9. Preventive methods and complications

analgesic effect. Sener et al. [72] found that in patients of septorhinoplasty lornoxicam (25 mg/day) has better tolerability and postoperative analgesia than dipyrone (5 mg/day) administered with a system of analgesia i.v. controlled by the patient. Gabapentinoids (gabapentin, pregabalin) and ketamine have additive or synergistic effects that decrease the doses of anesthetics in the

Although the analgesic mechanism of esmolol (ultrashort-acting cardio-selective β1-adrenergic receptor antagonist) is not well known [73], some clinical studies have resulted in a decrease in propofol during the induction of general anesthesia, a reduction of general anesthetics during maintenance, and a reduced dose of transoperative opioids, as well as it reduces immediate postoperative pain [74–76]. Its use in rhinoplasty seems to reduce the dose of opioids in the

Regional analgesia, as mentioned before, has a very important role: local anesthesia infiltra-

Outpatient or short-stay plastic surgery patients should observe home discharge criteria that have been established for other types of surgery. These basic criteria establish the home discharge of patients in a safe manner and avoid readmissions due to complications.

Alertness Patient awake, well oriented. Spinal anesthesia favors this state of alert which facilitates optimal

Analgesia Controlled postoperative pain (EVA <2/10) with oral analgesics. Subarachnoid anesthesia with

Ambulation Complete regression of the motor block is convenient. The patient can try to walk when he/she has

Headache Although the classic CPPD is presented as of the second post-block day, there are patients who can

Other Absence of bleeding at the operative site, ensure company, stay and transport to patients who do not drive, establish possible means of communication such as telephone, FAX, email

adjuvants provides a prolonged period of analgesia that facilitates early home discharge and reduces the dose of analgesics. It is convenient to prescribe a combination of opioid and non-opioid

This is a controversial requirement. Some centers consider it as mandatory to avoid readmissions by bladder balloon. In our practice we do not consider this requirement as indispensable, and the patient is informed of the remote possibility of difficulty urinating. We avoid the use of intrathecal

recovered the perianal sensitivity and can flex and extend the foot. In some cases, it is feasible to

develop it in the immediate postoperative period. It is prudent to investigate it with the patient

analgesics according to the expected postoperative pain and the profile of each patient

The return of vital signs to pre-anesthetic figures is mandatory

Tolerate the intake of liquids or solids without nausea or vomiting

intraoperative period and the intensity of immediate postoperative pain [77, 78].

transoperative and opioids in the immediate postoperative period.

22 Anesthesia Topics for Plastic and Reconstructive Surgery

tions and interfacial, paravertebral, intercostal, or epidural blocks.

8. Criteria for home discharge and home follow-up

home discharges

morphine to reduce this risk

semi-seated or standing

Table 11. Criteria for home discharge.

discharge without 100% recovery

Hemodynamic stability

Permeable oral route

Spontaneous micturition

Medical ethics and government regulations emphasize excellent care and safeguard the health needs of patients. The correct and sensitive communication of this carefulness is essential for a correct anesthesiological care. The lesions associated with anesthesia are a frequent cause of morbidity and litigation, so it is mandatory to identify the common factors associated with peri-anesthetic injuries and thus reduces possible demands. In anesthesia for plastic surgery, as in other surgical procedures, cardiopulmonary events are the most common errors or incidents that cause severe neurological damage or death. The keys to prevent legal action against the anesthesiologist are simple acts such as establishing an adequate relationship with the patient and his family from the pre-anesthetic period, appropriate pre-anesthetic evaluation, filling out the informed consent, always using the correct monitoring, performing the best anesthesia, and postanesthetic care [14].

The complications in plastic surgery are due to four general factors: (a) characteristics of the establishment where the procedure is performed, (b) type of surgery and surgeon, (c) physical condition of the patient, and (d) quality of anesthesiological care. The study by Clayman and Caffe [81] conducted in Florida, USA, with deceased patients who had been operated in officebased surgery facilities found 36 deaths in 5 years, 18 related to plastic surgery, 3 of which were seen by non-plastic surgeons, and 12 under general anesthesia, 10 of which were administered by anesthesiologists and 2 by nurse anesthetists. Seven of these cases died before discharge and 11 after apparent appropriate discharge. The deaths that occurred before patients were discharged from hospital were due to bronchospasm, deep sedation, one related to illicit drug use, and the other to fatty embolism. Of the 11 patients discharged, seven died due to possible thromboembolism. In the rest, the cause of death was not determined. Most of these deaths could be avoided with simple measures such as adequate trans-anesthetic surveillance, prophylaxis of DVT/PE, and optimal patient selection.

Deep vein thrombosis and pulmonary thromboembolism. These two entities are complications frequently related to plastic surgery (liposuction and tummy tuck). The frequency of PE is variable: circular abdominoplasty (3.4%), simple tummy tuck (0.35%), tummy tuck plus another plastic surgery procedure (0.79%), and abdominoplasty plus an intra-abdominal procedure (2.17%) [82, 83]. The plication of the rectus abdominis and the use of abdominal strips favor the increase of intra-abdominal pressure, decrease in venous flow, venous dilatation, and loss of normal biphasic venous flow at the popliteal level. The true impact of compression garment devices on DVT is still unknown [84], and pharmacological and mechanical protocols for thromboembolic prophylaxis in abdominoplasty seem to have similar results. This type of patients must be managed with a perioperative prophylactic scheme including graduated compression stockings, intermittent pneumatic compression tools, venous foot pumps, and drugs such as low molecular weight heparin or low-dose unfractionated heparin (20 mg of enoxaparin or equivalent daily for a week). Aspirin has been used successfully in major orthopedic surgery [85] and could have utility in plastic surgery with the risk of DVT/PE. The use of direct and indirect factor Xa inhibitions and thrombin inhibitors may be contraindicated since they induce greater postoperative bleeding [86, 87]. There is controversy about the risk of combining two or more plastic surgery procedures or other types (hysterectomy, colpoplasty, cholecystectomy). From anesthesia view, it is known that if there is longer operative time there are more possibilities of complications (bleeding, atelectasis, DVT, PE, alterations of the immune response, among others). The surgical literature is contradictory, and there are studies that favor combinations [83, 86, 87] and others that do not support this procedure [86].

idealized success, which is based on information lacking scientific basis. On the other hand, the increasing sites offering plastic surgery has favored a demand not only for quality but also for more accessible prices. This nonmedical challenge is combined with the challenges of anesthesiological care in healthy patients, in apparently normal cases, and in people with systemic comorbidities. Each of these groups always requires a scrupulous comprehensive preoperative medical assessment and the development of a modifiable anesthetic plan. Another problem is the short and mediate term follow-up of these patients, since one way to improve our anesthesiological techniques is to study the evolution outside the operating room. The anesthesiologist rarely can see this type of outpatient or short-stay patient. So, it is prudent to establish a means of communication from the time of the pre-anesthetic visit to a long postanesthesia period. The Internet is by far the most viable way to determine what kind of

Anesthesia for Plastic Surgery Procedures http://dx.doi.org/10.5772/intechopen.81284 25

Patient-tourists represent a significant challenge very little studied in plastic surgery. They are people who have traveled for several hours or days, who come from other countries and who usually have not had a surgical or pre-anesthetic evaluation. They must be evaluated quickly and correctly to determine their viability to the procedures they want. It is common to see uncommon pathologies that do not contraindicate anesthesia, but can influence perioperative

Ambulatory and short-stay plastic surgery is growing logarithmically around the world. Anesthesiologists are more often subjected to the challenge of providing anesthesia to these patients, who on the other hand are scheduled every day for longer procedures and high risks that previously disqualified them for outpatient procedures. To favor an adequate outcome in this group of ambulatory patients—healthy and not so healthy, anesthesiologists should be oriented to the rational use of short and intermediate action drugs, with the goal of reducing morbidity and mortality. Techniques to prevent pain, nausea and vomiting, and early ambulation will be the most accepted procedures. The anesthetic techniques for outpatient surgery differ greatly from the procedures for short-stay patients, since the latter are scheduled to remain hospitalized for a minimum of 24 hours, unlike outpatient in which to prolong their stay beyond 5 pm can be considered as a failure in the anesthetic plan. A short recovery time

after anesthesia is very important for the patient, his doctors, and the surgical unit.

death. The latter is the most feared and should not happen.

Plastic surgery performed in ambulatory surgery units has some potential benefits such as ease of programming, reduced costs, and comfort for the patient and surgical staff. On the other hand, the inconveniences of ambulatory anesthesia should be considered, such as nausea and vomiting, uncontrolled postoperative pain, unplanned hospitalization, and, finally, occasional

Ambulatory cosmetic surgeries can potentially be managed with any anesthesiological technique. Although most anesthesiologists use general anesthesia for these procedures, regional anesthesia techniques have shown certain advantages such as better pain control, attenuation

evolution each of these patients have, especially the study of complications.

pharmacological management [2, 89].

11. Conclusions

Emesis. Postoperative and post-discharge nausea and vomiting remain the common and upsetting complications after plastic surgery. These symptoms interfere with the comfort of patients; they can have harmful effects on the results of surgery favoring bleeding, delaying discharge, and increasing costs [74]. There are several preventive schemes that have shown their effectiveness at low costs; the most usual combinations are dehydrobenzoperidol-dexamethasone and dexamethasone-ondansetron. The setrons (ondansetron, dolasetron, granisetron, tropisetron, and palonosetron) belong to a group of antiemetics with selective and potent antagonist action on the serotonin receptors, which also have an action on gastrointestinal motility and which lack antidopaminergic activity. Propofol 10 mg administered at the end of anesthesia has an antiemetic effect. Metoclopramide continues to be used, although its low effectiveness compared to other drugs and its side effects has decreased its use. The combination of transdermal scopolamine with intravenous ondansetron is another effective management option [87]. Brattwall and his group [88] found an antiemetic effect of smoking in breast augmentation. A prophylactic multimodal antiemetic regimen, suitable hydration, and opioid-sparing postoperative analgesia will decrease postsurgical emesis.

Chapter 7 of this book discusses the most frequent and unusual complications of anesthesia and plastic surgery.

## 10. Challenges

The challenges in anesthesia for plastic surgery patients are multiple since it is about people with perfectionist ideas that seek to improve their self-esteem through showing a better figure. This special personality makes them to search for a surgical medical team that guarantees their idealized success, which is based on information lacking scientific basis. On the other hand, the increasing sites offering plastic surgery has favored a demand not only for quality but also for more accessible prices. This nonmedical challenge is combined with the challenges of anesthesiological care in healthy patients, in apparently normal cases, and in people with systemic comorbidities. Each of these groups always requires a scrupulous comprehensive preoperative medical assessment and the development of a modifiable anesthetic plan. Another problem is the short and mediate term follow-up of these patients, since one way to improve our anesthesiological techniques is to study the evolution outside the operating room. The anesthesiologist rarely can see this type of outpatient or short-stay patient. So, it is prudent to establish a means of communication from the time of the pre-anesthetic visit to a long postanesthesia period. The Internet is by far the most viable way to determine what kind of evolution each of these patients have, especially the study of complications.

Patient-tourists represent a significant challenge very little studied in plastic surgery. They are people who have traveled for several hours or days, who come from other countries and who usually have not had a surgical or pre-anesthetic evaluation. They must be evaluated quickly and correctly to determine their viability to the procedures they want. It is common to see uncommon pathologies that do not contraindicate anesthesia, but can influence perioperative pharmacological management [2, 89].
