Plastic & Reconstructive Surgery

Date Published: 
February 2009

Lethal Pulmonary Embolisms Are Avoidable

Congratulations to Keyes, et al(1), on their recent publication identifying pulmonary embolism as the leading cause of mortality in office-based abdominoplasty. Unfortunately, mortality from hospital-based abdominoplasty, not infrequently combined with hysterectomy, was not reported and, very likely, equals (or exceeds) on an annual rate the 23 deaths reported for the 5 years in their study. All abdominoplasty, as well as all cosmetic, deaths regardless of their operative location should be reported.(2)

In 2005, the late Dr. Ann Lofsky wrote that “immobility associated with general anesthesia is a significant risk factor for thromboembolism,” and that “newer techniques for intravenous sedation that include the use of propofol drips, often in combination with other drugs, have made it possible to perform lengthy or extensive surgeries without general anesthesia and without the loss of the patient's airway protective reftexes.”(3)

Dr. Lofsky was referring to propofol ketamine (PK) technique(4) which, in addition to essentially eliminating the risk of death from pulmonary embolism, is also devoid of triggering agents for malignant hyperthermia(MH). After the recent MH tragedy in Florida in an otherwise healthy 18 year-old woman, it is time to re-evaluate the routine use of general anesthesia in cosmetic surgery.

Independent of the extent of the dissection, abdominoplasty is an extra-peritoneal procedure. Despite commonly held beliefs, lengthy experience with PK has demonstrated that imbrication of the rectus abdominis sheath does not require profound muscle relaxation, but merely adequate local analgesia. PK does not demand perfection from the surgeon with local analgesia but merely persistence.

Unlike the common practice of administering local anesthesia under general anesthesia, local anesthesia in the dissociative model (i.e. diazepam ketamine or PK) provides reproducible preemptive analgesia. This eliminates the perceived need for muscle relaxants, enables patients to retain native muscle tone during surgery, and rapidly ambulate after surgery.

I have provided PK sedation for all cosmetic surgeries, including abdominoplasty, for more than 16 years for more than 4,000 patients of more than 100 different surgeons. There have been no fatal pulmonary embolisms, aspirations, pneumothoracices, or other airway misadventures. Also, there have been no hospitalizations for unmanageable postop pain or postoperative nausea and vomiting (PONV).

Readers interested in more specific information may find the clinical pathway on the home page of www.cosmeticsurgeryanesthesia.com.


1. Keyes, GR, Singer R, Iverson, R, et al.: Mortality in Outpatient Surgery. Plast Reconst Surg 122:245, 2008.

2. Friedberg BL: Preface in Anesthesia in Cosmetic Surgery, Cambridge University Press, New York, xviii, 2007.

3. Lofsky AS: Deep venous thrombosis and pulmonary embolism in plastic surgery office procedures. The Doctors’ Company Newsletter, Napa, CA, 2005

4. Friedberg BL: Propofol-ketamine technique, dissociative anesthesia for office surgery: a five-year review of 1264 cases. Aesth Plast Surg 23:70,1999.

Barry L. Friedberg, M.D.
Assistant Professor of Anesthesia
Volunteer Faculty
Keck School of Medicine
University of Southern California
Los Angeles, CA

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