**1. Introduction**

Elective cosmetic surgery *excludes* medically indicated procedures like postmastectomy breast reconstruction, burn and tendon repair that are the more properly included in the area of plastic surgery. As such, general anesthesia (GA) risks that may be acceptable for *medically indicated*, plastic surgery patients may not be acceptable for elective cosmetic surgery patients. Cosmetic surgery is "want to" surgery. Plastic surgery is "have to" surgery.

While all cosmetic surgery can be performed under local anesthesia only, most surgical candidates desire to not hear, feel or remember their procedures. Most surgeons prefer to concentrate on their surgery and not to have to speak with their patients during surgery. As such GA is commonly requested by many surgeons. Brain monitored propofol ketamine ("Goldilocks") anesthesia (not too much, not too little, but just right) bridges the patient care gap between surgery under local only and the more commonly performed GA. "Goldilocks" anesthesia

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2017 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

Pain and consciousness are processed at higher cortical levels (**Figure 2**). Fifty percent of patients experiencing awareness with recall under anesthesia had no HR or BP changes with which to alert their anesthesiologist [1]. Preventing anesthesia awareness is the *least* important value of direct brain monitoring. No deaths have yet been reported from anesthesia awareness. However, one American overmedication death occurs daily! [2]. **Preventing over** 

Brain Monitored Propofol Ketamine for Elective Cosmetic Surgery

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Complex mathematical modeling, i.e. pharmacodynamics (PD) and pharmacokinetics (PK), is based on body weight that may not accurately reflect individual cortical sensitivities. While currently unavailable in the US, target controlled infusion (TCI) only infers cortical response

With the Federal Drug Administration (FDA) 1996 approval of the bispectral index™ (BIS) brain monitor, the promise of *direct measurement* of cortical hypnotic response to anesthetic drugs was made available to the anesthesia community. Competing cortical monitors have been introduced since 1996, but the BIS monitor remains the most well-validated brain moni-

Anesthesia may be defined as the sum of hypnosis plus analgesia (**Figure 4**). Implicit in "hypnosis" is amnesia for surgery and within "analgesia" is sufficient muscle relaxation to imbricate the rectus abdominis sheath for classical abdominoplasty. Measured hypnosis enables differentiation of cortical- versus spinal cord–originated patient movement. As opposed to cortically originating patient movement, spinal cord–originated patient movement is devoid of awareness with recall concerns. Knowledge of the origin of patient movement facilitates origin-appropriate treatment of patient movement, thus assuring adequate local anesthesia

As an index, the BIS scale is from 0 to 100. The lower the number, the deeper the level of hypnosis (**Table 2**). Although validated in over 3500 published papers, the promise of direct

**medication** is the major value of direct brain monitoring (**Figure 3**).

based on blood drug concentrations, again with possible error.

tor on the market to date.

during sedation (**Table 1**).

**Figure 2.** Cortex and brain stem.

**Figure 1.** Friedberg's triad.

simulates GA conditions (nonverbal, predominantly immobile patients) while *trespassing the least* on patient physiology, satisfying both patient and surgeon desires. "Goldilocks" anesthesia is **numerically reproducible**. "Goldilocks" anesthesia embodies Friedberg's triad; i.e. Measure the brain, Preempt the pain, Emetic drugs abstain (**Figure 1**).
