Awake augmentation? Sleep on it before you decide.

Wouldn't it be great if, instead of having to decide before surgery what breast implant size you want, or having to leave it up to your surgeon, you could just be awake during surgery and have some input? That what some surgeons (notice I didn't say plastic surgeons) are doing. They use only local anesthesia so the patient is awake, and then a temporary expander is inserted which can be adjusted to preview what different sizes would look like. The patient gets to sit up and even have some friends or family weigh in. Sound like a good idea?
I can think of a lot of reasons why it isn't, and not very many why it is. Patients do like to have a say as to size, which is a good thing; in fact I insist that they make the final choice, with guidance as to what the limitations of their anatomy are. We have them try on implants at least two different times before deciding. But ultimately there is no way to make the process perfect, because what looks right at one point may not be later. There is a very typical sequence that goes something like this: Right after surgery, there is swelling and the implants haven't settled, so patients may feel they are too large; then after a few weeks, everything looks fantastic and they are proud of what a great decision they made about size; and after 6 months to a year, we might hear "I am happy with them, but if I had to do it all over again i would have gone a little larger." So a decision made during surgery really has no advantage in the long run.
But there are other problems. For one, doing an augmentation under local really won't work very well with implants under the muscle, which is how most of them are done and for good reason. so if the awake approach isn't limited to carefully selected patients, there will be a lot of fake looking results and unhappy patients. another is the question of sterile technique; having the patient sit up and look in a mirror may compromise the rules of sterility that are critically important whan placing an implant of any type. I could go on, but you get the idea.
Most telling is that the technique is being adopted by doctors with little training in plastic surgery. After nearly 20 years and thousands of breast implant patients, I can tell you that it is a lot more difficult to do consistently well than someone just embarking on breast augmentation can appreciate. So sleep in it, for a long time, before making a decision to do the wide awake augmentation.