11. Conclusions

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

24 Anesthesia Topics for Plastic and Reconstructive Surgery

that favor combinations [83, 86, 87] and others that do not support this procedure [86].

postoperative analgesia will decrease postsurgical emesis.

and plastic surgery.

10. Challenges

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

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

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 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.

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

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 of the response to operative stress, preserving perioperative immune function, better preservation of oxygenation and lung residual functional capacity, improvement of visceral vascular flow, early recovery of postoperative ileus, and reduction of venous thrombotic disease and pulmonary embolism.

[5] Cárdenas-Camarena L, Andrés Gerardo LP, Durán H, Bayter-Marin JE. Strategies for reducing fatal complications in liposuction. Plastic and Reconstructive Surgery. Global

Anesthesia for Plastic Surgery Procedures http://dx.doi.org/10.5772/intechopen.81284 27

[6] Whizar LV, Cisneros CR, Reyes AMA, Campos LJ. Anestesia para cirugía facial cosmética.

[7] Whizar LV, Cisneros CR, Reyes AMA, Ontiveros MP. Combined Lumbar Spinal-Epidural Anaesthesia (CLSEA) with Hyperbaric 0.75% Ropivacaine Plus Clonidine for Breast and Abdominal-Pelvic Plastic Surgery. An Open Trial. Paris, France: WCA; 2004. p. CD231 [8] Pitanguy I. Body-contouring surgery. Bulletin de l'Académie Nationale de Médecine.

[9] Whizar-Lugo V, Cisneros-Corral R, Reyes-Aveleyra MA, Campos-León J, Domínguez J. Anesthesia for plastic surgery procedures in previously morbidly obese patients. Anes-

[10] Heller J, Gabbay JS, Ghadjar K, Jourabchi M, O'Hara C, Heller M, et al. Top-10 list of herbal and supplemental medicines used by cosmetic patients: What the plastic surgeon needs to know. Plastic and Reconstructive Surgery. 2006;117:436-445. DOI: 10.1097/01.

[11] Caldera PS, Ayala CJL, Cortés BB. Herbolaria y anestesiología. Estudio en pacientes mexicanos sometidos a cirugía ambulatoria. Anesthesiology in Mexico. 2008;20:45-48 [12] Chin SH, Cristofaro J, Aston SJ. Perioperative management of antidepressants and herbal medications in elective plastic surgery. Plastic and Reconstructive Surgery. 2009;123:377-386.

[13] Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA. 2001;286:

[14] Whizar-Lugo V. Prevención en anestesiología. Anesthesiology in Mexico. 2009;21:118-138 [15] Caplan RA, Posner KL. Informed consent in anesthesia liability: Evidence from the Closed

[16] Chrimes N, Marshall SD. The illusion of informed consent. Anaesthesia. 2018;73:9-14.

[17] Andersen LP, Werner MU, Rosenberg J, Gögenur I. A systematic review of peri-operative

[18] Su X, Wang DX. Improve postoperative sleep: What can we do? Current Opinion in

[19] Borazan H, Tuncer S, Yalcin N, Erol A, Otelcioglu S. Effects of preoperative oral melatonin medication on postoperative analgesia, sleep quality, and sedation in patients undergoing elective prostatectomy: A randomized clinical trial. Journal of Anesthesia. 2010;24(2):

melatonin. Anaesthesia. 2014;69(10):1163-1171. DOI: 10.1111/anae.12717

Anaesthesiology. 2018;31(1):83-88. DOI: 10.1097/ACO.0000000000000538

Open. 2017;5(10):e1539. DOI: 10.1097/GOX.0000000000001539

Anesthesiology in Mexico. 2005;17:117-131

thesiology in Mexico. 2009;21:186-193

DOI: 10.1097/PRS.0b013e3181934892

Claims Project. ASA Newsletter. 1995;59:9-12

155-160. DOI: 10.1007/s00540-010-0891-8

2003;187:489-491

prs.0000197217.46219.a7

DOI: 10.1111/anae.14002

208-216
