Scope of Practice
The specific procedures that can be performed in office-based facial surgery are driven by the requirements and regulations established by the state in which the surgeon practices and/or an accrediting body that works with the state. Not surprisingly, rules stipulating the allowable type of anesthesia, maximum hours of surgery per day, staffing and insurance requirements, and types of drugs dispensed vary throughout the country. “What defines office-based surgery could be different in New York than it is in Texas,” pointed out Dr. Steiger. “Here in Florida, with cosmetic surgery, you have to have an accreditation. We’re an accredited AAAASF facility. We have the space, the supplies, and the equipment, but we’re not a hospital, so we’re considered an office-based surgery. We do nose jobs, face lifts, laser, and upper eyelid and lower eyelid surgery.”
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September 2021
Doctors tend to do the things that they’ve been taught and not stray from them—often for very valid reasons—but you can do plenty of procedures, even face lifts, under local anesthesia with oral sedation. —Peter Vila, MD
Dr. Steiger’s practice is accredited by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), established in 1980. In 1992, the AAAASF became an accrediting body for all American Board of Medical Specialties board-certified surgical specialties’ office-based surgery units. Strongly aligned with the 1994 American College of Surgeons’ Guidelines for Optimal Ambulatory Surgical Care and Office-based Surgery , the AAAASF targets its requirements to three separate classes of service, based on tiered classifications of anesthesia: 1) Local or topical anesthesia; 2) intravenous or parenteral sedation, regional anesthesia, and analgesia or dissociative drugs without the use of intubation or inhalation general anesthesia; and 3) both of the above but with use of intubation and/or inhalation anesthesia administered by an anesthesiologist or certified registered nurse anesthetist.
In 1996, with the involvement of the AAAASF, California became the first state to mandate accreditation for all outpatient facilities that administer sedation or general anesthesia. Subsequent varying laws and regulations guiding office-based surgery units were adopted by additional states such as Florida, Georgia, New Jersey, Pennsylvania, and Texas. As an AAAASF-accredited practice, Dr. Steiger’s facility has the latitude and capability to offer general anesthesia, although he opts for IV sedation with no intubation. “The anesthesiologists who come to my office are the same anesthesiologists who work at the hospital,” he said. “As an accredited practice, we’re held to the same high standards.”
In her Ohio-based practice, Dr. Ponsky has found that a combination of local anesthetic and oral sedation is all she needs for most of her procedures. “There are traveling anesthesiologists who would be willing to work with me in the office, but I haven’t needed to use those, and it’s a whole different level of regulation and accreditation that I don’t need for a majority of select procedures,” she said. “You just have to know your patient and prep them ahead of time.” That said, Dr. Ponsky does go to an ASC or hospital to operate on her patients who she knows will require general anesthesia.
Like Dr. Ponsky, Dr. Pham performs office-based surgeries using solely local anesthesia and optional oral sedation. “It’s important for the surgeon to be aware of what constitutes conscious sedation in their state regulations and follow standard monitoring precautions set forth by the state’s medical board. But otherwise, if there’s no conscious sedation or even IV sedation, the facility isn’t subject to any specific accreditation needs—just normal OSHA rules and regulations,” she noted. Her in-office procedure room is set up expressly for the purpose of performing surgical procedures and includes specialized equipment, a chair that can be set in a supine position, and an exhaust system to enhance circulation.