Expert: Ronald Levy, M.D. - 8/4/2011

Question
I am a 64-year-old woman who had scheduled an external DCR and ectropion eyelid repair.  I had also asked about getting some cosmetic work done on my lower eyelids as part of the surgery, and the surgeon muttered something about redistributing the fat.  I was dismayed to learn that the surgeon insisted on using general anesthesia for the DCR because I "might start bleeding and coughing up blood during the procedure," so he wanted a laryngeal mask airway (LMA) in place.  He said that he left the choice of anesthesia agents to the anesthesia provider.  Today I learned that my surgery was scheduled to last 2 1/2 hours, including a full hour for redistributing lower lid fat pads--all under general anesthesia.  That seemed too long to be under general anesthesia for elective surgery, so I cancelled the whole thing.

Although I'm healthy (except for a teary eye), I'm at an age when cognitive impairment related to anesthesia is more of a concern.  My work requires the full use of my cognitive abilities, and any degree of cognitive loss would be devastating to me.  So I have some questions about my anesthesia options.  Is a LMA possible with MAC?  What requests can I reasonably make regarding the choice of anesthetic agents (like no nausea-inducing gases?)  What can be done to minimize the risk of cognitive impairment?  Must general anesthesia be used for the final hour of surgery if it is used in the first 1 1/2 hours (or should I just omit the cosmetic procedure?)  Should I just find a different surgeon who does DCRs using local anesthesia?  What would you recommend to a family member in my situation?

Thank you for making this wonderful site available.

Answer
The effects of anesthesia on cognitive function are overstate in the lay literature and if you are otherwise healthy, there is no reason not to have the procedure under general. A MAC means that you are awake but very sedated. You cannot use an LMA on an awake patient, so that is not an option. 2 1/2 hours is not a long surgery and you shouldn't cancel the cosmetic part just becuase of the additional time. I cannot tell you to find another surgeon if you are so insistent about not having general, that is your decision. I can only tell you that your fears are overstated. I would recommend a family member to have the procedure under general if the surgeon is the one that I want to do my procedure.

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston