**Anesthesia for Plastic Surgery Procedures** Anesthesia for Plastic Surgery Procedures

DOI: 10.5772/intechopen.81284

#### Víctor M. Whizar-Lugo and Ana C. Cárdenas-Maytorena Víctor M. Whizar-Lugo and Ana C. Cárdenas-Maytorena

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.81284

#### Abstract

Plastic surgery is currently more popular and available with increasing frequency throughout the world. Its advances are related to progress in anesthesiology. Nowadays, it is possible to operate patients with pathologies that previously did not allow this type of surgery. The developments in perioperative monitoring, pharmacology, prevention of complications, and the wide communication between patients and physicians, as well as the development of surgical units that facilitate a prompt programming and reduce the total costs, have resulted in a logarithmic growth of plastic and reconstructive surgery procedures. Local, regional, or general anesthesia, anesthetic monitoring, or conscious sedation is used routinely, allowing to manage patients as ambulatory or short stay. Deep vein thrombosis and pulmonary embolism remain the most frequent complications, followed by postoperative pain, nausea, and vomiting.

Keywords: plastic surgery, anesthesia

#### 1. Introduction

The current demand for plastic surgery procedures has had a logarithmic growth. The American Society for Aesthetic Plastic Surgery reported that in 2016 in the USA 17.1 million surgical and nonsurgical cosmetic procedures were performed, a figure that indicates a 132% increase since 2000. These procedures represented an expenditure of approximately 16.4 billion US dollars, where breast augmentation is the most popular surgery and the application of Botox is the most performed nonsurgical procedure [1]. Other interesting aspects that have grown around plastic surgery are ambulatory surgery units, short-stay units, and procedures performed in plastic surgeons' medical offices. It is important that anesthesiological care does not decline when surgery is performed in this type of facility and the media and plastic

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

distribution, and eproduction in any medium, provided the original work is properly cited.

surgeons must be made aware, so they do not minimize the risks of this type of surgery, which from the point of view of the anesthesiologists are medium- and high-risk procedures [2, 3]. Regardless of where the surgery is performed, patient safety should be the primary issue at the time of anesthesia-surgery and during its immediate recovery. To ensure patient safety, there are several guidelines that list the most important points of accomplishment that should be followed in this regard. The published guide from SCARE [4], which emphasizes various points of safety, especially the mechanical and pharmacological prophylaxis of deep venous thrombosis (DVT) and pulmonary thromboembolism (PE). A review of the literature on liposuction complications establishes strict guidelines on lidocaine and epinephrine doses, PE prophylaxis, adequate hydration, and other management recommendations [5].

The advances in plastic surgery have been furthered by the progress in anesthesiology, making it the cornerstone on which the surgical progress has been made. Now, it is possible to carry out prolonged and more elaborate surgeries in patients with concomitant pathologies or with anesthesia risks that some years ago were not possible to achieve with the current safety. The availability of new anesthetics and adjuvant drugs, advances in trans- and postoperative monitoring, as well as the early prevention of complications have facilitated these advances. The list of plastic surgical procedures is very extensive, and anesthesia plays a vital role: from local techniques to neuraxial anesthesia and general inhaled or intravenous anesthesia procedures. The growth of outpatient procedures in cosmetic surgery requires effective anesthetic techniques that allow safe home returns shortly after the surgery is over. It is ideal that no surgical procedure in plastic surgery is performed without the presence of a qualified anesthesiologist.

This chapter serves as an introduction to this book, the most frequent plastic surgery procedures are listed, as well as the anesthesia techniques considered to be the most advanced.

## 2. Most frequent plastic surgery procedures

It is important that the anesthesiologist be familiar with all surgical procedures to establish an optimal anesthetic approach (see Graphic 1 and Tables 1 and 2). It is also important to keep in mind that the original surgical plan changes frequently; these last-minute modifications obey the wishes of the patient and sometimes the needs that arise during surgery, situations that lead to adjust the original anesthetic plan.

Table 2 lists the most frequent surgical procedures in plastic surgery and relates them to the most used anesthesia techniques, making some important observations in postanesthetic care and evolution. These techniques are the most recommended, being possible to use other alternatives or through combinations of anesthetic methods [6].

modified during surgery. For example, in a case where breast surgery is combined with abdomen procedures that could otherwise be managed with neuraxial anesthesia, a lumbar spinal anesthesia with hyperbaric local anesthetic and Trendelenburg position could disseminate the blockade up to T3 for breast surgery, which must be performed first, followed by the abdominal procedure [7]. This approach avoids general anesthesia and favors adequate postoperative analgesia with optimal recovery. Combined epidural-spinal anesthesia is another

Surgery Women Men

Anesthesia for Plastic Surgery Procedures http://dx.doi.org/10.5772/intechopen.81284 3

Liposuction 309,692 31,453 Blepharoplasty 166,426 28,678

Rhinoplasty 30,174 Gynecomastia 19,124 Hair implantation 18,062

management option in this surgical setting.

Graphic 1. Most frequent cosmetic surgeries.

Breast augmentation 355, 671

Abdominoplasty 143,005 Breast reduction 139,926

Table 1. Most frequent procedures according to gender [1].

In plastic surgery, it is common to combine two or more surgical procedures (breastabdominoplasty, mommy makeover), which in addition to increasing the risks, prolongs the surgical time, and therefore the anesthetic plan must be adapted to the surgeon's new approach. This fact can be determined before starting anesthesia, and in some patients, it is

Graphic 1. Most frequent cosmetic surgeries.

surgeons must be made aware, so they do not minimize the risks of this type of surgery, which from the point of view of the anesthesiologists are medium- and high-risk procedures [2, 3]. Regardless of where the surgery is performed, patient safety should be the primary issue at the time of anesthesia-surgery and during its immediate recovery. To ensure patient safety, there are several guidelines that list the most important points of accomplishment that should be followed in this regard. The published guide from SCARE [4], which emphasizes various points of safety, especially the mechanical and pharmacological prophylaxis of deep venous thrombosis (DVT) and pulmonary thromboembolism (PE). A review of the literature on liposuction complications establishes strict guidelines on lidocaine and epinephrine doses, PE

The advances in plastic surgery have been furthered by the progress in anesthesiology, making it the cornerstone on which the surgical progress has been made. Now, it is possible to carry out prolonged and more elaborate surgeries in patients with concomitant pathologies or with anesthesia risks that some years ago were not possible to achieve with the current safety. The availability of new anesthetics and adjuvant drugs, advances in trans- and postoperative monitoring, as well as the early prevention of complications have facilitated these advances. The list of plastic surgical procedures is very extensive, and anesthesia plays a vital role: from local techniques to neuraxial anesthesia and general inhaled or intravenous anesthesia procedures. The growth of outpatient procedures in cosmetic surgery requires effective anesthetic techniques that allow safe home returns shortly after the surgery is over. It is ideal that no surgical procedure in

This chapter serves as an introduction to this book, the most frequent plastic surgery procedures are listed, as well as the anesthesia techniques considered to be the most advanced.

It is important that the anesthesiologist be familiar with all surgical procedures to establish an optimal anesthetic approach (see Graphic 1 and Tables 1 and 2). It is also important to keep in mind that the original surgical plan changes frequently; these last-minute modifications obey the wishes of the patient and sometimes the needs that arise during surgery, situations that

Table 2 lists the most frequent surgical procedures in plastic surgery and relates them to the most used anesthesia techniques, making some important observations in postanesthetic care and evolution. These techniques are the most recommended, being possible to use other

In plastic surgery, it is common to combine two or more surgical procedures (breastabdominoplasty, mommy makeover), which in addition to increasing the risks, prolongs the surgical time, and therefore the anesthetic plan must be adapted to the surgeon's new approach. This fact can be determined before starting anesthesia, and in some patients, it is

prophylaxis, adequate hydration, and other management recommendations [5].

plastic surgery is performed without the presence of a qualified anesthesiologist.

2. Most frequent plastic surgery procedures

alternatives or through combinations of anesthetic methods [6].

lead to adjust the original anesthetic plan.

2 Anesthesia Topics for Plastic and Reconstructive Surgery


Table 1. Most frequent procedures according to gender [1].

modified during surgery. For example, in a case where breast surgery is combined with abdomen procedures that could otherwise be managed with neuraxial anesthesia, a lumbar spinal anesthesia with hyperbaric local anesthetic and Trendelenburg position could disseminate the blockade up to T3 for breast surgery, which must be performed first, followed by the abdominal procedure [7]. This approach avoids general anesthesia and favors adequate postoperative analgesia with optimal recovery. Combined epidural-spinal anesthesia is another management option in this surgical setting.


not intend to cure a disease but to improve their self-esteem through better physical appearance. On the other hand, they are extremely demanding patients in terms of perfection in the results and do not tolerate errors or side effects. It is prudent to explain the various anesthetic techniques available for the type of surgery scheduled, as well as the benefits and risks of each anesthetic procedure, especially those attributed to the planned technique. It is also the best time for them to meet the anesthesiologist and become familiar with his/her credentials and experience. These last points are fundamental to gain patient confidence and to diminish their

Anesthesia for Plastic Surgery Procedures http://dx.doi.org/10.5772/intechopen.81284 5

The pre-anesthetic evaluation should be made several days in advance. Regardless of the physical condition of each patient, a complete clinical history and detailed and oriented physical examination are fundamental in the pre-anesthetic assessment. It is essential to determine the physical integrity or possible deterioration of the patient, especially the neurological and cardiopulmonary systems, as well as a detailed analysis of the airway and the spine. The patients must be evaluated regarding their emotional state and their ability to tolerate surgeries with prolonged times and difficult recoveries. Plastic surgery patients are divided into two major categories: healthy patients and patients with one or more systemic pathologies, such as acquired heart diseases, pneumopathies, diabetes mellitus, venous insufficiency, and hyperlipidemia, this last one being the most common. The age at which cosmetic surgery is performed is variable: 35–50 years (45%), 51–64 years (26%), 19–34 (22%), 65 or more (6%), and minors to 18 years (2%) [3]. The healthy patient. Most plastic surgery patients are in good physical shape (ASA 1–2); those with facial surgery are usually more than 50 years old, although cosmetic facial surgery has currently increasing frequency in younger people. Patients who undergo surgery on body segments tend to be younger with purely esthetic goals, but recently there is a growing group of overweight patients who have undergone bariatric surgeries and consult the plastic surgeon seeking corrective procedures for skin excess secondary to excessive weight loss, which should be categorized as unhealthy patients [8, 9]. Patients without apparent comorbidities are potentially healthy people; however, we must be sure that this statement is true. Once the patient has been evaluated by the plastic surgeon, it is recommended that those over 50 years old are also evaluated by an internist and have complete clinical exams according to the surgery plan. These tests should include blood count with platelets, prothrombin time, partial thromboplastin time, INR, complete blood chemistry, and urinalysis. HIV testing is convenient, as well as hepatitis B and C antigens in some patients [3, 6]. Pregnancy test is recommended in women of

During this pre-anesthetic interview, the intake of medications such as nonsteroidal antiinflammatory drugs (NSAIDs), vitamin E, weight loss medications, contraceptives, herbs, as well as history of illegal drug use or any prescription medicines should be questioned. It is frequent that these "healthy" patients utilize thyroid hormones, antidepressants, benzodiazepines, high doses of vitamins and minerals, as well as herbs, food supplements, and teas that could interact with the drugs used in the perianesthesiological time. Patients underestimate the importance to ingest these products, so it is imperative that both the surgeon and the anesthesiologist emphatically investigate whether patients ingest such products since many of them have anticoagulant, antiplatelet, procoagulant, and arrhythmic or potentiate the effects

anxiety and the possibility of an eventual legal conflict.

childbearing age.

CS = conscious sedation; GA = general anesthesia; PDB = peridural block; SB = spinal block; MAC = monitored anesthetic care; fast track = direct access to hospital room.

Table 2. Most frequent procedures in cosmetic surgery.
