Office surgery on the awake patient

A good relationship between the physician and patient, a realistic surgical plan, and a frank discussion of the surgical theatre environment of the office are important when determining who is appropriate for office surgery.  (Also, I said “theatre”.)

The idea of office surgery, or any type of surgery being performed while awake, is frightening to some patients.   And, truth be told, not everyone is a great candidate for a real surgery in the office.  And not every surgery that I perform is appropriate for the office, needless to say, which is why most of my surgery happens in surgical centers or hospitals.   Nevertheless, I do perform a great number of office surgical cases each month. A representative case is presented below.

My rules of thumb on procedures that are appropriate for the office:

1. The procedure is not much more than an hour long.  

After too much time, patients tend to get stiff neck, or their backs get sore, or… the anesthetic wears off and needs to be re-injected.  So I limit patients to about an hour or so for office procedures, so that they can be completed as comfortably as possible.

2. The procedure does not require specialized equipment, e.g. drills, implants, suction, etc.

The quality of the sterile environment required for implants is generally better in a traditional operating room than one could expect to achieve in the office setting.  For eyelid surgery without implants, that really doesn’t matter all that much.  Eyelid infections are really quite rare after most eyelid surgeries, due to the exceptional blood supply of the eyelids.  I cannot recall an infection from an office surgery, and certainly not during the past couple of years.

3. The procedure can be done with the eyes closed; or if the eyes are open, the procedure is relatively short in duration.

Upper blepharoplasty is done with the eyes closed.  That’s pretty easy for most any patient to undergo.  Upper eyelid surgery done on the inside of the eyelid is also appropriate for the office, because it is relatively easy to keep the patient comfortable, and the weirdness factor is mitigated by the fact that internal ptosis repair is a relatively short procedure.  The video associated with this article is one of internal ptosis repair done in the office setting.

Some cosmetic lower lid procedures can be acceptable for the office, but certainly not all lower lid cosmetic procedures.  These are evaluated on a case-by-case basis, but in general, most cosmetic lower lid surgeries are best done in an operating room with sedation, at least in my experience.

My rule of thumb for patients who are appropriate for office surgery:

1. They don’t cry at the dentist.

2. They are relatively calm.

3. Most importantly, the patients self-identify as to whether or not office surgery is for them.  

I also do some subtle manipulation during the office visit:  does the patient shrink when I place eye drops, etc?  If the patient cannot tolerate fingers by their eyelids, then they are simply not good candidates for office surgery.

Why would someone choose office surgery instead of surgery in an operating room?

1. Office surgery can be less expensive — there is no anesthesiologist to pay, etc etc.  Cost is often an important factor for cash-paying cosmetic patients, as well as patients with massive deductibles that are more and more common in our society, which does not seem to value the health of its citizens as much as other developed nations do. (Oops, did I let that slip?)

Our facility currently, as of the time of this post, charges about $350 for a self-paying office patient, our “facility expense”. (This does not include the surgeon fee for the procedure — it covers things like rent, electricity, staffing, etc.) For that same hour in a surgical center, it costs the patient about $1500.

2. Office surgery can be more convenient for the patient.  For me, ain’t nobody gonna take away my chicken biscuit breakfast.  Patients can eat before office surgery, unlike at surgical centers, where they receive IV sedation and are restricted from eating for 8 hours prior to surgery.  Furthermore, surgery at a surgical center can take more time out of the day: (1) check in an hour or two early,; (2) get poked and prodded for a little bit; (3) then surgery; (4) then recover for a half hour in the PACU, etc etc.  It’s just usually faster for patients to do this in the office.

Like most things in life, there is no “right” answer.  But we can have an individualized discussion to come up with a responsible and comfortable plan for each patient.