7. Postoperative pain control

(b) liposuction of large volumes (aspirated ≥4 L) = maintenance liquids + the volume of the solution injected +0.25 mL intravenous crystalloids per mL of aspirate extracted after 4 L. These authors emphasize that this fluid replacement guide does not replace a good clinical criterion and communication between the surgeon and the anesthesiologist is always fundamental. The goal is to maintain a normal intravascular volume with a postanesthetic hemato-

The so-called 360 liposuction has become fashionable. It is a procedure that combines liposuction of the entire truncal midsection to accomplish a complete curvier contour figure from every angle. It can be combined with dermolipectomy, with plication of the rectus abdominis

Abdominoplasty. Surgery of the abdominal wall usually involves resection of skin excess and can be done with or without liposuction (lipoabdominoplasty) and with or without plication of the rectus abdominis muscle [63]. The most common patients include those that have had multiple pregnancies or patients that have lost a lot of weight either by dieting and exercise

Mommy makeover. The combination of two or more simultaneous cosmetic surgeries has become fashionable, particularly breast surgery and tummy tuck [64]. In our plastic surgery group, the most usual combination is breast-abdominoplasty, liposuction, and gluteal lipoinjection. For abdominal body contour surgeries (liposuction, abdominoplasty, and mommy makeover), we prefer spinal anesthesia with lumbar approach, taking the block up to T4. Due to the length of the procedure, it is prudent to use some adjuvant that prolongs the anesthetic time up to 4–5 hours. Bupivacaine 0.5% 15–20 mg added with clonidine 150–300 μg is strongly recommended [27]. Ropivacaine or L-bupivacaine can also be used. The combination of two or more surgeries of the body contour is now safe, having overcome the complications of the individual procedures. It is vital to establish measures to prevent DVT, PE, infections, and postoperative pain,

Rhytidoplasty. Cosmetic facial surgery involves several procedures, some of which are performed under local anesthesia injected by the plastic surgeon [65]. Surgeries in which the intervention of the anesthesiologist is required involve generally prolonged interventions, in healthy patients or with added pathologies, in which plastic surgeons request the support of an anesthesiologist to guarantee suitable transoperative care. Local anesthesia (subcutaneous and nerve blocks) combined with conscious sedation is the technique most used in our clinic [6]. Pre-anesthetic medication is the key to have a patient in optimal conditions: sedation, anxiolysis, and preventive analgesia. We recommend 10 mg oral melatonin, 2 mg sublingual lorazepam, and 0.1–0.2 mg of oral clonidine administered 1 hour before taking the patient to the operating room. A low dose of an opioid (morphine 5–10 mg, fentanyl 25–50 mg, buprenorphine 150–300 μg) may be given. To prevent nausea and vomiting, it is recommended to add dehydrobenzoperidol 1.25 mg, dexamethasone 4–8 mg, or any of the 5-HT3 receptor antagonists or setrons (ondansetron, granisetron, dolasetron, and palonosetron). For maintenance, one or more drugs may be used in infusion: ketamine-midazolam, ketaminepropofol, and dexmedetomidine with or without low doses of opioid [6, 25, 66]. These drugs should be infused and diluted, in separate i.v. bags solutions to adjust the sedative, analgesic, or dissociative dose with appropriate doses of each drug to maintain adequate sedation

muscle, and with or without umbilicoplasty or gluteal fat grafting [61, 62].

crit above 30% and albumin levels above 3 g.

20 Anesthesia Topics for Plastic and Reconstructive Surgery

or after bariatric procedures.

to name a few [64].

Acute postoperative pain is an unresolved issue, including plastic surgery patients. Most plastic surgery procedures are accompanied by moderate/intense postoperative pain that can be disabling and prolong the hospital stay. The multiple neural ending injuries in liposuction and tummy tuck, even muscle elongations during breast implants, are just some examples that make it necessary to plan a rational analgesic scheme. The ideal analgesia should start from the pre-anesthetic phase using preemptive and preventing drugs. The combined use of opioids with NSAIDs is the cornerstone in the prevention and management of pain after plastic surgery. The controversy not clarified about the utility versus the negative effects of cyclooxygenase inhibitors has favored multiple investigations whose results allow the safe use of these drugs. Celecoxib 400 mg preoperatively followed by 200 mg every 12 hours reduces pain; total dose of opioids facilitates early recovery [70]. Parecoxib 40 mg i.v. every 12 hours is effective, and when methylprednisolone 125 mg intravenously is associated before surgery, it significantly reduces emesis [71]. This combination also reduces postoperative fatigue. The combination of tramadol with ketorolac is part of our routine, being able to replace acetaminophen with codeine. Mild pain can be treated with acetaminophencodeine or sodium metamizole (dipyrone). Pregabalin and gabapentin may have a preventive analgesic effect. Sener et al. [72] found that in patients of septorhinoplasty lornoxicam (25 mg/day) has better tolerability and postoperative analgesia than dipyrone (5 mg/day) administered with a system of analgesia i.v. controlled by the patient. Gabapentinoids (gabapentin, pregabalin) and ketamine have additive or synergistic effects that decrease the doses of anesthetics in the transoperative and opioids in the immediate postoperative period.

Uncontrolled pain, nausea, vomiting, and urinary retention are examples of frequent readmission to the surgical unit or hospital. In some patients it is not necessary to meet 100% of these discharge criteria, but they should be warned of the natural evolution of the gradual disappearance of the side effects of anesthesia and facilitate telephone communication with the surgical unit, the surgeon, and the anesthesiologist. They require appropriate postanesthetic and postsurgical indications, transportation, and occasional professional company. Each ambulatory surgery unit/hospital must have its own discharge criteria, in accordance with the published guidelines and with its own characteristics and needs of their patients: from simple scales to more elaborate procedures such as the new Postoperative Quality Recovery Scale (PQRS) assessment that evaluates six areas: physiological, nociceptive, emotional, daily activities, cognition, and general patient perspective [79]. Table 11 shows the usual discharge home criteria. The proper information on the patient evolution at the recovery house or patient home favors the prevention

Anesthesia for Plastic Surgery Procedures http://dx.doi.org/10.5772/intechopen.81284 23

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

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

Deep vein thrombosis and pulmonary thromboembolism. These two entities are complications frequently related to plastic surgery (liposuction and tummy tuck). The frequency of PE is

and the opportune diagnosis of complications [80].

9. Preventive methods and complications

veillance, prophylaxis of DVT/PE, and optimal patient selection.

and postanesthetic care [14].

Although the analgesic mechanism of esmolol (ultrashort-acting cardio-selective β1-adrenergic receptor antagonist) is not well known [73], some clinical studies have resulted in a decrease in propofol during the induction of general anesthesia, a reduction of general anesthetics during maintenance, and a reduced dose of transoperative opioids, as well as it reduces immediate postoperative pain [74–76]. Its use in rhinoplasty seems to reduce the dose of opioids in the intraoperative period and the intensity of immediate postoperative pain [77, 78].

Regional analgesia, as mentioned before, has a very important role: local anesthesia infiltrations and interfacial, paravertebral, intercostal, or epidural blocks.
