Letter to the Editor: Reply to Trignano et al.: General Anesthesia Plus Sacral Erector Spinae Plane Block-Redefining...

We thank Köksal et al. for their correspondence regarding our retrospective series on intramuscular gluteal augmentation performed under tumescent local anesthesia with titrated sedoanalgesia. We clarify that, in our cohort, total lidocaine doses remained within accepted safety limits and no clinical evidence of local anesthetic systemic toxicity was observed; continuous multimodal monitoring was used throughout. Concerns about sedation in the prone position are acknowledged, but our protocol employs light-to-moderate, carefully titrated sedoanalgesia that preserves spontaneous ventilation and protective reflexes, and we encountered no airway complications. The suggestion of postoperative rebound pain related to lidocaine is not supported by our clinical experience: discomfort was effectively controlled with a standardized multimodal, opioid-sparing regimen and high patient satisfaction. We recognize the potential value of general anesthesia combined with sacral erector spinae plane block, as described by the authors, but note that this approach requires specific expertise and its purported advantages are currently based on limited evidence. Overall, our data support that, in appropriately selected patients and within strict safety and monitoring standards, tumescent anesthesia with sedoanalgesia is a safe and effective alternative to routine general anesthesia for intramuscular gluteal implant surgery, without compromising comfort or surgical quality.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .