**2. Significant general subjects**

In this clinical setting, there are certain general features of paramount importance that should always receive proper attention to avoid unexpected complications. Like any other types of surgical patients, people who desire plastic surgery should be meticulously evaluated regardless of the opinion of the plastic surgeon or the anesthesiologist involved. Standards and guidelines have been described with loose criteria or very strict principles according to the experiences of their authors. The main idea is to study these patients regarding factors that may be important to prevent unfortunate outcomes and staying away from unorthodox practices of our profession [6].

#### **2.1. Optimal preoperative evaluation**

The preanesthetic-preoperative assessment is vital and of paramount importance in all patients who undergo plastic surgery. This clinical assessment is an easy, inexpensive, and essential way to decrease catastrophic incidents and complications. Unfortunately, these patients are often considered healthy by their doctors and are not adequately reviewed as determined by the respective certified standards.

During the preanesthetic evaluation, two major groups will be considered; the healthy people and the patients with systemic pathologies that modify their physical conditions (ASA). The evolution and marketing of plastic surgery have generated a third special group of patients healthy or sick—who travel long distances in search of various aesthetic or reconstructive procedures. This group of patient-tourists has special characteristics that are challenging for the medical group, peculiarities that must be properly evaluated before the patients begin their trip to the surgical destination chosen by them or immediately after their arrival.

Preoperative assessment includes a complete medical history with physical examination. Laboratory and other exams are tailored to each patient depending on their past medical history and findings on previous exams. The current trend is to minimize this type of tests; however, when a perioperative complication occurs and the so-called routine tests (CBC, blood chemistry, blood clotting, blood group) were not carried out, the plaintiffs will have arguments against the medical-surgical team, which is why it is prudent to perform routine exams, leaving the electrocardiogram for hypertensive patients, patients with history of heart disease, diabetics, and healthy people over 50 years old. **Table 1** lists the usual exams for all types of patients.

#### **2.2. Informed consent**

patients, in local or distant locations from their place of residence, inside or outside of their country. Some of them make face-to-face consultations with several plastic surgeons before deciding where to have surgery [1]. They seek perfection and full satisfaction to their demands, the best prices, and high expectations with each planned surgical procedure. Complications—small or catastrophic—have no place in the final results. Medical care for these people with special expectancies is a continuous defy, a constant challenge that keeps us at the top of our professional practice and able to achieve excellent results while keeping us competitive in a growing medical market [2, 3]. Fortunately, complications in this clinical environment are rare but often are catastrophic and, to a lesser extent, can be fatal. As in other areas of surgery-anesthesia, adherence to existing guidelines and recommendations is mandatory to avoid any possible unwanted effects. In recent years, there has been an increase in litigation against the medical profession—

The aim of this chapter is to review several aspects related to complications that may occur in the perioperative period of people who undergo plastic surgery procedures under anesthesia.

In this clinical setting, there are certain general features of paramount importance that should always receive proper attention to avoid unexpected complications. Like any other types of surgical patients, people who desire plastic surgery should be meticulously evaluated regardless of the opinion of the plastic surgeon or the anesthesiologist involved. Standards and guidelines have been described with loose criteria or very strict principles according to the experiences of their authors. The main idea is to study these patients regarding factors that may be important to prevent unfortunate outcomes and staying away from unorthodox prac-

The preanesthetic-preoperative assessment is vital and of paramount importance in all patients who undergo plastic surgery. This clinical assessment is an easy, inexpensive, and essential way to decrease catastrophic incidents and complications. Unfortunately, these patients are often considered healthy by their doctors and are not adequately reviewed as

During the preanesthetic evaluation, two major groups will be considered; the healthy people and the patients with systemic pathologies that modify their physical conditions (ASA). The evolution and marketing of plastic surgery have generated a third special group of patients healthy or sick—who travel long distances in search of various aesthetic or reconstructive procedures. This group of patient-tourists has special characteristics that are challenging for the medical group, peculiarities that must be properly evaluated before the patients begin

Preoperative assessment includes a complete medical history with physical examination. Laboratory and other exams are tailored to each patient depending on their past medical

their trip to the surgical destination chosen by them or immediately after their arrival.

justified or not—increasing the costs of health care [4, 5].

**2. Significant general subjects**

130 Anesthesia Topics for Plastic and Reconstructive Surgery

**2.1. Optimal preoperative evaluation**

determined by the respective certified standards.

tices of our profession [6].

The patient, his/her relatives, or companions must be properly informed about the technical aspects and risks of surgery and anesthesia. This document is an indicator of communication between patients and their physicians and should be as complete as possible. While it is almost absurd to mention every risk inherent in each procedure, it is vital to mention the most frequent complications and talk about the possibility of catastrophic mishaps, always leaving


NE = not essential; R = recommendable.

**Table 1.** Complete parameters in the preoperative assessment in plastic surgery.

open communication for any questions they might have. Although a well-informed consent does not exempt us from the responsibility of a serious failure, its absence has been a reason of demand in plastic surgery up to 43.8% [5].

56.5% (26/46) were deaths and 49.8% (131/263) of the hospital transfers were related to cosmetic surgery. Of these, 67% of deaths and 74% of hospital transfers had been managed under general anesthesia. Liposuction, abdominoplasty with liposuction, and other cosmetic surgeries were related to 10 deaths and 34 hospital transfers. Only 38% of the units reporting adverse events were accredited, 93% of physicians were certified, and 98% had privileges in hospitals. Plastic surgeons reported the most events (45%). In 6 years, in Alabama, there were three deaths and 49 complications and hospital transfers; 42% (22/55) of the transfers and no deaths were associated with cosmetic surgery; 86% were done under general anesthesia. There were only two patients with complicated liposuction who were transferred to the hospital. Unlike units in Florida, 71% of units in Alabama were certified, with 100% certified surgeons. Plastic surgeons reported most events (42.3%). In both states, the complications of dermatologists were minimal or absent because their procedures are less invasive and with local or regional anesthesia. It is desirable that medical groups and health authorities establish a mandatory system that monitors deleterious events in this type of surgical environment to improve current guidelines based on the reality of each country or geographic region studied and can determine the permissible frequency of complicated events in plastic surgery [16].

Perioperative Complications in Plastic Surgery http://dx.doi.org/10.5772/intechopen.82269 133

There are several Government health agencies in charge of the certification of these surgical units that have the common goal of providing a similar and safe environment in this type of establishments. In Mexico, COFEPRIS and the Federal Sanitary System are responsible for verifying the functionality of this type of surgical units; from 2013 to February 2015, verified 1209 clinics provide cosmetic surgery services and found irregularities in 115, and 66 clinics were closed [17]. In the United States of America, the Joint Commission for Accreditation of Hospital Organizations (JCAHO), American Association for Accreditation of Ambulatory Surgery Facility (AAAASF), and American Osteopathic Association's Healthcare Facilities

Accreditation Program (HFAP) [18] are the organizations that regulate these aspects.

Perioperative safety is the primary goal in the comprehensive care of all patients; anesthesiologists, surgeons, nurses, paramedical staff, and health system administrators have developed guidelines aimed at improving safety in this surgical environment by strengthening preventive measures, assessment, pre-trans, and postoperative care to avoid complications. Some groups go beyond the usual recovery time, using pharmacological programs to reduce

In the operating room, patient safety is a shared responsibility between professionals and staff who interact directly or indirectly with patients. As anesthesiologists, our responsibility ranges from patient assessment, anesthesia technique, and immediate recovery, although it can be extended beyond this moment when we use drugs with prolonged pharmacological effects, either as a delayed action or as chronic damage as is the case of arachnoiditis, chronic postoperative pain and perhaps CNS effects of general anesthesia for neonates could be included. Adequate monitoring (cardiorespiratory, temperature, neurological, metabolic, or neuromuscular blocking effects), the position of the patient in the operating table to avoid neurovascular compression injuries, the placement of antiembolic devices, maintenance of normothermia, facial and ocular protection, positioning the head, and avoiding burns and fires are just some

**2.4. Patient safety**

the incidence of chronic postoperative pain.

#### **2.3. The surgical unit**

Surgical units located outside hospitals for outpatient and short-stay procedures in plastic surgery started in the 1960s [7] and rapidly expanded. Currently, most plastic surgeons want to have their own surgical unit. In these surgical units, surgical and nonsurgical procedures are performed; from Botox injection, fillers, CO<sup>2</sup> laser, minimally invasive surgeries such as hair transplantation to major surgeries such as abdominoplasty, breast reconstruction, body contouring procedures in post bariatric patients, and many more. Safety of each patient is the gold standard [8].

Although this type of surgery/anesthesia is valid from a point of view of functionality, resulting in lower costs and generating a higher income, it is prudent to mention that not these surgical units meet the normative requirements, transforming into surgical taverns [7], which could increase the possibility of considerable risks. Performing anesthesia outside a traditional hospital surgical room has gained popularity, and high-risk surgeries on ASA 2 and even some ASA 3 patients are frequently intervened in this area. Sometimes these scenarios are comparable to performing anesthesia outside the operating room [9–11], it is normative to have well-equipped anesthesia machines, standard monitoring (noninvasive blood pressure, electrocardiogram, oximetry, capnography, temperature), monitored recovery area, and well-trained nursing personnel, which ensures a morbidity-mortality rate comparable to that expected in a hospital operating room [10]. It is advisable to have equipment to avoid perioperative hypothermia as well as noninvasive ventilatory assistance equipment. Implementing WHO recommendations in relation to a surgical safety checklist allowed Rosenberg et al. [12] to reduce complications from 11.9 to 2.72% (*p* = 0.0006). These investigators optimized medical resource from 90.9 to 99.5% (*p* < 0.0001). Verbal confirmation on precautions on toxicity by local anesthetics increased from 0 to 91.3% (*p* < 0.0001), among other improvements. These authors also evaluated patient satisfaction, which increased from 57 to 90.8% (p < 0.0001). The current surgical room team must balance the safety and comfort of the patient and the medical group; light, sound, climate, air, temperature, humidity, ventilation, drafts, and noise are having a safer, efficient, and more professional environment [13].

The staff of ambulatory surgical units must receive continuing education to keep their certification up-to-date: surgeons, anesthesiologists, nurses, secretaries, and well-qualified administrators are required to ensure excellence. Simulation and educational programs enhance safety and make medical-surgical care systems more effective. Shapiro and his group [14] used a high-fidelity simulator mimicking various critical scenarios in a plastic surgery setting with a special regard to equipment training, communication, crisis, adherence to evidencebased protocols, and regulatory standards. They observed a high degree of acceptance and validity, arousing the participant's interest in the importance of changing processes that improve patient safety and avoid errors. A prospective study on the safety of office-based surgery in Florida and Alabama, USA [15]—where reporting adverse events is mandatory—reviewed complicated events for 10 and 6 years, respectively, and found 46 deaths in Florida and 263 complicated procedures that required moving patients to nearby hospitals; 56.5% (26/46) were deaths and 49.8% (131/263) of the hospital transfers were related to cosmetic surgery. Of these, 67% of deaths and 74% of hospital transfers had been managed under general anesthesia. Liposuction, abdominoplasty with liposuction, and other cosmetic surgeries were related to 10 deaths and 34 hospital transfers. Only 38% of the units reporting adverse events were accredited, 93% of physicians were certified, and 98% had privileges in hospitals. Plastic surgeons reported the most events (45%). In 6 years, in Alabama, there were three deaths and 49 complications and hospital transfers; 42% (22/55) of the transfers and no deaths were associated with cosmetic surgery; 86% were done under general anesthesia. There were only two patients with complicated liposuction who were transferred to the hospital. Unlike units in Florida, 71% of units in Alabama were certified, with 100% certified surgeons. Plastic surgeons reported most events (42.3%). In both states, the complications of dermatologists were minimal or absent because their procedures are less invasive and with local or regional anesthesia. It is desirable that medical groups and health authorities establish a mandatory system that monitors deleterious events in this type of surgical environment to improve current guidelines based on the reality of each country or geographic region studied and can determine the permissible frequency of complicated events in plastic surgery [16].

There are several Government health agencies in charge of the certification of these surgical units that have the common goal of providing a similar and safe environment in this type of establishments. In Mexico, COFEPRIS and the Federal Sanitary System are responsible for verifying the functionality of this type of surgical units; from 2013 to February 2015, verified 1209 clinics provide cosmetic surgery services and found irregularities in 115, and 66 clinics were closed [17]. In the United States of America, the Joint Commission for Accreditation of Hospital Organizations (JCAHO), American Association for Accreditation of Ambulatory Surgery Facility (AAAASF), and American Osteopathic Association's Healthcare Facilities Accreditation Program (HFAP) [18] are the organizations that regulate these aspects.

### **2.4. Patient safety**

open communication for any questions they might have. Although a well-informed consent does not exempt us from the responsibility of a serious failure, its absence has been a reason

Surgical units located outside hospitals for outpatient and short-stay procedures in plastic surgery started in the 1960s [7] and rapidly expanded. Currently, most plastic surgeons want to have their own surgical unit. In these surgical units, surgical and nonsurgical procedures are performed;

to major surgeries such as abdominoplasty, breast reconstruction, body contouring procedures in

Although this type of surgery/anesthesia is valid from a point of view of functionality, resulting in lower costs and generating a higher income, it is prudent to mention that not these surgical units meet the normative requirements, transforming into surgical taverns [7], which could increase the possibility of considerable risks. Performing anesthesia outside a traditional hospital surgical room has gained popularity, and high-risk surgeries on ASA 2 and even some ASA 3 patients are frequently intervened in this area. Sometimes these scenarios are comparable to performing anesthesia outside the operating room [9–11], it is normative to have well-equipped anesthesia machines, standard monitoring (noninvasive blood pressure, electrocardiogram, oximetry, capnography, temperature), monitored recovery area, and well-trained nursing personnel, which ensures a morbidity-mortality rate comparable to that expected in a hospital operating room [10]. It is advisable to have equipment to avoid perioperative hypothermia as well as noninvasive ventilatory assistance equipment. Implementing WHO recommendations in relation to a surgical safety checklist allowed Rosenberg et al. [12] to reduce complications from 11.9 to 2.72% (*p* = 0.0006). These investigators optimized medical resource from 90.9 to 99.5% (*p* < 0.0001). Verbal confirmation on precautions on toxicity by local anesthetics increased from 0 to 91.3% (*p* < 0.0001), among other improvements. These authors also evaluated patient satisfaction, which increased from 57 to 90.8% (p < 0.0001). The current surgical room team must balance the safety and comfort of the patient and the medical group; light, sound, climate, air, temperature, humidity, ventilation, drafts, and noise are

The staff of ambulatory surgical units must receive continuing education to keep their certification up-to-date: surgeons, anesthesiologists, nurses, secretaries, and well-qualified administrators are required to ensure excellence. Simulation and educational programs enhance safety and make medical-surgical care systems more effective. Shapiro and his group [14] used a high-fidelity simulator mimicking various critical scenarios in a plastic surgery setting with a special regard to equipment training, communication, crisis, adherence to evidencebased protocols, and regulatory standards. They observed a high degree of acceptance and validity, arousing the participant's interest in the importance of changing processes that improve patient safety and avoid errors. A prospective study on the safety of office-based surgery in Florida and Alabama, USA [15]—where reporting adverse events is mandatory—reviewed complicated events for 10 and 6 years, respectively, and found 46 deaths in Florida and 263 complicated procedures that required moving patients to nearby hospitals;

post bariatric patients, and many more. Safety of each patient is the gold standard [8].

having a safer, efficient, and more professional environment [13].

laser, minimally invasive surgeries such as hair transplantation

of demand in plastic surgery up to 43.8% [5].

132 Anesthesia Topics for Plastic and Reconstructive Surgery

**2.3. The surgical unit**

from Botox injection, fillers, CO<sup>2</sup>

Perioperative safety is the primary goal in the comprehensive care of all patients; anesthesiologists, surgeons, nurses, paramedical staff, and health system administrators have developed guidelines aimed at improving safety in this surgical environment by strengthening preventive measures, assessment, pre-trans, and postoperative care to avoid complications. Some groups go beyond the usual recovery time, using pharmacological programs to reduce the incidence of chronic postoperative pain.

In the operating room, patient safety is a shared responsibility between professionals and staff who interact directly or indirectly with patients. As anesthesiologists, our responsibility ranges from patient assessment, anesthesia technique, and immediate recovery, although it can be extended beyond this moment when we use drugs with prolonged pharmacological effects, either as a delayed action or as chronic damage as is the case of arachnoiditis, chronic postoperative pain and perhaps CNS effects of general anesthesia for neonates could be included. Adequate monitoring (cardiorespiratory, temperature, neurological, metabolic, or neuromuscular blocking effects), the position of the patient in the operating table to avoid neurovascular compression injuries, the placement of antiembolic devices, maintenance of normothermia, facial and ocular protection, positioning the head, and avoiding burns and fires are just some of the aspects of which we are responsible during the trans and postoperative period [19–21]. Proper management of the airway is a challenge since there is always the possibility of anatomical anomalies in a patient, which makes it difficult and even impossible to secure an airway.

**2.6. Surgeon without anesthesiologist**

classified as negligence.

**2.7. The tourist patient**

to their place of origin [30].

**2.8. Anesthesia technique**

This is a controversial context where plastic surgeons consider themselves qualified to perform some procedures with local anesthesia and superficial sedation without the presence of an anesthesiologist. Examples to these procedures are variable according to the routines and interests of each surgeon, such as, blepharoplasties, small volume liposuction, coronal and facial rhytidectomies, filler injections, and hair implants, to mention a few. The fact is that each surgical procedure should be properly monitored by the anesthesiologist in charge of patient safety (monitored anesthetic care), and let the surgeon concentrates on his procedures without distracting his attention in monitoring the patient, or administer sedative medications, analgesics, or anesthetics with a very narrow therapeutic window. Although complications are rare, there is no way to predict with certainty when a patient will have a sentinel event or a negative incident, for example, drug toxicity, overdose, drug interaction, hypertensive crisis, anxiety, airway obstruction, and broken heart syndrome, just to mention some of the many possibilities. These are complications that few surgeons are qualified to solve and are part of the anesthesiologist's usual practice. In a series of catastrophic events in ASA 1 and 2 patients, we found a case of death during a ritidoplasty performed without the presence of the anesthesiologist [29]. The frequency of these events is not known, and it is advisable to avoid surgical procedures without the presence of an anesthesiologist, which is

Perioperative Complications in Plastic Surgery http://dx.doi.org/10.5772/intechopen.82269 135

People who travel from one country to another to receive medical attention are called touristpatients, and their characteristics have different aspects that can modify their risks: cultural traditions, language, common diseases in their region of origin, and physiological adjustments from their recent voyage, especially when being by plane longer than 6 hours. Their preanesthetic evaluation is done shortly after they arrive, and there could be special conditions that are not known by the treating doctors. This type of patient has proliferated in plastic surgery. In our practice, we consider them a management challenge, emphasizing an effective communication that facilitates preoperative assessment, professional care, and a safe return

The choice of anesthesia method is the responsibility of the anesthesiologist, although patients and surgeons must be aware and consent with the anesthetic plan. In general terms, we can use any kind of anesthesia, although the anesthesiologist should be adapted to factors such as diverse as his/her own experience and knowledge, the characteristics of the surgical unit and the surgeon, the type and duration of surgery, and in particular the characteristics of each patient. It is noteworthy to mention that the *best anesthesia is not the one that is best handled by the anesthesiologist, but the anesthesia procedure that engages better to each patient.* In ambulatory patients, general anesthesia has a preponderant role due to its quick recovery [31], although its immediate side effects are more common when compared to regional anesthesia and have been linked to increased frequency of DVT/PE. When general anesthesia is given, protective

WHO began its safe surgery program, where checklists have proven their importance in reducing errors. No matter the surgical procedure—small or large—these recommendations list 10 essential objectives: (1) correct surgery site, (2) safe anesthesia, (3) airway management, (4) bleeding management, (5) avoid known allergies, (6) minimize risk of operative infections, (7) prevent the retention of foreign bodies, (8) correct identification of biopsies, (9) effective communication between the surgical team, and (10) systematic surveillance of surgical results. It is advisable to stick to this simple and very effective list. Its implementation is not easy, and it is necessary to understand the nature of the errors, the dynamics that exist between the systems and the people, as well as to create a culture that stimulates the patient's safety [22–24]. In plastic surgery, it should be emphasized that it is important to identify the risks of deep vein thrombosis and pulmonary embolism (DVT/PE) and to establish that patients can benefit from prophylactic anticoagulation. Patients with hypertension should also be identified because of the implications not only in the cardiovascular and CNS systems but also in the perioperative bleeding. Another important factor is to understand the importance of reducing and treating hypothermia [25].

#### **2.5. Surgery time**

The time a patient remains anesthetized is directly related to the frequency of complications; hypothermia, deep venous thrombosis, pulmonary thromboembolism, changes in coagulation, bleeding, alterations in the immune system, and neurovascular compressions are some of the usual drawbacks in prolonged surgery-anesthesia [26]. In plastic surgery, there are procedures that require prolonged times such as patients with combined surgeries and postbariatric cases with large weight loss. Unfortunately, there is not enough information on these possible complications. Phillips et al. [27] retrospectively studied the relationship between the anesthetic time and the incidence of deleterious effects in 2595 plastic surgery procedures performed under general anesthesia and found that the majority were women with a mean age of 41 years. These authors divided their patients into two groups (less than 4 or more than 4 hours of anesthetic time): nausea and vomiting (2.8 vs. 5.7%, *p* = 0.0175) and urinary retention (0.7 vs. 7.6%, *p* < 0.0001), and 2.5% required reoperations due to surgical complications without statistical differences between the two groups. They had one patient with PE and one with DVT in the group of less than 4 hours of anesthesia. Five (0.19%) were admitted to a hospital for medical or surgical treatment (3 hematomas, 1 PE, and 1 DVT). There were no deaths in this series. Another study of 1200 patients with facial plastic surgery [28] performed under general anesthesia compared the patients with anesthetic time of less than 4 hours (14%) vs. longer anesthesia (86%). There were no catastrophic complications, and the morbidity in 100% of the patients was minimal: one respiratory failure, one patient CNS deficit, one drug allergic reaction, and one patient requiring hospital transfer. There were six cases of prolonged anesthetic recovery time. The incidence of morbidity was similar in both groups. These two studies demonstrated that the time of general anesthesia was not a major determinant in the immediate evolution of these patients operated in ambulatory surgery units.

#### **2.6. Surgeon without anesthesiologist**

of the aspects of which we are responsible during the trans and postoperative period [19–21]. Proper management of the airway is a challenge since there is always the possibility of anatomical anomalies in a patient, which makes it difficult and even impossible to secure an airway.

WHO began its safe surgery program, where checklists have proven their importance in reducing errors. No matter the surgical procedure—small or large—these recommendations list 10 essential objectives: (1) correct surgery site, (2) safe anesthesia, (3) airway management, (4) bleeding management, (5) avoid known allergies, (6) minimize risk of operative infections, (7) prevent the retention of foreign bodies, (8) correct identification of biopsies, (9) effective communication between the surgical team, and (10) systematic surveillance of surgical results. It is advisable to stick to this simple and very effective list. Its implementation is not easy, and it is necessary to understand the nature of the errors, the dynamics that exist between the systems and the people, as well as to create a culture that stimulates the patient's safety [22–24]. In plastic surgery, it should be emphasized that it is important to identify the risks of deep vein thrombosis and pulmonary embolism (DVT/PE) and to establish that patients can benefit from prophylactic anticoagulation. Patients with hypertension should also be identified because of the implications not only in the cardiovascular and CNS systems but also in the perioperative bleeding. Another important factor is to understand the impor-

The time a patient remains anesthetized is directly related to the frequency of complications; hypothermia, deep venous thrombosis, pulmonary thromboembolism, changes in coagulation, bleeding, alterations in the immune system, and neurovascular compressions are some of the usual drawbacks in prolonged surgery-anesthesia [26]. In plastic surgery, there are procedures that require prolonged times such as patients with combined surgeries and postbariatric cases with large weight loss. Unfortunately, there is not enough information on these possible complications. Phillips et al. [27] retrospectively studied the relationship between the anesthetic time and the incidence of deleterious effects in 2595 plastic surgery procedures performed under general anesthesia and found that the majority were women with a mean age of 41 years. These authors divided their patients into two groups (less than 4 or more than 4 hours of anesthetic time): nausea and vomiting (2.8 vs. 5.7%, *p* = 0.0175) and urinary retention (0.7 vs. 7.6%, *p* < 0.0001), and 2.5% required reoperations due to surgical complications without statistical differences between the two groups. They had one patient with PE and one with DVT in the group of less than 4 hours of anesthesia. Five (0.19%) were admitted to a hospital for medical or surgical treatment (3 hematomas, 1 PE, and 1 DVT). There were no deaths in this series. Another study of 1200 patients with facial plastic surgery [28] performed under general anesthesia compared the patients with anesthetic time of less than 4 hours (14%) vs. longer anesthesia (86%). There were no catastrophic complications, and the morbidity in 100% of the patients was minimal: one respiratory failure, one patient CNS deficit, one drug allergic reaction, and one patient requiring hospital transfer. There were six cases of prolonged anesthetic recovery time. The incidence of morbidity was similar in both groups. These two studies demonstrated that the time of general anesthesia was not a major determinant in the immediate evolution of these patients operated in ambulatory surgery units.

tance of reducing and treating hypothermia [25].

134 Anesthesia Topics for Plastic and Reconstructive Surgery

**2.5. Surgery time**

This is a controversial context where plastic surgeons consider themselves qualified to perform some procedures with local anesthesia and superficial sedation without the presence of an anesthesiologist. Examples to these procedures are variable according to the routines and interests of each surgeon, such as, blepharoplasties, small volume liposuction, coronal and facial rhytidectomies, filler injections, and hair implants, to mention a few. The fact is that each surgical procedure should be properly monitored by the anesthesiologist in charge of patient safety (monitored anesthetic care), and let the surgeon concentrates on his procedures without distracting his attention in monitoring the patient, or administer sedative medications, analgesics, or anesthetics with a very narrow therapeutic window. Although complications are rare, there is no way to predict with certainty when a patient will have a sentinel event or a negative incident, for example, drug toxicity, overdose, drug interaction, hypertensive crisis, anxiety, airway obstruction, and broken heart syndrome, just to mention some of the many possibilities. These are complications that few surgeons are qualified to solve and are part of the anesthesiologist's usual practice. In a series of catastrophic events in ASA 1 and 2 patients, we found a case of death during a ritidoplasty performed without the presence of the anesthesiologist [29]. The frequency of these events is not known, and it is advisable to avoid surgical procedures without the presence of an anesthesiologist, which is classified as negligence.

#### **2.7. The tourist patient**

People who travel from one country to another to receive medical attention are called touristpatients, and their characteristics have different aspects that can modify their risks: cultural traditions, language, common diseases in their region of origin, and physiological adjustments from their recent voyage, especially when being by plane longer than 6 hours. Their preanesthetic evaluation is done shortly after they arrive, and there could be special conditions that are not known by the treating doctors. This type of patient has proliferated in plastic surgery. In our practice, we consider them a management challenge, emphasizing an effective communication that facilitates preoperative assessment, professional care, and a safe return to their place of origin [30].

#### **2.8. Anesthesia technique**

The choice of anesthesia method is the responsibility of the anesthesiologist, although patients and surgeons must be aware and consent with the anesthetic plan. In general terms, we can use any kind of anesthesia, although the anesthesiologist should be adapted to factors such as diverse as his/her own experience and knowledge, the characteristics of the surgical unit and the surgeon, the type and duration of surgery, and in particular the characteristics of each patient. It is noteworthy to mention that the *best anesthesia is not the one that is best handled by the anesthesiologist, but the anesthesia procedure that engages better to each patient.* In ambulatory patients, general anesthesia has a preponderant role due to its quick recovery [31], although its immediate side effects are more common when compared to regional anesthesia and have been linked to increased frequency of DVT/PE. When general anesthesia is given, protective ventilation should be used (a tidal volume of 6–8 mL/kg of ideal body weight, less than 30 cm H2 O peak pressure, and PEEP 6–8 cm H2 O), which prevents lung damage, specifically in prolonged surgery.

**3. Complications**

**3.1. Anesthesia complications**

*3.1.1. Unplanned hypothermia*

this clinical setting of which we have observed some.

A patient may be complicated by anesthesia, surgery, or a combination of both, for example, infections, venous thrombosis, thromboembolism, bleeding (anemia or hematomas), inadequate scarring, neural damage, overhydration, postoperative emesis, or burns, just to name a few. It is usually impossible to attribute these complications to one single member of the team; therefore, all professionals should function as a teamwork and must share responsibilities as in those patients complicated with DVT/PE. In this chapter, we review the expected complications in anesthesia-plastic surgery and a group of rare incidents that could occur in

Perioperative Complications in Plastic Surgery http://dx.doi.org/10.5772/intechopen.82269 137

Complications of anesthesia can be classified into four different etiological categories: (1) health personnel errors; (2) adverse events to the anesthesia technique; (3) the physical condition of the patients; and (4) sentinel incidents or events. Anesthesia morbidity and mortality rates are approximately the same in countries with a similar life expectancy. The anesthesiologic community of a given country reduces their anesthesia morbidity and mortality data by an acceptable range for their societies using techniques according to their medical culture and historical traditions [40]. Although complications will always exist since erring is human [41], preventive measures are obligatory to reduce complications of anesthesia and to regulate our professional activity to reduce morbidity and mortality statistics [6]. Complications related to anesthesia are rare in plastic surgery, ranging from simple events to catastrophic outcomes, including death.

It is the most frequent complication in plastic surgery. Under normal conditions, human thermoregulation mechanisms maintain body temperature from 36.5 to 37.5°C. This homeostasis is achieved by thermoregulatory defense mechanisms such as vasoconstriction, vasodilation, sweating, or chills. Hypothermia is considered when body temperature drops below 36°C. It can occur in the perioperative period; preoperative phase is defined as 1 hour before induction (when patients are prepared for surgery), during the intraoperative phase (total anesthetic time) and postoperative phase (24 postoperative hours) [42, 43]. Unintentional intraoperative decrease in body temperature occurs in a large percentage of surgeries and is secondary to multiple factors. In anesthetized patients, body temperature usually drops 2°C but can drop up to 6°C due to changes done by general anesthesia at the center of thermoregulation, a thermal decrease depending on the dose of the anesthetic. Other important factors of hypothermia are the exposure of the patient to the cold environment of the operating rooms and the failure to actively warm patients. Hypothermia has negative effects such as increased infections, delayed healing, increased intra and postoperative bleeding, increased blood transfusion requirements, increased cardiac morbidity, prolonged duration of anesthetics, and coagulopathies [44, 45]. Therefore, it is necessary to use different methods to avoid it, to reduce its intensity, and to manage it with opportunity; mattresses with forced air or water

In our ambulatory and short-stay surgical unit, regional procedures are preferred, especially subarachnoid anesthesia with a lumbar approach for surgeries below T6 segment. We also use spinal anesthesia in some patients with combined surgical procedures up to T4. Single injection of spinal anesthetics and adjuvants is safe, rapid, easy to administer, inexpensive, with a certain degree of postoperative analgesia, and fewer immediate and late residual effects than general anesthesia [32, 33]. We do not use subarachnoid anesthesia with a thoracic approach. In breast, nose, and arm surgeries, we prefer general anesthesia. For facial surgery, we use conscious sedation mixed with local anesthesia [34], and we have just adopted Friedberg's recommendation [35] with propofol or ketofol for facial surgery and sometimes as a sedative complement at the end of spinal anesthesia. The characteristics of propofol make it a safe drug when administered by an anesthesiologist and BIS (60–70) monitoring is recommended, although the Ramsey scale (3–4) can also be used [33, 35].

Monitored anesthesia care is a safe technique in ambulatory and short-stay units. It must be done by an anesthesiologist and goes from simple monitoring of the patient to the use of intravenous drugs and local anesthetics for longer procedures as rejuvenation facial surgery. The most used drugs are propofol, ketamine, midazolam, fentanyl, sufentanil, remifentanil, and dexmedetomidine always supplemented with nasal oxygen [34–39].

**Figure 1** shows a schema where the difference between alertness, conscious sedation, deep sedation, and general anesthesia are shown. The vertical line delimits the most relevant clinical data and the appropriate management [34]. Attachment to this scheme is a simple guide to avoid anesthesia complications, especially the airway and cardiovascular and central nervous systems.

**Figure 1.** Scheme showing the differences and limits of alertness, conscious sedation, deep sedation, and general anesthesia.
