The advent of anesthesia in the early 19th century-the first demonstration of Ether in 1846 by Morton at the Massachusetts General Hospital-allowed the surgical disciplines to flourish. Complex and painful surgery which would not be possible under "a glass of whiskey and biting down on a bullet" became routine in the middle 20th century. However, anesthesia was not refined at that stage and complications related to anesthesia itself were commonplace. These complications included adverse outcomes for patients including confusion, stupor, nausea and vomiting, strokes, and death. The introduction of technology and modern patient monitoring equipment radically changed the field. First with continuous Electrocardiogram monitoring, the activity of the heart could be continuously monitored and displayed, including it's minute to minute performance. Later, pulse oxymetry-measuring the amount of oxygen in the blood-also became part of the routine anesthetic armamentarium.

Finally, the anesthetic agents themselves changed. The first anesthetic agents developed had a risk of hepato toxicity-potential for damaging the liver, or renal toxicity-potential for impacting the kidneys. Furthermore, they lingered in the system for a long time and were difficult to reverse. Pharmacologic progress allowed the medications to be fine tuned to the point of being able to take instant effect and wear off immediately after being shut off. Additionally, other intravenous medications such as Propofol, Versed (cousin to valium) and intravenous narcotics such as Morphine and Fentanyl were developed.

Anesthesiologist, in search of minimizing the morbidity and complications then also sought out regional anesthetic techniques such as epidural's or spinal blocks to facilitate surgery of the lower limb.

In terms of managing the airway, progress came along in the form of new devices such as the oral airway, the laryngeal mask device (LMA), and others.

Summarily, anesthesia provision for surgery has changed radically since its inception. Now it delivers designer medications for specific effects with minimal side effects, extremely prudent yet extremely safe anesthetic agents, and second to second monitoring of the patient including EKG, oxygen saturations, carbon dioxide production, and urine output in addition to automation of signs such as temperature pulse and blood pressure which are recorded minute to minute. The goals of optimizing patient care and the paramount concern for patient safety are thus being met with these considerations.

The public perception of anesthesia being the most dangerous part of the surgery, fortunately, has started to be dispelled. With these advances, anesthesia is now a routine and safe procedure with an extremely low morbidity and an even lower risk of extreme events such as stroke or death. This has enabled surgeons to perform and develop cutting edge surgical techniques that would not have been possible in a prior era.

In the particular case of breast reconstruction, for the mastectomy and immediate reconstruction, the patient typically undergoes general anesthesia. The patient has an IV introduced under minimal discomfort in the preoperative area. The patient is then escorted into the operating room where she is placed on a comfortable OR table, padded with foam, and wrapped in warm blankets. Subsequently, she is given oxygen to breath which is an odorless colorless gas which is all around us in our atmosphere. This is delivered in higher concentrations in order to get the lungs prepared for intubation. While breathing oxygen, slowly anesthetic agents are added into the inhalational mixture to induce sedation, somnolesence, meanwhile through the intravenous line agents such as Versed are introduced for anxiolysis-to relieve the anxiety of being in the operating room. Furthermore, these agents also create "amnesia"-allowing the patient to forget the experience of being in the operation room. After satisfactory amount of sedation and induction of light anesthesia, an endotracheal tube is placed into the throat and taped to the cheek. Related to this, the patient may develop a sore throat or a hoarse throat after surgery for which they might require lozenges or occasionally throat spray. At this point, general anesthesia is fully induced so that the patient has no pain and no memory of the operating room and is adequately sedated.

A principal fear of patients remains "waking up in the operating room". This phenomenon or surgical recall, is rare. Patients remains anesthetized, unaware, and pain free throughout the entire procedure. At the surgeon's direction as the surgical case is completed, the anesthesiologist emerges the patient from anesthesia and removes the patients breathing tube before the patient is fully awake. At that point, the patient can breathe on her own and an oxygen mask is placed to facilitate better oxygen delivery to the patient.

During that anesthetic experience, the patient has EKG leads attached to her torso, arms, and abdomen to monitor the electrical activity of the heart. She has a clip placed on one of her fingers to monitor the level of oxygen in their blood. Additionally, a catheter is placed into the bladder when the patient is asleep to monitor the flow of urine which indicates that the patient has good hydration and circulation. Next to the breathing tube a temperature probe is placed which measures the patient's internal body temperature to ensure she is warm and at normal body temperature throughout the surgery.

Part of any breast reconstruction is a staged approach to perform the final shaping of the breast, the exchange of a tissue expander to an implant, or further contouring (touch ups) and nipple reconstruction. Since these operations are not so extensive as their original mastectomy and reconstruction, these follow-up operations do not require as intense of an anesthetic experience. In conjunction with the anesthesiologists, the patient may decide to have a LMA. This is a breathing tube that does not actually go down the windpipe, but remains in the back of the throat and facilitates protecting the airway, good flow of oxygen and the ability to deliver anesthetics. Not all patients are suitable for these novel techniques, but a great majority are. The LMA has the benefits of being easy to place and with lower risk of hoarseness and sore throat after surgery.

Other patients who have generalized decreased sensation in the reconstructed area may not feel any discomfort in the flap reconstruction. They would be candidates for local anesthesia and sedation. During this approach, the anesthesiologist does not place any tubes into the throat or mouth. Sedative medications are provided through the intravenous line. Again, they include agents such as Versed which provides sedation, relief from anxiety, mild amnesia, and somnalesence. In addition, a sedative anesthetic agent called Propofol may be used. If the patient feels pain, intravenous narcotics which are quick acting such a Fentanyl may additionally be utilized. The surgeon also delivers local medication (akin to Novocain in the dentist office) into the surgical site to be able to adequately perform the operation with minimal or no discomfort to the patient. This technique allows the patient to be awake and breathing on her own during the anesthesia without anxiety, fear, or pain. This facilitates an earlier recovery and return to function without that "hangover" feeling after anesthesia. This is particularly important for outpatient surgery where after a period of convalescence in the recovery room, the patient is suitable for discharge to home. Outpatient surgery which is possible because of advances in anesthesia, allows the patient a better and safer recovery in a comfortable environment familiar to the patient with minimal discomfort and maximal safety. Additionally, it removes the patient from acquiring or transmitting nosocomial infections-that is hospital-related infections.

Towards the end of the surgery, the anesthesiologists may administer agents to decrease the risk of nausea or vomiting in the post-operative period. It may include a small dose of a steroid or an anti-emetic agent such as Odansetron. These agents act in the central brain to prevent the nausea feeling which may accompany anesthesia.

Regional techniques such as spinal or epidural block are most often not appropriate for breast surgery since it would require blocking the spinal cord at the level of the chest. These have the possibility of interfering with breathing and so are not routinely utilized. However, in procedures of abdomen or lower extremities anesthetic techniques of regional anesthesia are routinely utilized.

In conclusion, the advances of anesthesia have permitted the development of advances in surgery. The two disciplines are intertwined and progress is joined. The provision of anesthesia now is an extremely safe part of surgery. It allows for routine delivery of the highest standard of care by decreasing anxiety, discomfort, and awareness of the operation both pre-operatively, intra-operatively, and post-operatively. It permits a rapid recovery after surgery with the possibility of outpatient procedures for the less complicated portions of a patient's breast reconstruction.