Patients spend weeks researching their surgeon and about four minutes thinking about their anesthesia. I understand why — the result is the exciting part. But the single most important safety variable in cosmetic surgery is not the surgeon's technique. It's what happens to your heart, your airway, and your blood pressure for the two or three hours you are not awake to advocate for yourself, and who is responsible for that.
I've overseen anesthesia in my own surgical facility for 25 years, and I've built the systems in my current practice from the ground up. Here is what I would want a family member to understand and to ask before having any procedure in any office — including mine.
First, the good news: office-based surgery is safe when it's done right
Most cosmetic surgery in the United States is now performed in office-based surgical suites rather than hospitals, and the safety record of accredited facilities is excellent. An accredited office OR offers real advantages: one surgeon controlling the environment, a dedicated team, no exposure to hospital-acquired infections, and lower cost. The risk is not office surgery. The risk is unaccredited, unregistered, or understaffed office surgery — and from the waiting room, those can look identical to a safe one.
The types of anesthesia used in cosmetic surgery
- Local anesthesia — numbing medication only; you are fully awake. Appropriate for small procedures.
- Local with oral sedation — a pill to relax you plus local numbing. You are awake but calm.
- IV sedation / MAC (monitored anesthesia care) — medication through an IV keeps you sleepy and comfortable while you breathe on your own. Often called "twilight." Depth ranges widely, and deep sedation carries the same airway responsibilities as general anesthesia.
- General anesthesia — you are fully unconscious, usually with a breathing tube or laryngeal mask, and a provider manages your breathing.
Which one is used depends on the procedure, your health, and the facility's capabilities. At BellaNova, we will offer patient the opportunity to choose between general anesthesia and Local Anesthesia with oral sedation for liposculpture/Renuvion cases but otherwise most surgeries are performed under General Anesthesia.
Who is allowed to administer it — and why the answer matters
Depending on the state and the level of sedation, anesthesia may be given by:
- An anesthesiologist — a physician who completed a residency in anesthesiology.
- A CRNA (certified registered nurse anesthetist) — an advanced-practice nurse with graduate training in anesthesia. In Florida, CRNAs practice under the supervision of a physician, and the supervising physician's responsibilities are defined by law.
- The surgeon — for local anesthesia and lighter sedation. A surgeon cannot safely operate and independently manage deep sedation at the same time; someone else must be dedicated to you.
What matters is not the credential alone. It is whether a qualified provider is present, dedicated solely to your anesthesia for the entire case, working within a clear supervisory structure, with documented training in airway and emergency management. At BellaNova, we typically work with a selected, small group of highly competent and extremely experienced CRNAs who specialize in out-patient cosmetic plastic surgery procedures.
Why my own anesthesia training matters to you
Most cosmetic and plastic surgeons are trained to operate, not to anesthetize. That is not a criticism — their residencies do not require it, and it is exactly why a dedicated anesthesia provider belongs in the room. My training was different, and I think patients deserve to know how.
Oral and maxillofacial surgery is the only surgical specialty in the United States whose accredited residency requires the surgeon to personally administer general anesthesia and deep sedation. The Commission on Dental Accreditation standards require every resident to rotate on the hospital anesthesiology service functioning as an anesthesia resident — same cases, same schedule, same level of responsibility — and to personally administer a minimum of 300 general anesthetics or deep sedations before graduating, at least half of them in the ambulatory setting, where the surgeon is responsible for the airway. Those numbers are floors, not ceilings. In my six-year combined oral and maxillofacial surgery/MD residency at UT Southwestern, administering IV sedation and general anesthesia was part of nearly every clinic day for six years, not a single rotation.
Board certification tests it. The American Board of Oral and Maxillofacial Surgery examines candidates on adult and pediatric medical assessment and anesthesia, and on office-based emergency management, as core sections of its oral certifying examination. I have been ABOMS board certified since 2004 and have maintained that certification through two recertification cycles.
What that means in the BellaNova operating room. I have personally administered well over 5,000 IV sedation and general anesthesia cases. During your surgery a dedicated CRNA manages your anesthesia and I operate — but the surgeon standing over you is also a physician trained and tested in airway management: intubation, laryngeal mask placement, and an emergency surgical airway if it were ever needed. In the unlikely event of an emergency, there are two people in the room who can run it, not one. That redundancy cannot be purchased or added to a facility; it has to be trained. Unless a cosmetic surgeon also completed an oral and maxillofacial surgery residency, they have not had this training — and I say that as a plain description of the two training pathways, not as a criticism of colleagues.
What facility accreditation actually verifies
Accreditation means an outside body inspected the facility against written standards. The recognized organizations for office surgery are AAAASF, AAAHC, and The Joint Commission. A survey typically verifies:
- Operating room construction, sterilization, and infection control
- Monitoring equipment — continuous pulse oximetry, blood pressure, ECG, and capnography (end-tidal CO2) for sedation and general anesthesia
- Emergency equipment — a stocked crash cart, defibrillator, difficult-airway equipment, and dantrolene for malignant hyperthermia
- Staff credentials and current ACLS certification
- Written policies: patient selection, controlled-substance handling, emergencies, transfer
- Peer review and quality reporting
BellaNova's surgical facility is registered with the Florida Board of Medicine as a Level III office surgery facility (Office Surgery Registration OSR 2082, held by AAG Medical Group LLC d/b/a BellaNova Cosmetic Surgery). Florida gives a facility two ways to satisfy the rule: national accreditation, or registration with a preregistration inspection and annual re-inspection by the Department of Health. We operate under the state inspection pathway today and are pursuing QUAD A (formerly AAAASF) accreditation on top of it. You can verify our registration yourself on the Department of Health's license lookup.
Our transfer agreement is with HCA Florida JFK Hospital at 5301 S. Congress Avenue in Atlantis — the same road as our facility, a few minutes south. Florida requires that hospital's name be given to you in writing before surgery, and we do.
Florida's office surgery rules, in plain language
Florida is one of the stricter states, and the rules are public. Any office where a physician operates under moderate sedation, deep sedation, or general anesthesia (Level II or Level III office surgery) must be registered with the Florida Board of Medicine under Section 458.328, Florida Statutes, and Rule 64B8-9.0091, Florida Administrative Code. The Department of Health inspects every office before it is registered and re-inspects it annually unless the office is accredited by a nationally recognized body. Rule 64B8-9.009 then sets the standard of care, and it is specific: deep sedation and general anesthesia in an office are limited to ASA Class I and II patients, with ASA III and above sent to a hospital or surgery center; the surgeon must hold hospital privileges for the procedure or have a transfer agreement with a hospital within 30 minutes, and must give you that hospital's name in writing before surgery; general anesthesia must be administered by an anesthesiologist, CRNA, anesthesiologist assistant, or qualified physician assistant who does nothing else during the case; the crash-cart contents, monitoring (including end-tidal CO2), dantrolene supply, and ACLS certifications are spelled out item by item; planned surgery time is capped at eight hours and liposuction at 4,000 cc; and an ACLS-certified physician or nurse must monitor you in recovery. You can look up any Florida office surgery registration on the Department of Health's license verification site.
A third party checks our work
Rules only protect patients if someone is checking the facility against them every month, not just on inspection day. BellaNova contracts Universal Healthcare Consulting, a Florida risk-management and compliance firm that works with more than 300 outpatient surgical facilities, as our outside risk-management group. Its co-founder is a licensed healthcare risk manager who helped develop Florida's current office surgery rules and later served as a state inspector; the firm is endorsed by the Florida Society of Plastic Surgeons. Their job is to hold us to the standard of care continuously: they credential every employee and every CRNA who works in our operating room, maintain our policy manual, track crash-cart and equipment currency, run our quality-assurance reporting, and keep the facility survey-ready between state inspections. I chose to pay for that scrutiny. A practice that is confident in its systems should welcome an outsider looking at them.
Controlled substances: the safety issue nobody asks about
Sedation and general anesthesia use controlled medications — opioids and benzodiazepines — that are federally regulated for a reason. A well-run facility can account for every milligram: what was dispensed, what was given, what was wasted, and who witnessed it. That accountability is not bureaucracy. It's how a facility ensures the dose in the chart is the dose you received, and it is one of the clearest markers of a disciplined surgical environment.
At BellaNova, our controlled substances are monitored in a per-case dispensing with an ongoing reconciliation log performed every time the drug safe is opened by Dr. Carlotti and either the CRNA or the Director of Nursing. We always perform double witness wasting and the day does not close until all drug counts are correct and they match all anesthesia or overnight nursing records.
Patient selection: a safe facility says no sometimes
Part of office-surgery safety is knowing which patients belong in a hospital instead. Every accredited facility should have written criteria — typically in Florida the rule itself restricts office general anesthesia to ASA Class I and II patients, and a good facility adds its own limits for BMI, sleep apnea, cardiac history, and procedure length — and a surgeon willing to refer you elsewhere when you fall outside them. If a practice will operate on anyone with a credit card, that is a warning sign, not a convenience.
BellaNova operates only on ASA I and II patients. That is the standard in outpatient cosmetic surgery and it is not negotiable here; if your health history places you outside it, I will tell you so and help you find the right setting.
The 10 questions to ask before any office procedure
Ask these of every practice. Write down the answers. A safe facility will be glad you asked.
- Is this facility accredited, by whom, and when was the last survey?
- Is the office registered with the state for the level of anesthesia you'll be using?
- Who will administer my anesthesia — an anesthesiologist, a CRNA, or the surgeon — and will that person be dedicated only to me for the entire case?
- Who supervises the anesthesia provider, and are they in the room?
- What monitoring is used — does it include capnography?
- What emergency equipment and medications are on site, including dantrolene?
- Does the surgeon have hospital privileges or a transfer agreement, and which hospital?
- Who recovers me after surgery, and what are their credentials?
- How are controlled medications tracked and reconciled?
- What are your patient-selection limits, and have you ever declined a patient for safety reasons?
Download the printable Surgical Facility Safety Checklist.
How to verify what you're told
- Look up the facility on the accrediting body's public directory
- Look up the surgeon's license, board certification, and any office surgery registration on the state health department site
- Verify the anesthesia provider's license the same way
- Ask to see the OR and recovery area during your consultation — a proud facility will show you
Frequently asked questions
Is it safe to have cosmetic surgery in an office instead of a hospital?
Yes, when the facility is accredited, properly registered, staffed by a dedicated anesthesia provider, and equipped for emergencies. The setting is not the risk; the standards are.
Is general anesthesia or IV sedation safer for cosmetic surgery?
Neither is inherently safer. The safety comes from matching the technique to the procedure and patient, and from who is monitoring you. Deep IV sedation requires the same airway vigilance as general anesthesia.
Is a CRNA as safe as an anesthesiologist?
CRNAs are highly trained and administer a large share of anesthesia nationally. What matters most is that a qualified provider is dedicated to you, properly supervised, and working in an accredited facility with emergency capability.
Can the surgeon himself manage my anesthesia if something goes wrong?
At BellaNova, yes. Dr. Carlotti trained as an oral and maxillofacial surgeon in a combined OMFS/MD residency — the one surgical specialty whose accredited training requires the surgeon to personally administer general anesthesia and deep sedation — and has personally performed more than 5,000 IV sedation and general anesthesia cases. His ABOMS board certification, maintained since 2004, examines anesthesia and office emergency management. He can perform every function of the CRNA or anesthesiologist in our facility, including intubation and emergency airway placement. See “Why my own anesthesia training matters to you” above.
What does AAAASF (QUAD A) accreditation mean?
It means the facility passed an independent inspection against written standards for equipment, staffing, monitoring, emergency readiness, and policies, and is re-surveyed periodically. AAAASF is now known as QUAD A. In Florida, accreditation is one of two accepted pathways; the other is registration with the Board of Medicine plus annual inspection by the Department of Health, which is the pathway BellaNova operates under while we pursue QUAD A accreditation.
What should I do if a practice won't answer these questions?
Go elsewhere. Every item on this list is basic, and a facility that treats it as an imposition is telling you something.
Ask us anything on this list
Safety is the part of my practice I'm proudest of and the part I'm happiest to be questioned about. Bring this list to your consultation at BellaNova in West Palm Beach — I'll answer every question and show you the facility. Call 561-834-6682 or request a consultation online. Learn more about our surgical facility and our team.