Plastic & Reconstructive Surgery

Date Published: 
October 2003

Plastic and Reconstructive Surgery®

Dear Dr. Goldwyn,

Standards and Credibility

Congratulations to Bitar et. al. (1) on the publication of their recent article. While I was honored to be among the cited references (2) on office based anesthesia, I was nevertheless quite dismayed by several egregious omissions in the article.

First and foremost was the lack of an institutional review board (IRB) approval for this retrospective chart review. Second, while this is most clearly an anesthesia article, the nurse administering the anesthesia was conspicuously absent from the authors. Curious minds must wonder why.

Third, while a BIS monitor was described as among the monitors used, no mention of the levels of BIS sedation were made in either the ‘Results’ or ‘Discussion.’. Why? Fourth, despite a typical postoperative nausea and vomiting (PONV) rate of 15-40% cited in the literature and the routine use of emetogenic fentanyl in all cases, Bitar, et. al. report a 0.5% rate without any anti-emetic treatment like droperidol, ondansetron, or dexamethasone. To say this report strains the limits of credibility is to be an understatement in the extreme.

Fifth, 99.9% of the cases reported on were either ASA class I or II. Healthy patients tend to do well despite the therapeutic regimen rather than because of it. Sixth, despite reporting the use of ketamine in some of their patients, there is no indication of any incidence of negative psychotropic experiences in these patients. Had they reported titrating the propofol to BIS of 60-70 for the cases (3), one would have had no issue with the failure to report on such outcomes.

Barry L. Friedberg, M.D.
Corona del Mar, CA


1. Bitar G, Mullis W, Jacobs W, et. al. Safety and efficacy of office-based surgery with monitored anesthesia care/sedation in 4778 consecutive plastic surgery procedures. Plast Reconstr Surg 2003;3:150-6.
2. Friedberg BL. Propofol-ketamine technique, dissociative anesthesia for office surgery: a five year review of 1264 Cases. Aesth Plast Surg 1999;23:70-75.
3. Friedberg BL, Sigl JC. Clonidine premedication decreases propofol consumption during bispectral (BIS)index monitored propofol-ketamine technique for office based surgery. Dermatol Surg 2000;26:848-52.

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