger who, she would later discover, was a physician’s assistant. according to Hacker’s Los Angeles Superior Court complaint, she could see people coming and going into the “operating room” – more like an oversized examination room – at the Rodeo Drive office of Dr Craig Alan Bittner, a “liposculpture” practitioner in LA. (Through his lawyer, Dr Bittner strongly denies all Hacker’s allegations.)
“Move her into the TV room – she’s making too much noise,” a confused and terrified Hacker heard another voice instruct. Her gurney was rolled down the hallway 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 recalls. then he manoeuvred her beside him and told her to smile for a photo.
Hacker had been excited about the procedure. The stay-at-home mum weighed 105kg and was trying to slim down; she’d lost 10kg 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 a general anaesthetic.
Surfing the web, Hacker had discovered the Awake procedure, which was advertised as a cheaper and more medically advanced alternative to conventional lipo – and, for those so inclined, abdominoplasty and breast enhancement, too. The price was right: Awake lipo with Dr Bittner would cost only about $700 for each body part, compared to $3000 if she had regular plastic surgery. she found it comforting that the lipo would be performed in a doctor’s cosy office, not in an intimidating out-patient surgical facility or hospital. best of all to Hacker, Awake advertising material 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,” remembers Hacker. “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,” according to Dr Joseph Gryskiewicz, of The American Society for Aesthetic Plastic Surgery (ASAPS). “It has to do with doctors not needing to involve an anaesthetic.” General anaesthetic 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 their offices. “This is just a gimmick by people who can’t operate their way out of a wet paper bag,” alleges Dr Gryskiewicz.
Hacker chose Dr Bittner after studying his website, which showcased his elite education, testimonials and photos of smiling patients next to the tall, tanned doctor. Hacker checked to make sure he was qualified, and there it was: “board-certified”. she didn’t realise that he was a board-certified radiologist. a non-plastic surgery background is the norm for Awake practitioners, who tend to be family doctors, obstetricians, ophthalmologists, pathologists – any doctor willing to shell out up to $7000 for two-day training courses held around 30 times a year by recently formed professional associations.
It’s emblematic of a growing problem of amateurism in the plastic surgery field, warns Dr Michael F McGuire, a director of the American Board of Plastic Surgery, the group that certifies plastic surgeons. a 2010 study found that in Southern California, 40 per cent of liposuction practitioners had no specific surgical training before entering practice. The study found one of the biggest 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 a “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, says Dr McGuire, because of the host of emergencies that could arise, including blocked airways, blood pressure changes or collapsed lungs. full tummy tucks are the most invasive of all, risking abdominal perforation. Dr McGuire calls it “inconceivable that anyone would do such a major procedure under anything less than a light general anaesthetic”. He cites Awake surgery as part of a disturbing trend of non-plastic surgeons attempting procedures that have not been thoroughly tested, and unabashedly touting them to the public as the next big Thing. “Awake surgery is a carnival sideshow event,” fumes Dr McGuire. “Your life could be at stake with some of these kooks.”
An Awake breast-implant procedure in the Texas office of Dr Jeffrey C Caruth often starts with a small dose of 5–10mg of valium to relax the patient. “If they take too much sedative, they’re going to have trouble picking out a size,” says Dr Caruth, a medical board-certified obstetrician and gynaecologist who has performed more than 200 Awake breast jobs since his training course in may 2008 (as well as 1000 Awake liposuctions, charging up to $5000 per surgery). Dr Caruth injects each breast with a small amount of anaesthetic fluid lidocaine. When the area numbs, he makes his first incision. There’s no anaesthetist 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,” claims Dr Caruth. “It’s actually a lot of fun; we play music and talk.” He says his patients feel nothing as he injects the tumescent fluid – a solution of saline, lidocaine and epinephrine – and makes more incisions. next, they feel pulling as he stretches skin and muscle to create a pocket large enough for implants. then comes the climactic moment: the gurney is adjusted upright so the patient 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 whether 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. 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.
However, when a patient is sedated, her judgement is clouded, making her more prone to irrational decisions or to being overly influenced by onlookers, says Dr Herluf Lund, a plastic surgeon 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 on minimal sedation – about half of his patients take no valium at all – and that he’s had only two patients who wanted another operation, both to go bigger. “I know people who say they do Awake breast augmentation and then slam the patient with narcotics,” he remarks. “That’s not the case here.” but even among patients who aren’t sedated, the time to make reasoned decisions is before surgery, asserts Dr Lund. “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!’” comments Dr Lund. “Later, if you’re not happy, the doctor can say, ‘Well, I gave you what you wanted.’”
Without an anaesthetist present, patients can also end up in agony. Dr Caruth says he’s able to resolve discomfort with an extra squirt of local anaesthetic. 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 carry on.
Soon after her painful procedures, Hacker returned home bandaged, swollen and sore. “I hurt so much, I couldn’t function,” she recalls. Her body swelled out of control despite her wearing a pressurised garment for eight weeks, and she had neck and back pain so wrenching, she couldn’t lift her young daughter for the next 18 months.
The more facts Hacker learnt about her physician, the more disturbed she became. Three other patients had come forward, alleging their Awake lipo was performed not by Dr Bittner but by his office manager (a woman with no medical licence 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. she also learnt that no doctor should have given her lipo in the first place. It is inappropriate for obese patients because of a higher risk of complications, and because surgeons can safely remove only two kilograms of fat, asserts Dr McGuire. Worse, experts say, multiple sessionson many body parts over sequential
days – common among Awake practitioners – vastly increases the dangers. When she shared post-operative reports from Dr Bittner’s office with another doctor, Hacker learnt her blood pressure went so high during the procedure that she could have had a stroke.
The main organisation pushing the Awake-training gold rush is the American Academy of Cosmetic Gynecologists, a group with an official-sounding title, but one that is open to any licensed obstetrician or gynaecologist willing to pay the $300 membership fee. Founded six years ago, the “academy” quickly attracted so many practitioners clamouring to join that other organisations, all linked to the original, sprouted up to accommodate them.
They offer two-day courses in Awake liposuction (at a cost of $5000), tummy tucks ($7000) and breast augmentation ($7000). Among the instructors is Dr Anil Gandhi, a general surgeon in California who is not board-certified in any field. his Awake breast augmentation workshop, which includes lectures on start-up costs, promotional materials and handling dissatisfied patients, lasts 22 hours. It takes more than five years in a US residency program to train surgeons to perform breast augmentation.
The threat to patients is very real. After a 37-year-old Florida woman went into shock and died after having lipo with a doctor trained only by short courses designed for gynaecologists, the state board of medicine found that “these courses do not provide adequate training to develop the proper surgical judgement” on who is a good candidate, which form of anaesthetic is safest and how to deal with complications.
A few US state medical boards have tried to stem the tide of doctors’ “scope drift” into cosmetic surgery, but with little oversight, “it’s a buyer-beware situation”, warns Dr McGuire.
Just ask Paulette Hacker, who hasn’t been the same since her Awake lipo. Her “bargain” surgery ended up costing her an additional $6000 worth of chiropractor sessions and hyperbaric oxygen treatments to ease her pain. And she estimates she’ll spend thousands more to correct the aesthetic damage; whenever she looks in the mirror, she’s reminded of her Awake mistake.
She’s been left with a lumpy back, misshapen belly, uneven hips, a neck striated with scar tissue, an asymmetrical jawline and a conga line of dots down her sides. “I thought I was an educated consumer, an intelligent person,” sighs Hacker. “I wish I had known. If they’re not properly trained and certified as a plastic surgeon, they have no business cutting through your skin. If something seems too good to be true, then it is.”
<a href="http://au.lifestyle.yahoo.com/marie-claire/features/world/article/-/10496965/awake-and-under-the-knife/tag:news.google.com,2005:cluster=http://au.lifestyle.yahoo.com/marie-claire/features/world/article/-/10496965/awake-and-under-the-knife/Wed, 19 Oct 2011 03:06:45 GMT”>Awake And Under The Knife