"Nipped, Tucked, and Wide Awake?"

For one thing, when a patient is sedated with Valium or Percocet, her judgment is clouded, making her more prone to irrational decisions or to being overly influenced by the onlookers, says Herluf Lund, M.D., a plastic surgeon in St. Louis 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 upon minimal sedation—about half of his patients take no

Valium at all—and that he’s had only two patients who wanted do-overs, both to go bigger. “I know people who say they do Awake breast augmentation and then slam the patient with narcotics," he says. “That’s not the case here." But even among patients who aren’t sedated, the time to make reasoned decisions is before surgery, Dr. Lund argues. The operating room is not a shopping mall, after all; if you regret your impulse purchase, you can’t easily go back and return it. “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!’" Dr. Lund says, adding, “Later, if you’re not happy, the doctor can say, ‘Well, I gave you what you wanted.’"

Another Awake premise is that patients are smart to avoid general anesthesia, which causes one death per 200,000 to 300,000 anesthetics given, the Institute of Medicine estimated in 2000. But the large volume of lidocaine used during an Awake surgery poses its own risks. “The amount of local anesthesia needed to anesthetize both breasts comes close to the toxic level," says Dr. McGuire, who is also immediate past president of the American Society of Plastic Surgeons (ASPS). Lidocaine has not been extensively studied for breast augmentation, but plastic surgeons say a limit of 35 mg to 50 mg per kilo is wise. Dr. Caruth says he uses about half this amount. But in reviewing more than a dozen cases of Awake surgery gone wrong, Dr. McGuire says patients got more than the limit—and warns that a lidocaine overdose can kill. The idea is that a high dose is safe in Awake surgery because it’s injected into fat, which, having fewer blood vessels than muscle does, is slower to absorb anesthetic. On the other hand, “that slow absorption could mean you’re just delaying peak toxicity," says Keith J. Ruskin, M.D., professor of anesthesiology at the Yale University School of Medicine. “So theoretically, you could have someone on her way home from surgery, and complications like seizures and heart arrhythmias could arise."

Without an anesthesiologist present, patients can also end up in agony. Dr. Caruth says he’s able to resolve discomfort with an extra squirt of tumescent fluid. 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 grimace and carry on. Responsible doctors would do the former; Dr. Caruth says he’s only once had to cut a surgery short. But not all surgeons act responsibly, Dr. McGuire says, and if patients were to writhe in pain at the wrong time, it could spell disaster. “The stories are just hair-raising," he says. “As a surgeon, I don’t want to be operating on screaming people."

Awake doctors aren't trained in plastic surgery
After her painful procedures, Hacker returned home bandaged, swollen and sore. “I hurt so much, I couldn’t function," she says. Her entire body swelled out of control despite her wearing a pressurized garment for eight weeks, and she had neck and back pain so wrenching that she couldn’t lift her young daughter for the next year and a half.

The more facts Hacker learned about her physician, the more disturbed she became. Three other patients had come forward, alleging their Awake liposuction was performed not by Dr. Bittner but by his office manager—a woman with no medical license 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. His lawyer, Benjamin Gluck of Los Angeles, notes that his client has “hundreds and hundreds of satisfied patients" versus “a few unhappy patients who have retracted their more colorful accusations under oath." Given this, Gluck says he strongly believes the criminal case will resolve in the doctor’s favor.

Hacker also discovered that no doctor should have given her lipo in the first place. It is inappropriate for obese patients because of their higher risk for complications and because surgeons can safely remove only about 5 pounds of fat, Dr. McGuire says. Worse, experts say, doing multiple sessions of lipo on many body parts over sequential days—common among Awake surgeons—is far outside the norm and vastly increases the dangers. When she shared post-op reports from Dr. Bittner’s office with another physician, Hacker learned her blood pressure went so high during the procedure she could have had a stroke. “This was all about greed, not about taking care of patients," she says.

The main organization pushing the Awake-training gold rush is the American Academy of Cosmetic Gynecologists in Tucson, Arizona—a group with an official-sounding title, but one that is actually open to any ob-gyn willing to pay $300 in dues. Founded seven years ago, the “academy" quickly attracted so many other specialists clamoring to join that other organizations sprouted up to accommodate them—the National Society of Cosmetic Physicians, which now boasts 1,200 members, as well as the American Academy of Cosmetic Family Medicine and the American Academy of Cosmetic Dermatologists. A fifth group, the National Society of Cosmetic Plastic Surgeons, contradicts its name by asking only that applicants be practicing “physicians," not plastic surgeons. (In contrast, doctors hoping to join more prestigious, long-standing societies like the ASPS and the ASAPS must be board-certified in plastic surgery, engage in continuing education and be sponsored by current members.)

In a surprise twist, reporting revealed that despite their various names, all five Awake groups seem to be the same organization, listed at the same Tucson address, sharing phone numbers and faculty. An employee who answered the phone refused to reveal the groups’ leadership, saying only that the director’s name was “Brad" and that the groups declined to comment.

The linked organizations offer two-day courses in Awake liposuction ($5,000), tummy tucks ($7,000) and breast augmentation ($7,000). Among the instructors is Anil Gandhi, M.D., a general surgeon in Cerritos, California, who is not board-certified in any field. Dr. Gandhi’s workshop—whi*****ludes lectures on start-up costs, promotional materials and handling the dissatisfied patient—is complete after 22 hours. It takes more than five years in a residency program to train surgeons to do breast augmentation.

The threat to patients is not theoretical: After a 37-year-old Florida woman went into shock and died after undergoing lipo with a doctor trained only by short courses designed for gynecologists, the state board of medicine found that “these courses do not provide adequate training to develop the proper surgical judgment" on who is a good candidate, what form of anesthesia is safest for her and how to avoid and react to complications.

Many surgeries done in unsafe facilities
Not only do Awake practitioners work outside their area of expertise, but many operate in facilities with few safety standards. Most facilities outfitted for moderate anesthesia and up are accredited by one of the major nonprofit organizations that oversees safety and doctor training. But because Awake practitioners use only local anesthesia, they often skip accreditation, too. “Do they know anything about sterility, about occupational health and safety standards, about infection control?" asks Lawrence S. Reed, M.D., immediate past president of the American Association for Accreditation of Ambulatory Surgery Facilities in Gurnee, Illinois. “Because they’re not accredited, there’s no way of knowing what goes on in their offices."

Unless, of course, something goes wrong—as happened in the office of Sean Su, M.D. Trained as a family physician, Dr. Su opened a clinic in Las Vegas called the Skin + Body Institute and advertised a “Makeover Wish" contest, the winner of which would get free Awake implants and then shill for his website. The prize went to a 29-year-old who explained in an entry essay that she suffered from low self-esteem, partly due to marital problems.

State authorities would soon come to call her Patient A. During her surgery in April 2009, Patient A experienced “significant pain and anxiety" for eight grueling hours, according to the Nevada State Board of Medical Examiners, which investigated her complaint. She was slow to heal—and seven weeks after surgery, her right implant started to pop out of its incision, says Douglas Cooper, executive director of the board. Dr. Su then performed yet another painful eight-hour Awake surgery, during which he washed the infected breast pocket, then returned the implant to her chest—right along with any bacteria that might have been left clinging to the implant.

Little surprise, then, that Patient A was admitted two weeks later to Sunrise Hospital for emergency surgery for a breast infection. As the surgeons removed her implants, they were shocked by what they saw. According to the investigators’ preliminary findings, Dr. Su had created a pocket too small for the implant. His incisions were “jagged and uneven" and three times longer than appropriate. And he’d left behind an “inexplicable mass of sutures" along the tissue of her right chest wall, increasing the odds for infection.

The board also discovered a second patient of Dr. Su’s with a similar complaint: a 25-year-old who’d also undergone an eight-hour Awake breast surgery, followed by serious infection. Investigators found an unsterile clinic with a canister of days-old liposuction waste left in a procedure room and expired tools and medications, including the lidocaine used for Awake procedures.

In March 2010, the board of medical examiners found Dr. Su guilty of malpractice, keeping inaccurate records and trying to deceive board staff. Yet his penalty didn’t seem that bad. He had to reimburse the cost of his $25,000 investigation, pay a $4,500 fine and serve out 18 months’ probation, during which he is barred from practicing or supervising cosmetic procedures. He is free to once again do family medicine and told self in an email that he has fixed the conditions in his office and, when his probation ends, he plans to restart his aesthetic practice, too: “I had no other alternative but to accept their agreement due to lack of finances for a prolonged defense with a biased medical board" driven by “antiquated physicians not up-to-date with knowledge in the advancement of safer treatments." There is a tendency for plastic surgeons to “protect their turf from outsiders," Dr. Su added. “As always will be the case, such pioneering physicians as myself will be criticized when known complications occur and will thus be judged harshly and unfairly."

A few state medical boards have become concerned enough to try to stem the tide of doctors’ “scope drift" into cosmetic surgery. After three liposuction patients died in the care of an internist in Anthem, Arizona, that state’s board was the first to draft guidelines reminding doctors that, upon expanding their practices into new areas, they need to be competent in those areas, says the board’s executive director, Lisa Wynn.

In North Carolina, the medical board suspended indefinitely the license of an ear, nose and throat doctor who did a series of substandard plastic procedures and is finalizing a policy that could result in discipline for doctors who venture too far from their expertise. Previously, a rash of liposuction deaths in Florida led to more stringent rules for office surgery. These rules make a small step in the right direction but still rely heavily on doctors’ willingness to adhere to the honor code. With little oversight, “it’s a buyer-beware situation," Dr. McGuire says.

Just ask Paulette Hacker, who hasn’t been the same since her Awake lipo. Her “bargain" surgery ended up costing $6,000 worth of chiropractors and hyperbaric oxygen treatments to ease her pain. And she estimates she’ll spend thousands more to correct the aesthetic damage—because whenever she looks in the mirror, she’s reminded of her Awake mistake.

She’s been left with a lumpy back, a misshapen belly, uneven hips, a neck striated with scar tissue, an asymmetrical jawline and a conga line of polka-dot scars down her sides. “I thought I was an educated consumer, an intelligent person," Hacker says. “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."