Dear Dr. Friedberg:
I just finished your wonderful book Anesthesia for Cosmetic Surgery. What a revelation. I have been using benzodiazepines and ketamine for 30 years for nearly all of my elective aesthetic plastic surgery cases and for many hand and trauma cases. During this time, I have never had a deep vein thrombosis, a pulmonary embolism, a positive pressure, a pneumothorax, a negative pressure pulmonary edema, a flash pulmonary edema, a chipped tooth, an injured vocal cord, a fire or explosion in the operating room or damage to the trachea of a patient, intractable postoperative nausea and vomiting, an awake but paralyzed surgical patient, aspiration, or litigation involving anesthesia. Recent teaching courses and patient safety continuing medical education (CMA) requirements in plastic surgery have focused on the prevention of deep vein thrombosis and postoperative nausea and vomiting. These are complications not of minimally invasive surgery but of maximally invasive general anesthesia.
When I have suggested to my colleagues that all cosmetic surgery can be performed safely, simply with IV sedation, they are reluctant to try because they are accustomed to having an anesthesiologist monitor the level of sedation and are concerned that clinical impressions are not adequate. Your book that clearly describes the use of propofol and the BIS monitor solves their dilemma. Studies have shown that incidents of deep vein thrombosis, subsequent pulmonary edema increases with every hour of general anesthesia. Universal acceptance of your principles of intravenous sedation for minimally invasive anesthesia for minimally invasive surgeries can save thousands of innocent lives each year.
Robert A. Ersek, M.D., F.A.C.S.
“Dr. Friedberg’s long-standing vision, innovation, and tireless devotion to the practice of cosmetic surgery anesthesia is efficient and thoughtful, while providing for a practical, outcomes-directed approach to office-based cosmetic surgery anesthesia. The sticking point for many patients is the post-surgical experience of nausea and vomiting (PONV). Dr. Friedberg’s PK technique, which is applicable to a variety of elective cosmetic surgical procedures, reduces this uncomfortable byproduct of an otherwise positive surgical outcome. As more consumers know about this option, elective cosmetic procedures may be more widely and easily embraced.”
David Mayer, MD
Board Certified Anesthesiologist
President, Esurg Corporation
Medical and Pharmaceutical Supply Company
“Dr. Friedberg is a wizard at providing anesthesia for patients undergoing cosmetic surgery. His propofol-ketamine technique has revolutionized the field. His patients receive an excellent depth of anesthesia yet rarely suffer from postoperative nausea or vomiting. Dr. Friedberg has taken the field of office based anesthesia to a new high level of patient care. His work is amazing, and I’m glad he has begun to publish his findings.”
Charles E. Laurito, MD
Professor of Anesthesiology and of Anatomy and Cell Biology
Director, Pain Management Program
President, Society for Office Based Anesthesia
“Yesterday I anaesthetized a 54 year old for mastectomy and tissue expander. Always sick after anesthesia, she was anaesthetized about 2 weeks ago whilst I was on holiday, and the anesthetist made bold efforts to prevent the heaving by adding in metoclopramide, and ondansetron during the anesthetic. She woke up and immediately felt sick. She was administered cyclizine (an antihistamine type anti-emetic) and immediately developed a kind of locked in syndrome. So not only did she continue to feel sick, but she had the terrifying experience of not being able to move.
Yesterday she was extremely apprehensive about a further anesthetic. I gave her the PK “its anesthesia Jim, but not as we know it”. She woke up, pain free, nausea free and laughing. Many thanks again.”
Chris G. Pollock MB ChB
Consultant in Anaesthesia and Pain Medicine
Hull , UK
“Barry Friedberg invented and popularized our techniques and does it in a more sophisticated fashion. The following is especially modified for liposuction…..PK technique: Safe, very little respiratory depression and NO post operative nausea or vomiting. Propofol (soporific only; short acting, anti-nausea) drip to sedate, then 50 mg of ketamine (dissociative anesthetic: salivation, great but brief analgesia, blood pressure elevation, short acting) slow IV push (watch for respiratory depression carefully for a few minutes) and two minutes later, pump in tumescent as rapidly as possible with your peristaltic pump. This is a very small dose of ketamine, and with this dose, the dysphoria that the anesthesiologists object to virtually doesn’t occur. Robinul (drying agent) 0.2 mg (1 cc) given IV at the start of the case; usually prevents salivation and occasional respiratory problems that occur occasionally with Ketamine.”
Robert Yoho, MD
“Yoho Method” liposuction anesthesia technique ABCS board certified in cosmetic surgery a ABMS board certified in emergency medicine
Hi! I am a CRNA in Louisiana interested in learning your PK technique. I am employed by 5 plastic surgeons and 2 of which trained at Stanford (these both state that propofol was the main anesthetic used there). I am willing to learn, but they have a hard time realizing that the patients may move at times. I did a blepharoplasty that went well with a propofol drip and the patient was real happy. Of course, I trained 23 years ago and was always told that ketamine gives the nightmares. At what BIS reading do you find that it is ok to give the ketamine? Does this last for the duration of the local if the doc takes 5-6 hours? Let me know I will download your articles at work and read them.
Thank you very much for your interest in PK.
Doing PK MAC* is much more an attitude than an aptitude. You already possess 1,000X the talent to do PK. It’s very simple and it works. Picture yourself removed from the ‘analgesia’ business and posture yourself as a propofol hypnotist (99%). The dissociative dose of ketamine(1%) creates the window of opportunity in which to inject the local without hurting the patient. Good local is the key.
Hypnosis first, then dissociation is the other key. Without the BIS, hypnosis is loss of lid reflex and loss of verbal response before dosing with the ketamine. With the BIS, it’s 70-75 before ketamine. Also, when the patient moves at BIS = 60-70, they must realize more lidocaine not propofol is the correct response. All of my surgeons are now trained to ask what the BIS is when the patient moves.
Ketamine is not a fentanyl substitute. Once the local is injected there is no reason to persist in giving more ketamine. I logged 2,680 PK cases in ten years. Surveying my last 500 cases, 40% were done with a single 50 mg bolus of ketamine, 40% were done with two 50 mg boluses, and only 20% required additional ketamine. Do not exceed an aggregate of 200 mg ketamine in any case and absolutely none in the last 20 min….and does this last for the duration of the local if the doc takes 5-6 hours?
The length of case is irrelevant as is the patient weight. The small portion of the midbrain and spinal cord containing the NMDA receptors does not vary appreciably in adults, so 50 mg works pretty darn well (95-98%) of the time. I cut back to 25 for Asian born Asian patients. Also, 25 mg will get you about an 80% response rate in gringos. Too tedious for me.
As a point of curiosity, did your surgeons express an interest in PK or did you suggest it to them? I am curious because I want to know what the force for change in your interest was? Did you see one of my ads celebrating 10 years of better anesthesia?
The web site was created to inform patients about PONV free anesthesia in PK and to ask for it!
Please keep me posted on your experiences if you can. I am always interested in feedback from my ‘disciples.’
Most of my 5 articles are on the web site under ‘Published Articles.’
Yours for better (and reproducible) outcomes,
Barry L. Friedberg, M.D.
Look for 2003 International Anesthesiology Clinics Vols I and III for my two chapters on PK including ‘the cookbook.’ I’ll be at the Lippincott booth at 2003 IARS, SAMBA, ASA,and PGA to autograph copies. Hopefully, one will be for you. I don’t receive royalties or any other form of remuneration. Just trying to promote PK. Tell your friends. Tell your surgeons that one of my main clients is Nicanor Isse and watch their eyes get big with recognition. Isse pioneered endoscopic browlift in ’92, ironically the same year I pioneered PK. Took us minimalists a while to find each other. He does minimally invasive cosmetic surgery and I do minimally invasive anesthesia®.
*PK MAC is derived from Vinnik’s diazepam ketamine technique, published 1981 in PRS. PK TIVA wherein the two are mixed together is derived from Guit 1991 Anaesthesia. Mixing involves two hazards – 1) one may not achieve the all-or-nothing threshold of dissociative effect (i.e. patient does not move for local injection) and 2) more likely to exceed the 200 mg aggregate dose of ketamine producing an unsatisfactory emergence.
I am a CA-2 at Scott and White hospital in Temple, TX and recently read with interest your MIA technique in the book Anesthesia for Cosmetic Surgery.
I am currently doing vascular surgery this month, and our vascular surgeons here have started recently requesting MAC anesthesia for many previously GETA procedures including endovascular thoracic and abdominal aneurysm repairs, iliac and femoral stenting, thrombectomies, and etc. We have done these succesfully with various techniques, and I was curious about applying your MIA technqiue to this group of patients as I didn’t see vascular surgery listed in your book as a typical surgery one would consider MIA on.
So far this week, I have used it as written on 4 separate patients, and am currently writing you from the head of the OR table where I am doing a 63 y/oM ASA3, mod COPD, h/o MI x 2 with angioplasty, having a aortofemoral graft distal reconstruction and fem/pop bypass thrombectomy.
The technique is working rather well with the exception of some very occasional light patient movement with BIS 65, 3 local injections on the field and 75mg ketamine.
Most impressively, the hemodynamics are incredibly stable. My first patient with a AAA and iliac aneurysm repair this AM did have a brief laryngospasm 2 minutes after ketamine after a distinct coughing episode. Thanks to your recommendations, I was able to quickly break the spasm with an 2mg/kg bolus of lidocaine and the remainder of the case was flawless.
The patients have all been awake quickly without post-op pain medication required. Besides starting the propofol a bit slower and sometimes with a lower starting infusion rate, I have essentially applied the protocol as written without much deviation even on this quite different patient population.
I have shared this technique with our surgeons after they have seen how well the (admittedly few so far) patients have done, and they are quite pleased, as are the staff anesthesiologists I have worked with so far who have allowed me to use this technique.
Tony W. Spatz, M.D.
Department of Anesthesiology
Scott and White Memorial Hospital and Clinic
Texas A&M Health Sciences Center
Dear Dr. Friedberg:
All of our blog readers should know that Dr. Friedberg’s book is the bible in my office, and I will not hire an anesthesiologist unless he reads parts of his book and is willing or able to justify to me why he should NOT be using Dr. Friedberg’s methods.
So far everybody that has tried his methods adapts to them well. If I am able to do 8 hour cases and send them home one hour after the end of the case it is because of Dr. Friedberg.
More importantly, my conscience rests easier because it is safer. 4 years, 1,200 procedures later, not one single deep vein thrombosis or pulmonary embolus.
Ricardo L. Rodriguez MD
Board Certified Plastic Surgeon
1300 Bellona Avenue
Baltimore, Maryland 21093
PK anesthesia is a powerful solution that raises the standard of care for outpatient anesthesia.
F. Don Parsa, M.D., F.A.C.S
Professor of Surgery (Plastic)
University of Hawaii
The John A. Burns School of Medicine
Chief of Plastic Surgery Division – The Queen’s Medical Center
The practice of medicine requires a lifetime commitment to learning and flexibilty to provide the best care for our patients. Unfortunately, the practice of plastic surgery tends to be inflexible and focused on the use of general anesthesia which in my opinion is more for the surgeon’s convenience rather than the patient’s in many cases.
As it has been my focus to perform natural aesthetic procedures which are safe, under local anesthesia with light sedation and with a quicker recovery. Dr. Friedberg’s contribution to my practice through his experience is truly appreciated.
Amiya Prasad MD
New York, NY
I have been doing Cosmetic Surgery for over 16 years, and one of the biggest worries is the anesthesia, which the surgeon doesn’t have any control over. I read the book ‘Anesthesia for Cosmetic Surgery,’ and I was very impressed with Dr. Barry Friedberg’s technique.
It wasn’t until he came to our office to proctor Dr. Candelaria that made me a believer. It was like the patient’s having general anesthesia but a lot safer.
Our patients woke up with smiles on their face, and were more cooperative than ever.
His expertise is a major contribution to cosmetic surgery anesthesia.
Efrain Gonzalez, MD, FACS
I thought your course was great. The concept makes perfect sense
It should be no surprise to you that the biggest problem for me is getting my anesthesiologists to try it. Two have and the results were great. No nausea, no pain and overall a good feeling about their surgery. These were 2-3 hour cases and many of mine are 5-7 hours and one of the problems we have now is getting enough P and K.
Also, the longer cases are the difficult ones for me to get buy-in from the anesthesiologists. I am going to continue to try (the younger docs are more willing) and over time I think I could have enough experience with the technique that I could endorse.
Thanks for agreeing to present at our meeting. You can, of course, mention that I have been so impressed with the technique that I asked you to join the faculty for the 2014 AAFPRS course.
Keith LaFerrier, M.D.
Clinical Professor of Surgery
Department of Otolaryngology – Head and Neck Surgery
University of Missouri
Thank you for the autographed copy of your book. It was very thoughtful of you and it will have a special place in my library.
You have made an important contribution to the clinical practice of anesthesiology and this publication should further its use among our colleagues.
Keep up the good work. I am proud of you.
C. Philip Larson, Jr., MD
Chaiman of the Deparment of Anesthesia at Stanford University during Doctor Friedberg’s training from 1975 to 1977.
“Dr. Barry Friedberg – Cosmetic Surgery Anesthesia – Propofol Ketamine is my primary technique for almost all office based anesthesia cases including facelifts, eyelifts, laser skin resurfacing, liposuction, rhinoplasty(closed), and frankly any other case that is superficial… Another advantage of this technique is the low incidence of post operative nausea and vomiting (PONV).
Marshall M. Garland, MD
Assistant Professor of Anesthesiology
NYU Medical Center
New York, NY
“Well indeed, I had to see it to believe it, my last 15 cases where I have used your technique, no narcotics, and they have done well! It is also so enjoyable to see them awake and be so happy. Not even a hint of nausea and vomiting. Fantastic.”
Frank Kunkel, MD
Private Practice Anesthesiologist
“Dr. Friedberg’s PK technique has worked wonders for my patients. They awaken from anesthesia with a very happy affect, frequently reporting an enjoyable experience! This is what distinguishes PK from other anesthesia techniques. Furthermore, the paucity of nausea, hallucinations, or delayed discharge has made the technique an invaluable component of my armamentum. Dr. Friedberg deserves all the accolades for enlightening our company. His zeal to educate colleagues and patients is unmatched.”
Marc Koch, MD, MBA
President and CEO
New Rochelle, NY
I am deeply impressed with your carefully researched letter to Dr. Gupta. Instead of obfuscating ketamine’s merits as some “experts” have in recent past, you have published in peer reviewed journals and thereby have provided us with an empirical basis to move forward with exciting new applications for this old drug. In addition, the presentation of your research before state anesthesiology societies, such as ours in Florida, has been a great benefit to our profession. I hope that people like Dr. Gupta will not become a member of that crowd who fail to understand that clinical science can and has been advanced by people like you.
The tide of history is at times slow for us humans human beings, but it moves nonetheless. More and more anesthesiologists are growing uncomfortable with the view about your work expressed by people like Dr. Gupta.
Once again, I commend you for your important contribution consonant with the highest principles of our profession.
Anthony Kirkpatrick, M.D., Ph.D.
“Dr. Barry Friedberg has revolutionized my anesthesia service. We have performed over 100 abdominoplasties under propofol ketamine anesthesia. The patients are extremely happy with his anesthesia. They feel great upon awakening and have almost no nausea or vomiting. Wow, what a difference it makes!!!”
Nikolas V. Chugay, D.O.
Internationally recognized aesthetic plastic surgeon
Developer of buttock, bicep and tricep augmentation
“Friedberg is a respected anesthesiologist, frequently cited for spearheading the innovation of PK to tame the negative effects of cosmetic surgery anesthesia. His deep sense of commitment to patients and the surgeons he works with is globally known, and his selfless efforts to educate both populations is a tribute to the field of medicine, surgery, and anesthesia.”
Nicanor G. Isse, MD
Internationally recognized plastic surgeon
Specialist in Scarless and Minimal Incision Surgery
Director of Isse Institute for Cosmetic Surgery
Los Angeles, CA
It was a great pleasure meeting you in California recently, on the occasion of the endoscopic seminar. Your anesthesia techniques are superb and your chapter in the anesthesia textbook for head and neck, as well as oral surgery is very clear and most informative.
Again, thank you for everything. I learned a great deal talking to you and watching you provide anesthesia.
F. Don Parsa, M.D., F.A.C.S
Professor of Surgery (Plastic)
University of Hawaii
The John A. Burns School of Medicine
Chief of Plastic Surgery Division – The Queen’s Medical Center
Just a quick line to let you know that the residents, and other faculty, have been impressed with PK. Recently, I used PK for an ASA IV patient. He was a 60+ year old w/IDDM and just several days “out” from a severe acute AWMI. His EF was under 20%. The patient required an emergent BKA.
I did the case, with a resident, with a combined anterior sciatic block and femoral block. PK worked just fine. The residents (anesthesia and surgical) were amazed. So was the vascular surgeon.
In addition, PK worked extremely well, as a supplement, to an axillary block for a renal failure patient. The patient needed the usual AV graft for dialysis access. He was awake and ready for d/c almost as soon as the “stuff” was shut off.
Glen Atlas, M.D., M.Sc.
Associate Professor of Anesthesia
New Jersey College of Medicine and Dentistry
Good article in the Spring 2009 issue of the Anesthesia Patient Safety Foundation (APSF) Newsletter.
I do mainly critical care now, but half the anesthesia I still do is outpatient cosmetic stuff in a plastic surgeon’s office, all PK, no narcotics, no oxygen.
The interesting part is the preemptive analgesia from the ketamine. I never really thought about it in that way, but when I think back, more than 90% of patients require no narcotics until long after they hit the recovery room (PACU).
The results I get (compared to the other anesthetists who work there) are so good that all that staff who have surgery there ask me to do their anesthesia, including the recent, 6 hour face, eyelids, and brow-lift that the surgeon did on his wife.
She never felt a thing, walked out of the OR on her own two feet, had no pain. She was raving about the anesthesia for weeks.
Keep up the good work,
Leo I. Stemp, MD
Dear Dr. Friedberg,
I read your book and [it] totally changed my everyday practice.
I managed to do [everything] from open cholecystectomy (with a paravertebral block) to aortic aneurysm.
When the surgeons place an intra-aortic stent and [I] personally [use either an] inguinal field block or bilateral paravertebral with your technique.
It was the “silver bullet” – as you say in a part of your book – that I was trying to find.
Again, thank you so much!
Serpetinis Ioannis, MD, PhD
European Diploma in Regional Anaestheia
In response to her question, ‘Do I have a financial relationship to brain monitor makers?’
Answer: Neither I nor the non-profit Goldilocks Anesthesia Foundation have any financial relationship with either drug or brain monitor makers.
So many times it appears for financial gain that people push a product such as the brain monitor, so I apologize, but I had to ask. I enjoy your articles and am a fan. I work for cosmetic surgeons so your work is of special interest to us.
Beginning 1 August, I will be the President of the Virginia Association of Nurse Anesthetists serving over 1100 members. We have a publication which we produce quarterly in which we like to include articles from which our members can benefit. I have always found your articles to be both interesting and applicable. Would you be opposed to my including your posts from time to time? You would of course receive full acknowledgement.
Thank you so much for your dedication to the safety of anesthesia!
Jan Setnor, CRNA, MSN
P.S. By the way, I’m a Californian as well! My husband was in the Air Force and we had so many assignments to Virginia my kids think this is home. Thank you again, Jan
Jan Setnor, CRNA, MSN
2010-2011 President, Virginia Association of Nurse Anesthetists
Hope all is well. Just wanted to let you know that I had a real treat to watch the famous Dr. Barry Friedberg in action with his method of procedural sedation a few weeks ago. It was amazing. After the tummy tuck, the patient walked herself to the restroom after surgery. No vomiting or nausea. She was smiling. I am having him take care of me on my next tummy tuck
Although the economy is not at its best for our patients, Dr. Friedberg’s rate is very reasonable compared to most dental anesthetists out there, and he is a medical anesthesiologist, M.D. He will be presenting lectures in the near future locally. I will keep you posted.
He is very professional, easy to talk to and a great teacher. He is my new mentor to say the least. Let me know if you ladies have a break to meet him or see him in action.
He would be a great for your future surgeries. Who wants to work on squeamish patients just under local anesthetic anyways.
He has written over 60 publications. The latest one, Getting Over Going Under, is great for patients to read. Let me know if you would like one and I will let him know. He won’t sell them to you. He will give it to you and only ask you to donate to his non-profit Goldilocks Anesthesia Foundation.
Talk to you all soon!
P.S. Please forward this email to the other dentist friends I do not have emails of who are among our circle of lady dentists. Thanks!
Looking forward to our next get together ladies!
Mai Ky DDS
I second Dr Rodriguez.
I started using your anesthesia technique in 2006, and in concert with my rapid recovery breast augmentation procedure, after more than 1400 cases, I have never had a single DVT, PE, or any other significant complication.
It had been a struggle finding the right anesthesia providers, but I found some that were very open to trying, and now they use this technique at their other surgical offices, most of the time unbeknownst to the surgeons!
When I do back-to-back-to-back breast augmentations, I NEVER have more than one person in recovery. They are all awake, alert, eating, drinking, smiling, and best of all, without pain!! They rave about what we do, and I credit this in large part to the anesthesia that Dr Friedberg has described.
Thank you, very much.
Dr Kirk Moore
Board Certified Plastic Surgeon
5292 South College Drive
Murray, UT 84123
Dear Dr Friedberg,
I am every anesthesiologist’s nightmare: A plastic surgeon who has read, understands and believes in your book!
I just got off the phone with a patient I performed an abdominoplasty on, and she was annoyed that I woke her from a restful sleep at home without medication.
It is a tough ‘sell” to your stubborn colleagues, but well worth it.
Thank you for your great work,
Richard Bensimon MD
Hello Dr. Friedberg,
What an honor it is to receive an email from you.
I just finished my 150th case using your Goldilocks Technique.
We did a two-hour bilateral implant exchange on a 73 year-old ASA III. We finished the case at 11:15 and discharged her fully awake at 11:50. This was following a bathroom stop and her drinking a bottle of water.
Best technique I’ve ever used in my 33 years as a CRNA.
My partner and I, Dr. Todd Fincher, DDS, plan to attend your live seminar in December. We both look forward to meeting you and chatting about your technique and our successful use of it in Dr. Fincher’s cosmetic dental practice.
I have purchased several copies of both of your books that have since been given away or confiscated by envious colleagues.
Thank you for your kind words. I will pass along the info about your upcoming seminar, as well as your online one, to my colleagues. My partner and I look forward to meeting you in December.
Bill Reid, CRNA
Goldilocks Anesthesia Foundation
For pioneering “Keta-Dip” technique. It is invaluable on medical mission work where anesthesia equipment and supplies are erratic to say the least. In Haiti 10 days post quake the majority of cases were done with Ketamine-Dip for local/regionals c Keta Dip. at the American Clinic in Jacmal.
I teach your technique through out Central America often quoting you. Ernest Ayo CRNA
Ernest Ayo via LinkedIn