6. Anesthesia for most common plastic surgeries

Without pretending to exhaust the topic, this section reviews the usual anesthesia techniques for most common procedures in plastic surgery: breast implants, liposuction, abdominoplasty, rhytidoplasty, combined cosmetic surgeries, and fat transfer.

### 6.1. Breast implants

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

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

facilitate unnecessary legal medical problems [28].

16 Anesthesia Topics for Plastic and Reconstructive Surgery

Absolute

Relative • Septicemia

• Patient rejection

• Multiple sclerosis • Spina bifida • Neoplasms

• Aortic stenosis

• Derived hydrocephalus • Anticoagulation

• Severe coagulation disorders

• Cutaneous sepsis at the possible puncture site

• Pre-existing diseases of the central nervous system

• Thrombocytopenia and thrombasthenia • Severe anatomical alterations • Conditions dependent on the preload

• Obstructive hypertrophic cardiomyopathy • Travel by plane in a postanesthetic medium

Table 10. General contraindications for neuraxial anesthesia.

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 interfacial plane blocks for postoperative breast analgesia; modifications to the initial technique have been published [43–45]. Interfacial blocks score over traditional regional anesthetic procedures as they have no risk of sympathetic blockade, intrathecal or epidural spread which may lead to hemodynamic instability, and prolonged hospital stay [44]. These blocks are not an alternative to general anesthesia, epidural anesthesia, or paravertebral blocks since they do not produce adequate regional surgical anesthesia. However, they can be supplemented with intravenous sedation techniques, general anesthesia, or neuraxial anesthesia. Postoperative pain not only involves the breasts; it can extend to the sternum, lateral aspect of the thorax, armpits, and middle back, being more severe when the implants are submuscular. Postoperative pain can be managed with NSAIDs such as parecoxib, ibuprofen, ketoprofen, ketorolac, or diclofenac combined with low doses of opioids. Tramadol is recommended because of its dual mechanism of analgesic action. Methocarbamol can be associated with the previous scheme. Some investigators have found adequate analgesia with the continuous or intermittent administration of local anesthetics through catheters implanted during surgery [46, 47]. It has not been defined if paravertebral blocks decrease the incidence of chronic postoperative pain in breast surgery [48].

this type of liposuction is frequently done with epidural block, with spinal anesthesia, or with general anesthesia, in addition to infiltration with Klein's solution (50 mL of 1% lidocaine solution (500 mg), 1 mL of 1:1000 epinephrine (1 mg), 1000 mL of 0.9% saline, and 12.5 mL of 8.4% NaH2CO3 solution (12.5 mEq)) [50]. This type of anesthesia involves a dose of lidocaine 35–55 mg/kg of body weight and added epinephrine to achieve concentrations of 0.25–1.5 mg/L, without exceeding total adrenaline total dose of 50 μg/kg. These high doses make it obligatory to perform these procedures in surgery rooms that have all the facilities for monitoring, cardiac resuscitation, ventilatory support, and, always, recovery area under the care of an anesthesiologist. It is an apparently low-risk procedure, which can be complicated by systemic toxicity from local anesthetics, hypothermia, fat embolism, electrolyte imbalances with fluid overload, and/or acute anemia [51, 52]. One of the limitations during cosmetic surgery, especially during tumescent liposuction, is the total dose of the local anesthetic. For this reason, it is advisable not to combine liposuction with other procedures that require the injection of local anesthetics as the maximum dose of these drugs can be exceeded. There is no informed agreement in the literature on what is the top dose of lidocaine; the literature written by dermatologists and plastic surgeons mentioned 55 mg/kg of weight [50, 52–54], whereas the literature that comes from investigations carried out by anesthesiologists mentions 5 mg/kg of weight. In Europe, it is considered safe to use a total of 200 mg of lidocaine without epinephrine, and up to 300 mg is allowed in the United States of America. When epinephrine is added, the lidocaine dose in both regions is 500 mg. Epinephrine 1:200,000 reduces absorption of subcutaneous lidocaine by 50% and intercostal, epidural, and brachial in 20–30% [55]. PPX local anesthetics should never be used in tumescent liposuction. There is no agreement on the best anesthetic technique for liposuction, whether it is the modality under local anesthesia with the Klein solution or with general anesthesia or neuraxial block. With both procedures deaths

Figure 3. Plasticine model made by the patient to accurately show us the shape and size that she wants for her buttocks.

Anesthesia for Plastic Surgery Procedures http://dx.doi.org/10.5772/intechopen.81284 19

have been reported [49, 56, 57], and the reports are not completely reliable.

The total volume of fat removed should not exceed 5 L in a single intervention or not be greater than 5% of body weight [58, 59]. Higher volumes increase the risk of complications, especially hypovolemia due to bleeding and acute hydro-electrolytic alterations. Another topic of interest in the management of these patients is the replacement of fluids during the trans-anesthetic period; Trott et al. [60] recommended the following scheme: (a) liposuction of small volumes (<4 L of aspirate) = maintenance liquids + the volume of the injected subcutaneous solution and

#### 6.2. Surgeries for abdominal contour

The evaluation of candidates for abdominal contour surgery allows patients to be classified according to the possibilities of surgery taking in consideration the skin, fat, and muscles. This group includes liposuction, abdominoplasty, abdominal muscle repair, and various combinations that lengthen the operative time such as a 360 liposuction and mommy makeover.

Liposuction. Liposuction is the second most common procedure in plastic surgery, and it is perhaps the one with the highest morbidity and mortality [49]. Liposuction consists in removing fat from unwanted areas to build and improve contour. It can be performed in most subcutaneous fat deposits, being more frequent in the abdomen, hips, waist, torso, neck, and extremities. In men, it is usually done also in the pectoral region. The selection of patients is a determining factor since there are people who want to sculpt their silhouette because they have failed in weight loss and are looking for massive liposuction as a fast track to their false expectations of a suitable silhouette without taking into consideration that this procedure is not an alternative for the management of obesity. The pre-anesthetic assessment should be meticulous and must reject patients with moderate or severe cardiomyopathies or pneumopathies and those with thrombophilia or a history of pulmonary embolism. It is advisable not to associate liposuction with nonplastic procedures such as gynecological surgery. Surgeon and anesthesiologist must make a comprehensive management plan to meet the goals of patients, when possible. Figure 3 is a plasticine model developed by one of our patients to inform the surgeon of her esthetic goals with liposuction and fat gluteal grafting.

There are two types of liposuction: the dry technique and the tumescent one. The latter is defined as the removal of subcutaneous fat under anesthesia infiltrated with large volumes of saline solution added with epinephrine and a local anesthetic, usually lidocaine. The original definition excludes the use of another type of anesthesia, whether it is neuraxial or general, as well as the fact that it is done without the presence of an anesthesiologist. However, currently

interfacial plane blocks for postoperative breast analgesia; modifications to the initial technique have been published [43–45]. Interfacial blocks score over traditional regional anesthetic procedures as they have no risk of sympathetic blockade, intrathecal or epidural spread which may lead to hemodynamic instability, and prolonged hospital stay [44]. These blocks are not an alternative to general anesthesia, epidural anesthesia, or paravertebral blocks since they do not produce adequate regional surgical anesthesia. However, they can be supplemented with intravenous sedation techniques, general anesthesia, or neuraxial anesthesia. Postoperative pain not only involves the breasts; it can extend to the sternum, lateral aspect of the thorax, armpits, and middle back, being more severe when the implants are submuscular. Postoperative pain can be managed with NSAIDs such as parecoxib, ibuprofen, ketoprofen, ketorolac, or diclofenac combined with low doses of opioids. Tramadol is recommended because of its dual mechanism of analgesic action. Methocarbamol can be associated with the previous scheme. Some investigators have found adequate analgesia with the continuous or intermittent administration of local anesthetics through catheters implanted during surgery [46, 47]. It has not been defined if paravertebral blocks decrease the incidence of chronic postoperative pain in

The evaluation of candidates for abdominal contour surgery allows patients to be classified according to the possibilities of surgery taking in consideration the skin, fat, and muscles. This group includes liposuction, abdominoplasty, abdominal muscle repair, and various combinations that lengthen the operative time such as a 360 liposuction and mommy makeover.

Liposuction. Liposuction is the second most common procedure in plastic surgery, and it is perhaps the one with the highest morbidity and mortality [49]. Liposuction consists in removing fat from unwanted areas to build and improve contour. It can be performed in most subcutaneous fat deposits, being more frequent in the abdomen, hips, waist, torso, neck, and extremities. In men, it is usually done also in the pectoral region. The selection of patients is a determining factor since there are people who want to sculpt their silhouette because they have failed in weight loss and are looking for massive liposuction as a fast track to their false expectations of a suitable silhouette without taking into consideration that this procedure is not an alternative for the management of obesity. The pre-anesthetic assessment should be meticulous and must reject patients with moderate or severe cardiomyopathies or pneumopathies and those with thrombophilia or a history of pulmonary embolism. It is advisable not to associate liposuction with nonplastic procedures such as gynecological surgery. Surgeon and anesthesiologist must make a comprehensive management plan to meet the goals of patients, when possible. Figure 3 is a plasticine model developed by one of our patients to inform the surgeon of her esthetic goals

There are two types of liposuction: the dry technique and the tumescent one. The latter is defined as the removal of subcutaneous fat under anesthesia infiltrated with large volumes of saline solution added with epinephrine and a local anesthetic, usually lidocaine. The original definition excludes the use of another type of anesthesia, whether it is neuraxial or general, as well as the fact that it is done without the presence of an anesthesiologist. However, currently

breast surgery [48].

6.2. Surgeries for abdominal contour

18 Anesthesia Topics for Plastic and Reconstructive Surgery

with liposuction and fat gluteal grafting.

Figure 3. Plasticine model made by the patient to accurately show us the shape and size that she wants for her buttocks.

this type of liposuction is frequently done with epidural block, with spinal anesthesia, or with general anesthesia, in addition to infiltration with Klein's solution (50 mL of 1% lidocaine solution (500 mg), 1 mL of 1:1000 epinephrine (1 mg), 1000 mL of 0.9% saline, and 12.5 mL of 8.4% NaH2CO3 solution (12.5 mEq)) [50]. This type of anesthesia involves a dose of lidocaine 35–55 mg/kg of body weight and added epinephrine to achieve concentrations of 0.25–1.5 mg/L, without exceeding total adrenaline total dose of 50 μg/kg. These high doses make it obligatory to perform these procedures in surgery rooms that have all the facilities for monitoring, cardiac resuscitation, ventilatory support, and, always, recovery area under the care of an anesthesiologist. It is an apparently low-risk procedure, which can be complicated by systemic toxicity from local anesthetics, hypothermia, fat embolism, electrolyte imbalances with fluid overload, and/or acute anemia [51, 52]. One of the limitations during cosmetic surgery, especially during tumescent liposuction, is the total dose of the local anesthetic. For this reason, it is advisable not to combine liposuction with other procedures that require the injection of local anesthetics as the maximum dose of these drugs can be exceeded. There is no informed agreement in the literature on what is the top dose of lidocaine; the literature written by dermatologists and plastic surgeons mentioned 55 mg/kg of weight [50, 52–54], whereas the literature that comes from investigations carried out by anesthesiologists mentions 5 mg/kg of weight. In Europe, it is considered safe to use a total of 200 mg of lidocaine without epinephrine, and up to 300 mg is allowed in the United States of America. When epinephrine is added, the lidocaine dose in both regions is 500 mg. Epinephrine 1:200,000 reduces absorption of subcutaneous lidocaine by 50% and intercostal, epidural, and brachial in 20–30% [55]. PPX local anesthetics should never be used in tumescent liposuction. There is no agreement on the best anesthetic technique for liposuction, whether it is the modality under local anesthesia with the Klein solution or with general anesthesia or neuraxial block. With both procedures deaths have been reported [49, 56, 57], and the reports are not completely reliable.

The total volume of fat removed should not exceed 5 L in a single intervention or not be greater than 5% of body weight [58, 59]. Higher volumes increase the risk of complications, especially hypovolemia due to bleeding and acute hydro-electrolytic alterations. Another topic of interest in the management of these patients is the replacement of fluids during the trans-anesthetic period; Trott et al. [60] recommended the following scheme: (a) liposuction of small volumes (<4 L of aspirate) = maintenance liquids + the volume of the injected subcutaneous solution and (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 hematocrit above 30% and albumin levels above 3 g.

(Ramsay 3–4, BIS 80–70). Nasal oxygen should be administered throughout the procedure to maintain normal O2 saturation. The patient must be monitored, as well as corneal protection to avoid abrasive injuries. It is mandatory that the surgical group looks out frequently the total dose of local anesthetic administered to avoid exceeding the recommended top doses. In the first hour of surgery, the previous fast fluid deficit should be replaced and then administer

Anesthesia for Plastic Surgery Procedures http://dx.doi.org/10.5772/intechopen.81284 21

In our opinion, general anesthesia should be avoided and reserved for very select, complex cases or for patients who cannot tolerate or cooperate with conscious sedation [6]. The selection is indistinct and must be based on the physical conditions of the patient. In Lotus Med Group, we use isoflurane, sevoflurane, or desflurane and avoid or minimize the use of muscle relaxants. When the patient is extubated, special attention should be paid to avoid coughing

Autologous fat grafting. Autologous fat grafting refers to the transfer of fat from one or more areas to other areas to improve body contouring. It is in vogue among plastic surgeons and their patients. It is a natural filler, available, and easy to obtain, which is usually reintegrated in the receptor sites, although it has an unpredictable percentage of resorption. The most frequent areas where fat is transferred include the hips, buttocks, breast, face, and hands. A typical grafting procedure is done in three phases: harvesting of adipose tissue from the donor area; processing of the lipoaspirate to eliminate cellular debris, acellular oil, and excess of infiltrated solution; and reinjection of the adipose tissue at the receptor site [67–69]. Lumbar approached subarachnoid anesthesia is the technique of choice when the fatty tissue to be extracted is below T4–T6, to be subsequently grafted to the buttocks, breast, and/or hips. We have observed that spinal anesthesia decreases bleeding at the donor site when compared to general anesthesia and facilitates rapid recovery, with less postoperative pain and home discharge on

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

adequate volume to obtain diuresis of 0.5 mL/kg/hour.

and bowing that may facilitate bleeding in the surgical site.

the same day without complications.

7. Postoperative pain control

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

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 or after bariatric procedures.

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, to name a few [64].

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

(Ramsay 3–4, BIS 80–70). Nasal oxygen should be administered throughout the procedure to maintain normal O2 saturation. The patient must be monitored, as well as corneal protection to avoid abrasive injuries. It is mandatory that the surgical group looks out frequently the total dose of local anesthetic administered to avoid exceeding the recommended top doses. In the first hour of surgery, the previous fast fluid deficit should be replaced and then administer adequate volume to obtain diuresis of 0.5 mL/kg/hour.

In our opinion, general anesthesia should be avoided and reserved for very select, complex cases or for patients who cannot tolerate or cooperate with conscious sedation [6]. The selection is indistinct and must be based on the physical conditions of the patient. In Lotus Med Group, we use isoflurane, sevoflurane, or desflurane and avoid or minimize the use of muscle relaxants. When the patient is extubated, special attention should be paid to avoid coughing and bowing that may facilitate bleeding in the surgical site.

Autologous fat grafting. Autologous fat grafting refers to the transfer of fat from one or more areas to other areas to improve body contouring. It is in vogue among plastic surgeons and their patients. It is a natural filler, available, and easy to obtain, which is usually reintegrated in the receptor sites, although it has an unpredictable percentage of resorption. The most frequent areas where fat is transferred include the hips, buttocks, breast, face, and hands. A typical grafting procedure is done in three phases: harvesting of adipose tissue from the donor area; processing of the lipoaspirate to eliminate cellular debris, acellular oil, and excess of infiltrated solution; and reinjection of the adipose tissue at the receptor site [67–69]. Lumbar approached subarachnoid anesthesia is the technique of choice when the fatty tissue to be extracted is below T4–T6, to be subsequently grafted to the buttocks, breast, and/or hips. We have observed that spinal anesthesia decreases bleeding at the donor site when compared to general anesthesia and facilitates rapid recovery, with less postoperative pain and home discharge on the same day without complications.
