3. Pre-anesthetic evaluation

"Primum non nocere" is a Latin phrase meaning "first, to do no harm" and is an old statement that has been one of the principal precepts of bioethics for several centuries. This concept is the purpose of pre-anesthetic assessment, which in patients scheduled for plastic surgery should not be any different from that of patients operated of other procedures and should be timely, complete, interdisciplinary, and dynamic. This evaluation is a vital instrument for the medical and nursing team, as well as for the patients and their families since it gives them the opportunity to know the patient and their environment, the reasons that led to surgery, fears of, and above all, to discuss the prejudices and doubts about anesthesia. These patients have peculiarities that make them different; on the one hand, most are healthy people, individuals who do 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 anxiety and the possibility of an eventual legal conflict.

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 childbearing age.

3. Pre-anesthetic evaluation

care; fast track = direct access to hospital room.

Table 2. Most frequent procedures in cosmetic surgery.

• Facial surgery

4 Anesthesia Topics for Plastic and Reconstructive Surgery

• Body surgery

• Limb surgery

"Primum non nocere" is a Latin phrase meaning "first, to do no harm" and is an old statement that has been one of the principal precepts of bioethics for several centuries. This concept is the purpose of pre-anesthetic assessment, which in patients scheduled for plastic surgery should not be any different from that of patients operated of other procedures and should be timely, complete, interdisciplinary, and dynamic. This evaluation is a vital instrument for the medical and nursing team, as well as for the patients and their families since it gives them the opportunity to know the patient and their environment, the reasons that led to surgery, fears of, and above all, to discuss the prejudices and doubts about anesthesia. These patients have peculiarities that make them different; on the one hand, most are healthy people, individuals who do

CS = conscious sedation; GA = general anesthesia; PDB = peridural block; SB = spinal block; MAC = monitored anesthetic

Procedures Anesthesia Patient stay Observations

Rhytidoplasty CS/GA 24 hours Moderate pain Coronal CS/GA Ambulatory Fast track Open rhinoplasty CS/GA Ambulatory Fast track Rhinoplasty with bone fracture GA Ambulatory Moderate pain Blepharoplasty MAC/CS Ambulatory Fast track Otoplasty MAC/CS Ambulatory Fast track Laser dermabrasion CS Ambulatory Moderate pain Implants MAC/CS Ambulatory Fast track Fat grafting, synthetic materials MAC/CS Ambulatory Fast track

Breasts or pectorals PDB/GA Ambulatory Moderate pain

Torso PDB /GA Ambulatory Moderate pain

Buttocks implants SB/PDB/GA Ambulatory Moderate pain

Brachioplasty PDB/GA Ambulatory Moderate pain Cruroplasty SB/PDB/GA Ambulatory 24 hours Moderate pain Liposuction SB/PDB/GA Ambulatory Mild pain

Liposuction SB, PDB, GA, or local Ambulatory 24 hours Mild to moderate pain,

Abdominoplasty SB, PDB/GA 24 hours Moderate pain, anemia Breast pexia of inferior segment PDB/GA 24 hours Moderate pain, anemia

bleeding, anemia

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 of anesthetics. Heller et al. [10] found that plastic surgery patients used herbs or supplements in 55% versus the general population 24% (p < 0.001). The most used by their patients were chondroitin 18%, ephedra 18%, echinacea 8%, garlic 6%, ginseng 4%, and ginger 4%. Fifty-four percent of the supplements/herbs taken by these patients have pharmacological interference with anesthetic drugs or can affect surgery. In 85% of the cases, patients were not told to stop taking these herbs or supplements before surgery, except for those who ingested ephedra in which 100% of the surgeons indicated their suspension. This study demonstrated the ignorance of physicians regarding the undesirable effects of herbalism in plastic surgery patients. A Mexican study in ambulatory patients [11] found that 65% took ginseng and Ginkgo biloba combined, 17.5% ingested garlic, and 5% chamomile tea. Table 3 lists some herbs and food supplements that should be discontinued 1–2 weeks before the surgery [10–13].

The patient with comorbidities. There are a group of patients who undergo cosmetic surgery and who have one or more added pathologies that warrant a more thorough pre-anesthetic evaluation, which may end up postponing surgical intervention or suspend it indefinitely. Diabetic, hypertensive, cardiac, pulmonary, obese, anemic, hypo-/hyperthyroid, patients with rheumatological diseases, and so on are subjects for consultations with the internist or the appropriate subspecialist to stabilize their concomitant pathologies before programming plastic surgery. It is common for the plastic surgeon to miss some of these systemic pathologies during patient evaluation, so it is mandatory that in the initial anesthesiological assessment a condition that may interfere not only with anesthesia but also with surgery itself or during the healing period should be meticulously researched, such as thrombophilias, hypo-/hyperthyroidism, pheochromocytoma-paragangliomas, lupus, sickle cell disease, drug addiction, and many more. It is the anesthesiologist's role, in conjunction with the surgeon, to refer the patient to the appropriate specialist. Once the patient has been assessed by the internist or a subspecialist, it is advisable to perform a second pre-anesthetic evaluation to be sure that the patient is able to

be anesthetized, as well as to know in advance the specialist's recommendations.

Observations

alterations, family environment, and possibility of a lawsuit Physical

Clinical history Yes Yes The general and oriented clinical review made by the anesthesiologist

Chest X-ray NE Yes Useful in smokers, suspected tuberculosis, neoplasms, emphysema,

Echocardiogram No R Compulsory study in patients with severe arterial hypertension, ischemic

Spirometry No R Its usefulness has not been demonstrated; however, it is recommended in chronic pneumopathy and smokers

Yes Yes Kidney, hepatocellular, metabolic, and electrolyte evaluation

Coagulation tests Yes Yes TP, TPT, INR, and bleeding time are mandatory in anticoagulants,

malnutrition

Urinalysis NE Yes Loss of blood and proteins, changes in urine density

kyphosis

NE Yes It is prudent to know the opinion of the geriatrician, pulmonologist,

Yes Arrhythmias, ischemia, growth, or dilatation of heart cavities

patients, and patients with dilated cardiomyopathy

R R They are requested based on the clinical history and experience data. HIV is

polypharmacy, drug interactions, etc.

anticipates problems such as difficult airway, spinal anomalies, mental

Anesthesia for Plastic Surgery Procedures http://dx.doi.org/10.5772/intechopen.81284 7

cardiologist, endocrinologist, surgeon, and family therapist in search of

hepatocellular damage, severe sepsis, prolonged fasting, and extreme

prudent for the protection of medical and paramedical personnel

2–3

Blood test Yes Yes Diagnosis of subclinical anemia

Table 4. Parameters for pre-anesthetic evaluation in plastic surgery [5].

Yes Yes

years old

Parameters ASA 1 ASA

Electrocardiogram Only >50

examination

Complete blood chemistry

HIV, hepatitis, drugs, pregnancy

NE = not essential; R = recommendable.

Specialist consultation


Table 3. Effects of some herbs and foods.

The patient with comorbidities. There are a group of patients who undergo cosmetic surgery and who have one or more added pathologies that warrant a more thorough pre-anesthetic evaluation, which may end up postponing surgical intervention or suspend it indefinitely. Diabetic, hypertensive, cardiac, pulmonary, obese, anemic, hypo-/hyperthyroid, patients with rheumatological diseases, and so on are subjects for consultations with the internist or the appropriate subspecialist to stabilize their concomitant pathologies before programming plastic surgery. It is common for the plastic surgeon to miss some of these systemic pathologies during patient evaluation, so it is mandatory that in the initial anesthesiological assessment a condition that may interfere not only with anesthesia but also with surgery itself or during the healing period should be meticulously researched, such as thrombophilias, hypo-/hyperthyroidism, pheochromocytoma-paragangliomas, lupus, sickle cell disease, drug addiction, and many more. It is the anesthesiologist's role, in conjunction with the surgeon, to refer the patient to the appropriate specialist. Once the patient has been assessed by the internist or a subspecialist, it is advisable to perform a second pre-anesthetic evaluation to be sure that the patient is able to be anesthetized, as well as to know in advance the specialist's recommendations.


NE = not essential; R = recommendable.

of anesthetics. Heller et al. [10] found that plastic surgery patients used herbs or supplements in 55% versus the general population 24% (p < 0.001). The most used by their patients were chondroitin 18%, ephedra 18%, echinacea 8%, garlic 6%, ginseng 4%, and ginger 4%. Fifty-four percent of the supplements/herbs taken by these patients have pharmacological interference with anesthetic drugs or can affect surgery. In 85% of the cases, patients were not told to stop taking these herbs or supplements before surgery, except for those who ingested ephedra in which 100% of the surgeons indicated their suspension. This study demonstrated the ignorance of physicians regarding the undesirable effects of herbalism in plastic surgery patients. A Mexican study in ambulatory patients [11] found that 65% took ginseng and Ginkgo biloba combined, 17.5% ingested garlic, and 5% chamomile tea. Table 3 lists some herbs and food

supplements that should be discontinued 1–2 weeks before the surgery [10–13].

root)

Anticoagulant, antiplatelet Wild lettuce Enhances warfarin

proteinase I)

(Glycyrrhiza glabra)

Enhances warfarin Kelp Anticoagulant

longa)

Gingko biloba Antiplatelet Asiatic ginseng Anticoagulant, antiplatelets,

(Hypericum perforatum)

Ginseng (Panax ginseng) Anticoagulant

Interacts with local anesthetics, barbiturates, increase sedative potency

Induces cytochrome P450 3A4. Interacts with midazolam, alfentanil, lidocaine, calcium blockers, and serotonin receptor agonists

Hemorrhage risk

Antiplatelet

Antiplatelet

hypoglycemic

Valeriana officinalis Increases sedative effect

Vitamin E Antiplatelets

Product Effect Product Effect

Antiplatelet St. John's wort

Anise Anticoagulant Black cohosh Antiplatelet Celery Antiplatelet Arnica Anticoagulant

Bromelain Anticoagulant Plantago major Coagulant Castanea sativa Anticoagulant Horseradish Anticoagulant

Clove Antiplatelet Red clover Anticoagulant

Antiplatelet Turmeric (Curcuma

Fish oil Antiplatelet, vasodilation Kava (Piper methysticum

Anticoagulant

6 Anesthesia Topics for Plastic and Reconstructive Surgery

effect

Ephedra Vasoconstriction, cardiac

Table 3. Effects of some herbs and foods.

Echinacea Promotes infections, allergies,

Enhances warfarin and ginger

Saffron Anticoagulant Papain (papaya

Onion Antiplatelet Licorice root

infarction, cerebral thrombosis, arrhythmias, hypertension

probable hepatotoxic and impaired blood flow

Garlic (Allium sativum)

Alfalfa (Medicago sativa)

Dong quai (Angelica

Boldo (Peumus boldus)

Chili pepper (Nahuatl chili)

sinensis)

Table 4. Parameters for pre-anesthetic evaluation in plastic surgery [5].

Elderly patients require a more elaborate evaluation, in which it is wise to include the geriatrician. In this group of sick patients, a list that includes all the medications they take should be made, including antihypertensive, diuretic, vasodilator, MAO inhibitors, antidepressants, analgesics, hormones, hypoglycemic agents, vitamins and minerals, etc. The anesthesiologist must be familiar with these drugs and know their possible drug interactions. The usual pre-anesthetic assessment parameters in healthy patients and patients with comorbidities are listed in Table 4.

discussed and are related primarily to outpatient surgery since most plastic surgery patients are discharged the same day of their intervention. Figure 1 shows all the anesthetic techniques that can be used in plastic surgery procedures, a wide range of combinations being possible. For more details of some anesthetic technique, the reader is referred to the pertinent chapters

Anesthesia for Plastic Surgery Procedures http://dx.doi.org/10.5772/intechopen.81284 9

The objective of conscious sedation is to have a patient in a status of restfulness that allows the surgeon to inject local anesthetics and perform their operative procedure with safety and comfort for the patient, while the anesthesiologist is responsible for drug sedation and checking the stability of all systems using conventional monitoring and added BIS. The most frequent surgeries are those of the face and neck, hair implants, liposuction of small areas, dermabrasion with laser, and occasionally breast implants. A clear understanding must be established with the patient and the surgeon about the objectives of conscious sedation: the technique is not anesthesia, so the operative pain is managed by the surgeon through the frequent injection of local anesthetics. The opioids used in these cases are a primary part of sedation, not for analgesia. Figure 2 shows the most important differences between conscious sedation and general anesthesia; note that in conscious sedation the patient maintains the integrity of the airway and its protective reflexes, unlike general anesthesia. There is a tenuous

of this book.

5.1. Conscious sedation

Figure 1. Anesthesia techniques that can be used for plastic surgery.

There are patients who should not be operated, and this decision must be made by the anesthesiologist, regardless of the opinion of the patient and his/her surgeon since loss of safety rules leads to catastrophic nonreversible events [14].

Once the anesthetic assessment has been finalized and the best anesthetic plan has been agreed upon and the possible eventualities discussed, the informed consent must be obtained, which as a rule must be signed by the patient, the doctor, and a witness. This document should mention the details of the proposed anesthetic technique, its side effects, and possible complications in a detailed manner. A well-prepared informed consent is a legal document that does not exclude us from a lawsuit, but when it is not done properly, it can be a legal component against the medical team [14–16].

## 4. Pre-anesthetic medication

The goal of pre-anesthetic medication is to help the patient to arrive to the operating room with sedation, hypnosis, prevention of nausea and vomiting, and with preemptive analgesia. Midazolam and lorazepam are the most commonly used benzodiazepines. Midazolam is more useful in short procedures, although it is less amnesic than lorazepam. There is evidence that melatonin 3–10 mg administered as part of pre-anesthetic medication reduces preoperative anxiety, decreases postoperative pain intensity and opioid consumption, improves postoperative sleep quality, and reduces emergence behavior and postoperative delirium. Also, preoperative melatonin could reduce oxidative stress and anesthetic requirements [17–20]. To prevent nausea and vomiting, it is advisable to use two or more drugs [21]; combining droperidol with dexamethasone is as effective as the combination of ondansetron with dexamethasone. Metoclopramide tends to disappear due to its low clinical effectiveness compared to the new antiemetics. It is convenient to administer omeprazole or ranitidine to reduce the acidity and volume of the gastric secretion. Preemptive analgesia is achieved with the administration of various drugs such as intravenous magnesium, NSAIDs, gabapentinoids, and ketamine to name a few.

## 5. Anesthesia techniques

In general terms, regional anesthesia techniques are more recommendable than those of general anesthesia since they have less complications and favor a safer recovery, with better postoperative analgesia. In the following paragraphs, several anesthetic procedures are discussed and are related primarily to outpatient surgery since most plastic surgery patients are discharged the same day of their intervention. Figure 1 shows all the anesthetic techniques that can be used in plastic surgery procedures, a wide range of combinations being possible.

For more details of some anesthetic technique, the reader is referred to the pertinent chapters of this book.

#### 5.1. Conscious sedation

Elderly patients require a more elaborate evaluation, in which it is wise to include the geriatrician. In this group of sick patients, a list that includes all the medications they take should be made, including antihypertensive, diuretic, vasodilator, MAO inhibitors, antidepressants, analgesics, hormones, hypoglycemic agents, vitamins and minerals, etc. The anesthesiologist must be familiar with these drugs and know their possible drug interactions. The usual pre-anesthetic assessment parameters in healthy patients and patients with comorbidities are listed in Table 4. There are patients who should not be operated, and this decision must be made by the anesthesiologist, regardless of the opinion of the patient and his/her surgeon since loss of

Once the anesthetic assessment has been finalized and the best anesthetic plan has been agreed upon and the possible eventualities discussed, the informed consent must be obtained, which as a rule must be signed by the patient, the doctor, and a witness. This document should mention the details of the proposed anesthetic technique, its side effects, and possible complications in a detailed manner. A well-prepared informed consent is a legal document that does not exclude us from a lawsuit, but when it is not done properly, it can be a legal component

The goal of pre-anesthetic medication is to help the patient to arrive to the operating room with sedation, hypnosis, prevention of nausea and vomiting, and with preemptive analgesia. Midazolam and lorazepam are the most commonly used benzodiazepines. Midazolam is more useful in short procedures, although it is less amnesic than lorazepam. There is evidence that melatonin 3–10 mg administered as part of pre-anesthetic medication reduces preoperative anxiety, decreases postoperative pain intensity and opioid consumption, improves postoperative sleep quality, and reduces emergence behavior and postoperative delirium. Also, preoperative melatonin could reduce oxidative stress and anesthetic requirements [17–20]. To prevent nausea and vomiting, it is advisable to use two or more drugs [21]; combining droperidol with dexamethasone is as effective as the combination of ondansetron with dexamethasone. Metoclopramide tends to disappear due to its low clinical effectiveness compared to the new antiemetics. It is convenient to administer omeprazole or ranitidine to reduce the acidity and volume of the gastric secretion. Preemptive analgesia is achieved with the administration of various drugs such as intravenous

In general terms, regional anesthesia techniques are more recommendable than those of general anesthesia since they have less complications and favor a safer recovery, with better postoperative analgesia. In the following paragraphs, several anesthetic procedures are

safety rules leads to catastrophic nonreversible events [14].

magnesium, NSAIDs, gabapentinoids, and ketamine to name a few.

against the medical team [14–16].

8 Anesthesia Topics for Plastic and Reconstructive Surgery

4. Pre-anesthetic medication

5. Anesthesia techniques

The objective of conscious sedation is to have a patient in a status of restfulness that allows the surgeon to inject local anesthetics and perform their operative procedure with safety and comfort for the patient, while the anesthesiologist is responsible for drug sedation and checking the stability of all systems using conventional monitoring and added BIS. The most frequent surgeries are those of the face and neck, hair implants, liposuction of small areas, dermabrasion with laser, and occasionally breast implants. A clear understanding must be established with the patient and the surgeon about the objectives of conscious sedation: the technique is not anesthesia, so the operative pain is managed by the surgeon through the frequent injection of local anesthetics. The opioids used in these cases are a primary part of sedation, not for analgesia. Figure 2 shows the most important differences between conscious sedation and general anesthesia; note that in conscious sedation the patient maintains the integrity of the airway and its protective reflexes, unlike general anesthesia. There is a tenuous

Figure 1. Anesthesia techniques that can be used for plastic surgery.

dexmedetomidine), sedatives and analgesics intended for general anesthesia (e.g., propofol, ketamine, and etomidate), recovery care, and creation and implementation of quality improve-

Anesthesia for Plastic Surgery Procedures http://dx.doi.org/10.5772/intechopen.81284 11

General anesthesia can be used in all plastic surgery procedures if the location where they have been scheduled fulfills with all safety regulations. This rule should not be violated, especially in medical offices that have been supplemented with an operating room (office based). General anesthesia techniques are used in very short procedures, in patients who reject regional techniques, and as a complement to regional anesthesia when this is not sufficient. In prolonged surgeries of more than 3 hours, it is prudent to avoid the use of general anesthesia when this is possible to prevent risks and undesirable side effects such as nausea, vomiting, oropharyngeal discomfort secondary to the endotracheal tube or laryngeal mask, DVT, PE, postoperative pain, postoperative delirium, and so on. The costs of general anesthesia, although not a definitive factor, do influence the anesthesiological decision, particularly when the procedures are very long. The selection of patients for general anesthesia must be meticulous and exclude those cases with associated pathologies: angina, recent history of cardiac infarction, cardiomyopathies, uncontrolled arterial hypertension, terminal renal failure, sickle cell anemia, patients in need of organ transplantation, active multiple sclerosis, severe chronic obstructive pulmonary disease, difficult airway, malignant hyperthermia, abuse of illegal drugs, dementia, myasthenia gravis, obstructive sleep apnea, and etcetera [23, 24]. In some of these associated pathologies, it is possible to perform plastic surgery; however, precautions must be taken for

When general anesthesia has been chosen, the drugs to be used should be selected for safety and anesthetic efficacy, in accordance with the surgical location. The ideal technique does not exist, but it must be ensured that it is with a gentle and rapid induction, with adequate operative conditions, with great hemodynamic stability and fast recovery, without side effects, with good control of postsurgical acute pain, with emesis, and with preventive management of postoperative chronic pain. There is not enough evidence to select one drug over another; however, the halogenated anesthetics desflurane, sevoflurane, and isoflurane have demonstrated their versatility in outpatients with a minimum of differences that do not impact the transoperative evolution or the recovery of patients [23, 25]. It is convenient to avoid nitrous oxide due to the high incidence of postoperative nausea and vomiting. Propofol, ketamine, and remifentanil have been widely accepted in this field, each of them having certain advantages. The combination of propofol-ketamine has been studied by Friedberg [25] and proposed

Regional anesthesia has had an increasing resurgence since it favors several positive aspects in the trans, operative period, and in the recovery phase. Local anesthesia is performed by the plastic surgeon in cases of minimal invasion such as blepharoplasty, chin implant, and some small liposuction among other procedures. Neuraxial anesthesia, especially spinal anesthesia,

ment processes [22].

5.2. General anesthesia

each disease due to potential complications.

as an alternative to inhalational anesthesia.

5.3. Regional anesthesia

Figure 2. Spectrum of alertness, conscious sedation, deep sedation, and general anesthesia [6].

line of separation between deep sedation and general anesthesia, a situation that often warrants securing the airway and protecting the patient changing the technique to general anesthesia.

There are several types of drugs that are used in conscious sedation: anxiolytics, sedatives, butyrophenones, barbiturates, hypnotics, opioids, and alpha2 agonists (Table 5).

The 2018 ASA guidelines for sedation added the following recommendations: patient evaluation and preparation, continual monitoring of ventilatory function with capnography to supplement standard monitoring by observation and pulse oximetry, presence of an individual in the procedure room with knowledge and skills to recognize and treat airway complications, sedatives and analgesics not intended for general anesthesia (e.g., benzodiazepines and


Table 5. Anesthesia techniques and examples of usual drugs.

dexmedetomidine), sedatives and analgesics intended for general anesthesia (e.g., propofol, ketamine, and etomidate), recovery care, and creation and implementation of quality improvement processes [22].

#### 5.2. General anesthesia

line of separation between deep sedation and general anesthesia, a situation that often warrants securing the airway and protecting the patient changing the technique to general

There are several types of drugs that are used in conscious sedation: anxiolytics, sedatives,

The 2018 ASA guidelines for sedation added the following recommendations: patient evaluation and preparation, continual monitoring of ventilatory function with capnography to supplement standard monitoring by observation and pulse oximetry, presence of an individual in the procedure room with knowledge and skills to recognize and treat airway complications, sedatives and analgesics not intended for general anesthesia (e.g., benzodiazepines and

Opioids Benzodiazepines Hypnotics Alpha-2 Anesthetic

ketamine

Propofol, ketamine, thiopental

Propofol, ketamine, barbiturates

TCI Remifentanil No Propofol No No No

Midazolam Propofol,

Midazolam, diazepam

Midazolam, lorazepam

MAC = monitored anesthetic care; TCI = target-controlled infusion.

Table 5. Anesthesia techniques and examples of usual drugs.

gases

oxide

Desflurane Sevoflurane Isoflurane

No No

Dexmedetomidine Nitrous

Clonidine, dexmedetomidine

Clonidine, dexmedetomidine Muscle relaxants

Vecuronium rocuronium, atracurium

Vecuronium rocuronium, atracurium

butyrophenones, barbiturates, hypnotics, opioids, and alpha2 agonists (Table 5).

Figure 2. Spectrum of alertness, conscious sedation, deep sedation, and general anesthesia [6].

anesthesia.

Anesthesia techniques

Conscious sedation

TIVA Fentanyl,

General Fentanyl

remifentanil, alfentanil

10 Anesthesia Topics for Plastic and Reconstructive Surgery

Morphine

Fentanyl Remifentanil Morphine Buprenorphine General anesthesia can be used in all plastic surgery procedures if the location where they have been scheduled fulfills with all safety regulations. This rule should not be violated, especially in medical offices that have been supplemented with an operating room (office based). General anesthesia techniques are used in very short procedures, in patients who reject regional techniques, and as a complement to regional anesthesia when this is not sufficient. In prolonged surgeries of more than 3 hours, it is prudent to avoid the use of general anesthesia when this is possible to prevent risks and undesirable side effects such as nausea, vomiting, oropharyngeal discomfort secondary to the endotracheal tube or laryngeal mask, DVT, PE, postoperative pain, postoperative delirium, and so on. The costs of general anesthesia, although not a definitive factor, do influence the anesthesiological decision, particularly when the procedures are very long. The selection of patients for general anesthesia must be meticulous and exclude those cases with associated pathologies: angina, recent history of cardiac infarction, cardiomyopathies, uncontrolled arterial hypertension, terminal renal failure, sickle cell anemia, patients in need of organ transplantation, active multiple sclerosis, severe chronic obstructive pulmonary disease, difficult airway, malignant hyperthermia, abuse of illegal drugs, dementia, myasthenia gravis, obstructive sleep apnea, and etcetera [23, 24]. In some of these associated pathologies, it is possible to perform plastic surgery; however, precautions must be taken for each disease due to potential complications.

When general anesthesia has been chosen, the drugs to be used should be selected for safety and anesthetic efficacy, in accordance with the surgical location. The ideal technique does not exist, but it must be ensured that it is with a gentle and rapid induction, with adequate operative conditions, with great hemodynamic stability and fast recovery, without side effects, with good control of postsurgical acute pain, with emesis, and with preventive management of postoperative chronic pain. There is not enough evidence to select one drug over another; however, the halogenated anesthetics desflurane, sevoflurane, and isoflurane have demonstrated their versatility in outpatients with a minimum of differences that do not impact the transoperative evolution or the recovery of patients [23, 25]. It is convenient to avoid nitrous oxide due to the high incidence of postoperative nausea and vomiting. Propofol, ketamine, and remifentanil have been widely accepted in this field, each of them having certain advantages. The combination of propofol-ketamine has been studied by Friedberg [25] and proposed as an alternative to inhalational anesthesia.

#### 5.3. Regional anesthesia

Regional anesthesia has had an increasing resurgence since it favors several positive aspects in the trans, operative period, and in the recovery phase. Local anesthesia is performed by the plastic surgeon in cases of minimal invasion such as blepharoplasty, chin implant, and some small liposuction among other procedures. Neuraxial anesthesia, especially spinal anesthesia, has been favored by its advantages (Table 6). Capdevila and Dadure [26] consider that the various techniques of regional anesthesia, including spinal anesthesia, are superior to general anesthesia in limiting adverse effects and readmissions to the hospital, with better control of postoperative pain [27]. In the following paragraphs, subarachnoid and epidural block are described, although the latter is less used because it has more possibilities of undesirable effects.

Atraucan 26, Quincke 26, and Whitacre 27, in young patients and found a very low incidence of post-dural-puncture headache (PDPH), without statistical significance among the three groups. In plastic surgery spinal anesthesia is used for surgical procedures involving the abdomen, perineum, and lower extremities. Any surgical procedure below the sixth dermatome is viable to be managed with spinal anesthesia. In some ambulatory plastic surgery procedures, it is possible to use lumbar subarachnoid block with diffusion up to T2–T3 dermatomes, for breast surgery and chest liposuction [7, 8, 27, 28]. Tables 7 and 8 list cosmetic surgery procedures and the doses of local anesthetics in which it is possible to use subarachnoid anesthesia, including the cases mentioned up to T2–T3 dermatomes. In some circumstances, it is prudent to use the combined epidural-intrathecal technique to ensure enough

Anesthesia for Plastic Surgery Procedures http://dx.doi.org/10.5772/intechopen.81284 13

When the scheduled plastic surgery is longer than 2 hours, it is advisable to add an adjuvant drug such as clonidine in doses of 75, 150–300 μg, fentanyl 12.5–25 μg, or sufentanil 5–10 μg [27, 35]. It is imperative to consider that the operative time could be longer than the surgeon's estimate since there are many "dead times" that prolong the total time required to complete the surgery. Table 9 shows the possibilities of mixtures of local anesthetic plus adjuvants according to the expected surgical times. Note that the possibility of 1-hour surgeries is included, which is rare in this field: scar reviews, small areas of liposuction, perineal plasties, etc. The combination of procaine + clonidine + fentanyl is excellent. Low doses of local anesthetic of the family pipecoloxylidide (PPX) (bupivacaine, mepivacaine, ropivacaine, and levobupivacaine) are good but usually last longer, and in a very busy environment, they could prolong the time of home discharge. For surgeries lasting up to 2 hours, local anesthetic PPX in low

The local hyperbaric anesthetics have an ampler intrathecal cephalic diffusion than the isobaric ones, which is useful in the operative procedures in high dermatomes (upper abdomen and thorax). On the other hand, isobaric local anesthetics are better in the pelvis and lower extremities. Opioids, especially fentanyl, improve the quality of anesthesia without affecting recovery.

Liposuction L, B, LB, R, M C, F L, R, B, LB, M C, F L, R,B, LB, M C, F, S Liposculpture B, LB, R, M C, F L, R, B, LB, M C, F L, R,B, LB, M C, F, S Buttocks implants L, B, LB, R, M C L, B, LB, R, M C L, R,B, LB, M C, F, S Calf implants L, B, LB, R, M C L, B, LB, R, M C L, R,B, LB, M C, F, S Breast with liposuction B, LB, R, M C, F L, R, B, LB, M C, F L, R,B, LB, M C, F, S Breast — — L, R, B, LB, M no — —

APEC = combined peridural-spinal anesthesia; L = lidocaine; B = racemic bupivacaine; LB = levobupivacaine; R = ropi-

Anesthetic Adjuvant Anesthetic Adjuvant Anesthetic Adjuvant

Surgery Spinal Epidural APEC

Table 7. Frequent procedures and regional techniques in ambulatory cosmetic surgery [20].

duration in some procedures [7].

doses and added adjuvant drugs are an ideal combination.

vacaine; M = mepivacaine; C = clonidine; F = fentanyl; S = sufentanil.

#### 5.3.1. Neuraxial anesthesia

Neuraxial blocks offer several advantages over general anesthesia, as shown in Table 6. The decrease in metabolic response to trauma, postoperative analgesia, lower incidence of nausea and postoperative vomiting, and their low costs are just some of these advantages.

Subarachnoid anesthesia. Spinal anesthesia satisfies the current requirements of efficacy and safety that allow early home discharges. It produces an optimal anesthetic status, is easy to administer, has a quick start, and has a low cost. The recovery of the motor and sensory block can be manipulated according to the operative time when local anesthetics and adjuvant drugs available for clinical use are used rationally. Side effects are easy to manage, and complications are rare [27, 28]. There are multiple studies in various clinical scenarios that demonstrate the benefits of spinal anesthesia using small spinal needles (gauge 26–29), with cutting or pencil tip in patients undergoing ambulatory or short-stay surgical procedures [29–31]. Spinal anesthesia versus desflurane [32] in ambulatory patients demonstrated, in addition to a lower cost with spinal anesthesia, that 50% of those who received general anesthesia required postoperative analgesia versus 0% in those who were managed with subarachnoid block. Another research [33] found no cost difference between both techniques and showed that administering spinal anesthesia consumes more time (18 8 min vs. 10 3 min), with more time in the postanesthesia recovery room (123 51 min vs. 94 48 min). The antiemetic requirements were higher in general anesthesia (8% vs. 14%), while the need for analgesics in the immediate postsurgical period was only 25% in those who were treated with spinal anesthesia versus 75% in the group treated with general anesthesia. Carrada et al. [34] compared three spinal needles,


Table 6. Advantages and disadvantages of the different techniques in anesthesia for plastic surgery.

Atraucan 26, Quincke 26, and Whitacre 27, in young patients and found a very low incidence of post-dural-puncture headache (PDPH), without statistical significance among the three groups. In plastic surgery spinal anesthesia is used for surgical procedures involving the abdomen, perineum, and lower extremities. Any surgical procedure below the sixth dermatome is viable to be managed with spinal anesthesia. In some ambulatory plastic surgery procedures, it is possible to use lumbar subarachnoid block with diffusion up to T2–T3 dermatomes, for breast surgery and chest liposuction [7, 8, 27, 28]. Tables 7 and 8 list cosmetic surgery procedures and the doses of local anesthetics in which it is possible to use subarachnoid anesthesia, including the cases mentioned up to T2–T3 dermatomes. In some circumstances, it is prudent to use the combined epidural-intrathecal technique to ensure enough duration in some procedures [7].

has been favored by its advantages (Table 6). Capdevila and Dadure [26] consider that the various techniques of regional anesthesia, including spinal anesthesia, are superior to general anesthesia in limiting adverse effects and readmissions to the hospital, with better control of postoperative pain [27]. In the following paragraphs, subarachnoid and epidural block are described, although the latter is less used because it has more possibilities of undesirable

Neuraxial blocks offer several advantages over general anesthesia, as shown in Table 6. The decrease in metabolic response to trauma, postoperative analgesia, lower incidence of nausea

Subarachnoid anesthesia. Spinal anesthesia satisfies the current requirements of efficacy and safety that allow early home discharges. It produces an optimal anesthetic status, is easy to administer, has a quick start, and has a low cost. The recovery of the motor and sensory block can be manipulated according to the operative time when local anesthetics and adjuvant drugs available for clinical use are used rationally. Side effects are easy to manage, and complications are rare [27, 28]. There are multiple studies in various clinical scenarios that demonstrate the benefits of spinal anesthesia using small spinal needles (gauge 26–29), with cutting or pencil tip in patients undergoing ambulatory or short-stay surgical procedures [29–31]. Spinal anesthesia versus desflurane [32] in ambulatory patients demonstrated, in addition to a lower cost with spinal anesthesia, that 50% of those who received general anesthesia required postoperative analgesia versus 0% in those who were managed with subarachnoid block. Another research [33] found no cost difference between both techniques and showed that administering spinal anesthesia consumes more time (18 8 min vs. 10 3 min), with more time in the postanesthesia recovery room (123 51 min vs. 94 48 min). The antiemetic requirements were higher in general anesthesia (8% vs. 14%), while the need for analgesics in the immediate postsurgical period was only 25% in those who were treated with spinal anesthesia versus 75% in the group treated with general anesthesia. Carrada et al. [34] compared three spinal needles,

General Sedation Peridural Spinal Combined PNB\*

Bleeding ++++ ++ ++ ++ + a ++ + a ++ DVT/TEP risk High Low Low Low Low Low Anesthetic toxicity Remote Remote Feasible Very remote Feasible Feasible Hypoxia PO Frequent Possible Possible Possible Possible Possible Analgesia PO No No Yes Yes Yes Yes Technical difficulty Remote No Possible Possible Possible Frequent Cognitive disorders ++++ ++ ++ ++ + No Cost High High Medium Low High High

Table 6. Advantages and disadvantages of the different techniques in anesthesia for plastic surgery.

and postoperative vomiting, and their low costs are just some of these advantages.

effects.

5.3.1. Neuraxial anesthesia

12 Anesthesia Topics for Plastic and Reconstructive Surgery

\*Peripheral nerve block.

When the scheduled plastic surgery is longer than 2 hours, it is advisable to add an adjuvant drug such as clonidine in doses of 75, 150–300 μg, fentanyl 12.5–25 μg, or sufentanil 5–10 μg [27, 35]. It is imperative to consider that the operative time could be longer than the surgeon's estimate since there are many "dead times" that prolong the total time required to complete the surgery. Table 9 shows the possibilities of mixtures of local anesthetic plus adjuvants according to the expected surgical times. Note that the possibility of 1-hour surgeries is included, which is rare in this field: scar reviews, small areas of liposuction, perineal plasties, etc. The combination of procaine + clonidine + fentanyl is excellent. Low doses of local anesthetic of the family pipecoloxylidide (PPX) (bupivacaine, mepivacaine, ropivacaine, and levobupivacaine) are good but usually last longer, and in a very busy environment, they could prolong the time of home discharge. For surgeries lasting up to 2 hours, local anesthetic PPX in low doses and added adjuvant drugs are an ideal combination.

The local hyperbaric anesthetics have an ampler intrathecal cephalic diffusion than the isobaric ones, which is useful in the operative procedures in high dermatomes (upper abdomen and thorax). On the other hand, isobaric local anesthetics are better in the pelvis and lower extremities. Opioids, especially fentanyl, improve the quality of anesthesia without affecting recovery.


APEC = combined peridural-spinal anesthesia; L = lidocaine; B = racemic bupivacaine; LB = levobupivacaine; R = ropivacaine; M = mepivacaine; C = clonidine; F = fentanyl; S = sufentanil.

Table 7. Frequent procedures and regional techniques in ambulatory cosmetic surgery [20].


safe, and economic technique that produces a deep anesthetic and motor block, with a low incidence of failure and undesirable side effects. It is the procedure most used in short- and medium-length surgeries, being able to be used in some prolonged procedures such as abdominoplasties with or without breast surgery. It is recommended to use small spinal needles G26, G27, and G29, with blunt tip, cutting tip, or special cutting tip. Low doses of long-acting local anesthetics play an important role in outpatients [27, 28]. A comparative study with 6 mg of hypobaric bupivacaine (0.5% in 1.2 mL) versus 6.1 mg of almost hypobaric bupivacaine (0.18% in 3.4 mL) had similar effects on the anesthetic level, duration of sensory, and motor block [36]. Dosage of 6 mg of bupivacaine versus 7.5 mg of bupivacaine [37], both doses added with 25 μg of fentanyl, has similar results in terms of diffusion, duration, and regression of the sensory block. Doses between 5 and 8 mg of ropivacaine, levobupivacaine, or bupivacaine provide up to 150 minutes of intrathecal anesthesia, enough time for most outpatient procedures in cosmetic surgery, time that can be prolonged with the addition of 150–300 μg of spinal clonidine up to 3–5 hours. The most used doses vary from 10 to 15 mg of hyperbaric bupivacaine, being possible to increase these doses up to 20–25 mg in special cases. Drowsi-

Anesthesia for Plastic Surgery Procedures http://dx.doi.org/10.5772/intechopen.81284 15

ness, bradycardia, and hypotension of easy control are the most frequent effects.

prophylactic factor of DVT and resultant PE.

through the previous dural orifice [38].

Epidural block. The epidural block is indicated in the same type of surgery as spinal anesthesia, although there are some important considerations: (a) The doses of local anesthetic should be monitored since in prolonged procedures or those in which local anesthetics are injected by the surgeon, there is the possibility of systemic toxicity when the recommended total doses are exceeded or in a delayed form by absorption from the injection site. It is important to remember that lidocaine metabolites have a neuro- and cardiotoxic systemic effect. (b) The initial epidural test dose with local anesthetic should always be repeated before applying a booster dose, especially when the patient has been repositioned in the surgical table (a frequent situation in plastic surgery), due to the possibility that the epidural catheter may be moved from its initial epidural placement [38]. (c) Apparent or unnoticed accidental dural puncture and subsequent PDPH is a possibility, even in the most experienced hands. (d) The quality of the anesthesia is not as deep as that produced by the subarachnoid injection. On the other hand, extradural blockade has the advantage of being able to be prolonged during several days for postoperative analgesia in patients who require it. Ropivacaine, levobupivacaine, and racemic bupivacaine, added with clonidine, fentanyl, sufentanil, or morphine, are recommended, according to the expected surgical time. Hafezi et al. [39] compared 24 cases of tummy tuck-liposuction performed with general anesthesia versus 371 patients managed with epidural block and found a case with PE in the first group (4%). No cases of DVT/PE were found in the second group. The authors attribute this finding to the differential blockade with epidural bupivacaine that allows transoperative movements of the lower extremities which could be a

Combined subarachnoid-epidural anesthesia. In cases with prolonged surgeries, it is advisable to place an inert lumbar epidural catheter with a cephalad direction to guarantee that in case surgery is prolonged, the anesthetic time can be amplified [7]. When this technique is used, an epidural test dose should always be injected since it is possible that the catheter may migrate to the subdural or subarachnoid space, or there may be migration of the anesthetic or adjuvants

\*Local hyperbaric anesthetics. The addition of adjuvants will depend on the expected time of surgery. Lumbar approach, with local hyperbaric anesthetic. With or without high lumbar epidural catheter.

Table 8. Outpatient plastic surgery procedures and doses of intrathecal local anesthetics\* [20].


Table 9. Local anesthetics and coadjuvant drugs in spinal anesthesia [20].

Subarachnoid anesthesia in plastic surgery procedures can be done with a single injection, with or without adjuvant drugs, usual doses, low doses or high doses, or combined with extradural anesthesia. The single injection with spinal anesthesia with mono-dose is an easy, safe, and economic technique that produces a deep anesthetic and motor block, with a low incidence of failure and undesirable side effects. It is the procedure most used in short- and medium-length surgeries, being able to be used in some prolonged procedures such as abdominoplasties with or without breast surgery. It is recommended to use small spinal needles G26, G27, and G29, with blunt tip, cutting tip, or special cutting tip. Low doses of long-acting local anesthetics play an important role in outpatients [27, 28]. A comparative study with 6 mg of hypobaric bupivacaine (0.5% in 1.2 mL) versus 6.1 mg of almost hypobaric bupivacaine (0.18% in 3.4 mL) had similar effects on the anesthetic level, duration of sensory, and motor block [36]. Dosage of 6 mg of bupivacaine versus 7.5 mg of bupivacaine [37], both doses added with 25 μg of fentanyl, has similar results in terms of diffusion, duration, and regression of the sensory block. Doses between 5 and 8 mg of ropivacaine, levobupivacaine, or bupivacaine provide up to 150 minutes of intrathecal anesthesia, enough time for most outpatient procedures in cosmetic surgery, time that can be prolonged with the addition of 150–300 μg of spinal clonidine up to 3–5 hours. The most used doses vary from 10 to 15 mg of hyperbaric bupivacaine, being possible to increase these doses up to 20–25 mg in special cases. Drowsiness, bradycardia, and hypotension of easy control are the most frequent effects.

Epidural block. The epidural block is indicated in the same type of surgery as spinal anesthesia, although there are some important considerations: (a) The doses of local anesthetic should be monitored since in prolonged procedures or those in which local anesthetics are injected by the surgeon, there is the possibility of systemic toxicity when the recommended total doses are exceeded or in a delayed form by absorption from the injection site. It is important to remember that lidocaine metabolites have a neuro- and cardiotoxic systemic effect. (b) The initial epidural test dose with local anesthetic should always be repeated before applying a booster dose, especially when the patient has been repositioned in the surgical table (a frequent situation in plastic surgery), due to the possibility that the epidural catheter may be moved from its initial epidural placement [38]. (c) Apparent or unnoticed accidental dural puncture and subsequent PDPH is a possibility, even in the most experienced hands. (d) The quality of the anesthesia is not as deep as that produced by the subarachnoid injection. On the other hand, extradural blockade has the advantage of being able to be prolonged during several days for postoperative analgesia in patients who require it. Ropivacaine, levobupivacaine, and racemic bupivacaine, added with clonidine, fentanyl, sufentanil, or morphine, are recommended, according to the expected surgical time. Hafezi et al. [39] compared 24 cases of tummy tuck-liposuction performed with general anesthesia versus 371 patients managed with epidural block and found a case with PE in the first group (4%). No cases of DVT/PE were found in the second group. The authors attribute this finding to the differential blockade with epidural bupivacaine that allows transoperative movements of the lower extremities which could be a prophylactic factor of DVT and resultant PE.

Combined subarachnoid-epidural anesthesia. In cases with prolonged surgeries, it is advisable to place an inert lumbar epidural catheter with a cephalad direction to guarantee that in case surgery is prolonged, the anesthetic time can be amplified [7]. When this technique is used, an epidural test dose should always be injected since it is possible that the catheter may migrate to the subdural or subarachnoid space, or there may be migration of the anesthetic or adjuvants through the previous dural orifice [38].

Subarachnoid anesthesia in plastic surgery procedures can be done with a single injection, with or without adjuvant drugs, usual doses, low doses or high doses, or combined with extradural anesthesia. The single injection with spinal anesthesia with mono-dose is an easy,

in a dose-dependent manner Levobupivacaine 10–15 + clonidine

excellent postoperative analgesia Levobupivacaine 15–20 mg + clonidine

Surgery Concentration of local anesthetic and total dose in mg

14 Anesthesia Topics for Plastic and Reconstructive Surgery

Liposuction 10–22.5 7.5–18 7.5–15 50–100 Liposculpture 10–22.5 7.5–18 7.5–15 50–100 Buttocks implants 15 10 10 100 Calf implants 15 10 10 100 Breast with liposuction 22.5 18 18 No

Surgery up to 1 hour Lidocaine 30–100 mg The use of lidocaine tends to disappear due to the possibility of local neurotoxicity Lidocaine 30–50 mg + clonidine 75 <sup>μ</sup><sup>g</sup>

\*Local hyperbaric anesthetics. The addition of adjuvants will depend on the expected time of surgery. Lumbar approach, with local hyperbaric anesthetic. With or without high lumbar epidural catheter.

Table 8. Outpatient plastic surgery procedures and doses of intrathecal local anesthetics\* [20].

Approximate duration Drugs and recommended doses Observations

or fentanyl 25 μg

or fentanyl 25 μg

Surgery from 1 to 2 hours

Surgery greater than

2 hours

75 μg or fentanyl 25 μg

75 μg or fentanyl 25 μg

Lidocaine 30–50 mg + fentanyl 25 μg Bupivacaine 5–7.5 mg + clonidine 75 μg

Levobupivacaine 5–7.5 mg + clonidine

Procaine 100–200 mg + clonidine 75 μg

Ropivacaine 7.5–10 mg + clonidine

Bupivacaine 10–15 mg + clonidine 150 μg and/or fentanyl 25 μg

Bupivacaine 15–20 mg + clonidine 150–300 μg and/or fentanyl 25 μg

150–300 μg, and/or fentanyl 25 μg Ropivacaine 20–30 mg + clonidine 150–300 μg and/or fentanyl 25 μg

150 μg and/or fentanyl 25 μg Ropivacaine 15–20 + clonidine 75 μg

and/or fentanyl 25 μg

Table 9. Local anesthetics and coadjuvant drugs in spinal anesthesia [20].

Ropivacaine (0.75%) Levobupivacaine (0.75%) Bupivacaine (0.5–0.75%) Lidocaine (2%)

Local anesthetics of the PPX family used in low doses tend to replace the use of lidocaine in brief procedures

Its short duration improves with the addition of

The duration of the average doses of PPX local anesthetics is prolonged with the addition of clonidine

High doses of clonidine favor spinal anesthesia that can reach 3–5 hours of surgical anesthesia, with

adjuvants

Contraindications of neuraxial anesthesia. Contraindications of neuraxial anesthesia have been modified and are currently reduced to well-defined situations as shown in Table 10. In addition to these general contraindications, there are few situations in which it is not appropriate to use spinal anesthesia in this group of patients. Patients planning a flight in the days immediately following their surgery should not receive spinal anesthesia, since pressure changes in the aircraft cabins could facilitate the exit of cerebrospinal fluid through the hole in the dura mater. Patients who live far from the site where they are anesthetized and who are not willing to return to the surgical location should not be managed with spinal anesthesia since in both instances the patient could develop PDPH. Although this is not likely to occur, the mere fact of not being able to return to the place where they were anesthetized could imply that they should be treated by other anesthesiologists in their place of origin, which could facilitate unnecessary legal medical problems [28].

ventricle are stimulated by the fall of the ventricular volume. The vagal response to the preload decrease produces even more bradycardia that can be accompanied by nausea, vomiting, diaphoresis, and syncope, which can progress to cardiovascular collapse and death. (b) Later complications occur when the anesthetic block has ended and within a month of evolution: transient irritation syndrome of posterior roots, PDPH. Other uncommon complications are bleeding, neuroinfections, arachnoiditis, and low back pain. Complications of epidural anesthesia are due to inadequate technique: perforation of the dura, PDPH, injection of drugs into extradural veins with systemic manifestations of acute toxicity, inadequate anesthesia, rupture

Anesthesia for Plastic Surgery Procedures http://dx.doi.org/10.5772/intechopen.81284 17

Peripheral nerve blocks. This type of regional anesthesia is rarely used in plastic surgery since most of these surgeries are bilateral. However, some blockages such as thoracic paravertebral, intercostal approaches have been recommended in breast surgery because, in addition to anesthesia, they produce excellent postoperative analgesia, reduction in postoperative opioid consumption, less nausea and vomiting, as well as decrease in length of hospitalization time. Interfacial plane blocks, although they do not produce adequate surgical anesthesia, are recommended techniques for postoperative analgesia. Some of these blocks are discussed later

Without pretending to exhaust the topic, this section reviews the usual anesthesia techniques for most common procedures in plastic surgery: breast implants, liposuction, abdominoplasty,

Breast implant surgery occupies the first place among cosmetic surgery procedures in the USA, and it is likely that the same happens in other countries. Most patients are healthy, but there are some cases of women with breast reconstruction and implants who have a history of surgery for breast cancer. Several anesthesia techniques have been described for this procedure such as general inhaled or intravenous anesthesia, cervicothoracic epidural block, intercostal blocks, facial plane blocks, and tumescent injection with lidocaine. The advantage of regional techniques is that it produces less nausea, vomiting, postoperative pain, and has a lower cost [41, 42]. Cervicothoracic epidural block with approach in C7–T1 and T3–T4, with lidocaine 1%, ropivacaine 0.75%, bupivacaine 0.5%, or levobupivacaine 0.5% (8–12 mL), produces enough anesthesia with better postoperative analgesia than general anesthesia. A single dose of one of the mentioned local anesthetics is adequate in most cases, and when required, a second epidural dose must be injected through the epidural catheter. Epinephrine 1:80,000 can be added (except when ropivacaine is used) to prolong duration of local anesthetics. The most common side effects include transient elevation of blood pressure with tachycardia, tremor, nasal congestion, and nausea. Hypotension and difficulty breathing are rare [42]. It is also possible to use paravertebral or intercostal nerve blocks. Since Blanco et al. described ultrasound-guided

or knot in the catheter, retention of the epidural catheter, local infections, etc.

6. Anesthesia for most common plastic surgeries

rhytidoplasty, combined cosmetic surgeries, and fat transfer.

and in other chapters of this book.

6.1. Breast implants

Complications of neuraxial anesthesia. Although spinal anesthesia started with a complicated case of PDPH more than 100 years ago, it has been shown to be safe in outpatient and nonambulatory patients. Its complications include (a) The immediate ones that include failure of the procedure, total spinal anesthesia due to high doses, direct trauma to the spinal nerves, and injury to the conus medullaris or the spinal cord. Arterial hypotension and bradycardia are frequent, especially in young patients, which can progress to cardiac arrest if not managed in a timely manner. In 1988, Caplan [40] drew attention by publishing 14 cases of unexpected cardiac arrest during spinal anesthesia, an event that continues to occur with an incidence as variable as 1.3–18 cases in 10,000 or 6.4 1.2 in 10,000 spinal anesthesia. The decrease in preload volume promotes bradycardia mediated by three different reflex mechanisms: decrease in the frequency of the cardiac pacemaker due to a decrease in the distension of its fibers, decrease in the trigger pressure of the baroreceptors of the right atrium and the vena cava superior, and the involvement of the Bezold-Jarisch reflex when the receptors of the left

#### Absolute


#### Relative


Table 10. General contraindications for neuraxial anesthesia.

ventricle are stimulated by the fall of the ventricular volume. The vagal response to the preload decrease produces even more bradycardia that can be accompanied by nausea, vomiting, diaphoresis, and syncope, which can progress to cardiovascular collapse and death. (b) Later complications occur when the anesthetic block has ended and within a month of evolution: transient irritation syndrome of posterior roots, PDPH. Other uncommon complications are bleeding, neuroinfections, arachnoiditis, and low back pain. Complications of epidural anesthesia are due to inadequate technique: perforation of the dura, PDPH, injection of drugs into extradural veins with systemic manifestations of acute toxicity, inadequate anesthesia, rupture or knot in the catheter, retention of the epidural catheter, local infections, etc.

Peripheral nerve blocks. This type of regional anesthesia is rarely used in plastic surgery since most of these surgeries are bilateral. However, some blockages such as thoracic paravertebral, intercostal approaches have been recommended in breast surgery because, in addition to anesthesia, they produce excellent postoperative analgesia, reduction in postoperative opioid consumption, less nausea and vomiting, as well as decrease in length of hospitalization time. Interfacial plane blocks, although they do not produce adequate surgical anesthesia, are recommended techniques for postoperative analgesia. Some of these blocks are discussed later and in other chapters of this book.
