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N931 Advanced Principles > Anesthesia Considerations of Plastic Surgery > Flashcards

Anesthesia Considerations of Plastic Surgery Flashcards

1
Q

What are complications to anesthesia plastics?

A

DVT and PE remain the most frequent complications

N/V also common

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2
Q

What are four general anesthetic considerations for plastics anesthesia?

A

patient safety is most important
DVT/PE prophlyaxis
Liposuction guidelines on lidocaine and epi doses
adequate hydration

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3
Q

What are most common plastic surgery procedures performed?

A 
breast augmentation (most common)
liposuction, nose reshaping, eye lid surgery and facelift
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4
Q

What are the most common plastic surgical procedures for females?

A

breast augumentation
liposuction
blepharoplasty

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5
Q

What are the most common plastic surgical procedures for males?

A

liposuction
rhinoplasty
blepharoplasty

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6
Q

What case examples can be done by conscious sedation?

A

facial surgeries: rhytidoplasty, coronal, open rhinoplasty, blepharoplasty, otoplasty, laser dermabrasion, implants, fat grafting/ synthetic materials

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7
Q

What case examples can be done GA?

A

facial surgeries: rhytidoplasty, coronal, open rhinoplasty, rhioplasty with bone fracture
body surgery: breasts or pectorals, liposuction, torso, breast pexia of inferior segment, buttocks implants,

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8
Q

What case examples can be done by MAC?

A

blepharoplasty, otoplasty, implants, fat grafting/ synthetic materials

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9
Q

What case examples can be done by epidural?

A 
breast or pectoralis
liposuction
torso
abdominoplasty
breast pexia of inferior segment
buttock implants
brachioplasty
liposuction
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10
Q

What case examples can be done by spinal?

A

liposuction, abdominoplasty, buttock implants, cruroplasty

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11
Q

What case examples have moderate pain?

A

rhytidoplasty, rhinoplasty with bone fracture, laser dermabrasion, breast pectorals, torso, abdominoplasty, breast pexia of inferior segment, buttock implants, brachioplasty, cruroplasty

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12
Q

Pre-anesthesia Evaluation

A

most patients are healthy
low tolerance of errors or side effects
explain anesthetic technique- risk/ benefits
gain patient trust
reduce anxiety
complete history and physical examination are fundamental
NPO: 8 hours solid food and 2 hour liquids
Most (45%) of patients are 35-50 years of age
Most ASA 1/2
oveweight patients surgery may seek skin removal surgery following bariatric surgery

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13
Q

If patient is over what age, should they seek clearance for internist?

A

> 50 years of age

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14
Q

What labs may be necessary in plastic surgery procedures?

A

pregnancy

CBC CMP Coags HIV Hep B/C

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15
Q

What medications could a plastic surgery patient possibly be on?

A 
NSAIDS
vitamin E
weight loss medications
contraceptives
herbs
illegal drug use
prescription medications
thyroid hormones
antidepressants
benzodiazepines
vitamins and minerasl
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16
Q

What is important to evaluate in patient’s medications prior to surgery?

A

Assess anticoagulation, antiplatelet and procoagulant effects of medications
Potentiate effects of anesthesia

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17
Q

What % of patients are possibly taking herbs as medicaitons?

A

54

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18
Q

What % of patients taking herbal medications are not told to stop prior to surgery?

A

85

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19
Q

What are possible pre-operative testing/ labs that are appropriate for an ASA 1?

A 
clinical history
physical examination
blood test
complete blood chemistry
coagulation tests
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20
Q

What are possible pre-operative testing/ labs that are appropriate for an ASA 2/3?

A 
clinical history
physical examination
specialist consultation
EKG
Chest Xray
blood test
complete blood chemistry
UA
coagulation tests
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21
Q

What preoperative testing may be requested?

A

ECHO for ASA 2/3
HIV
hepititis
pregnancy (2/3)

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22
Q

What is melatonin preoperatively help with?

A

reducing anxiety, decrease post-operative pain intensity and opioid consumption
improves postoperative sleep quality and reduces post-operative/ emergence and delirium
May also reduce oxidative stress and anesthetic requirements

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23
Q

What monitors are needed intra-operatively for plastic surgical procedures?

A

PIV, EKG, BP, pulse oximetry, EtCO2, temperature probe

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24
Q

What equipment is needed intra-operatively for plastic surgical procedures?

A 
compression boots
foley catheter if longer than 4 hour surgery
proper positioning 
access to airway
eyes taped (opthalamologic lubricant)
sterile tape often used on eyelids
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25
Q

Goal for emergence

A

no increase in BP/HR, no bucking and no respiratory complications

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26
Q

What surgical procedure can temperature decrease quickly and why?

A

liposuction because irrigating with cool fluids

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27
Q

What are the benefits of regional anesthesia for plastic surgeries?

A

fewer complications
safer recovery
post operative analgesia

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28
Q

What are general anesthetic techniques for plastics?

A

inhalations

IV combined

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29
Q

What are regional anesthetic techniques for plastics?

A

neuraxial, peripheral nerve blocks, local, bier blocks

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30
Q

What are conscious sedation/MAC considerations for plastics?

A

important to remember that patient maintains the integrity of the airway and its protective reflexes (unlike general anesthesia)
need to be prepared to secure the airway and covert to GA technique

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31
Q

What combinations of medications are heavily utilized in plastics?

A

anxiolyitcs, sedatives, hyponotic agents, opioids and alpha 2 agonist

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32
Q

What are level of the BIS monitor is awake?

A

98-100

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33
Q

What is BIS level is minimal sedation?

A

78-82

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34
Q

What is BIS level is moderate sedation?

A

70-80

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35
Q

What is BIS level is deep sedation?

A

60-70

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36
Q

What is BIS level is general anesthesia?

A

45-60 goal 45-50

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37
Q

What is BIS level is overmedicated?

A

<45

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38
Q

What a BIS helpful for?

A

useful for patients receiving propofol- ketamine anesthesia

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39
Q

How long is the recording delay with a BIS?

A

15-30 seconds in real time

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40
Q

What is helpful to have in conjunction with BIS?

A

EMG electrolmygram (EMG)

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41
Q

What does the EMG with the BIS monitor?

A

electrical activity of frontalis muscle between the eyebrows

spikes suggest patient arousal

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42
Q

What are the goals of general anesthesia in the plastic surgery relam?

A

rapid induction, adequate operative conditions, hemodynamic stability, fast recovery, absence of side effects and good control of pain and emesis

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43
Q

What are the risks of general anesthesia in PS?

A 
difficult intubation
failed intubation
kinked/occluded ETT
AGM errors
MH
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44
Q

What airway is more frequently used in plastics?

A

LMA

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45
Q

What is a risk of airway fire?

A

room air general/ LMAs are considered “okay”

airway fire with open airway above the xiphoid process

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46
Q

What plastic surgical procedures have possible high fire risk?

A

facelifts

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47
Q

What medication is not given in the office setting?

A

relaxation/ NMR

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48
Q

What plastic surgical procedures are good for subarachnoid anesthesia?

A

liposuction, buttock implants, calf implants, breast (?)

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49
Q

What medication can be added to subarachnoid anesthesia as an adjunct for surgeries more then 2 hours?

A

clonidine
fentanyl
sufentanil

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50
Q

What are the advantages to subarachnoid anesthesia?

A

safe
early discharde
low cost
rare complications

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51
Q

What surgeries can LA be inserted by the plastic surgeon?

A

blepharoplasty
chin implant
liposuction

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52
Q

What is the risk of epidural or combined spinal-epidural or peripheral nerve blocks?

A

How long the block will last and when it will were off in relation to the surgical time

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53
Q

What are three breast procedures?

A

breast augmentation
breast reduction
breast lift

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54
Q

Describe blood supply to the breast

A

Medial aspect is the internal mammary artery

Lateral aspect is the lateral thoracic artery

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55
Q

What is venous drainage for the breast?

A

superficial veins under the dermis and deep that parallel the arteries

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56
Q

Where does lymph drain in the breast?

A

retromammary lymph plexus in the pectoral fascia

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57
Q

Describe nerve supple to the breast

A

peripheral nervous system innervation of the anterior and lateral cutaneous branches of the 4th and 5th and 6th intercostal nerves
thoarcic spinal nerve, T4 innervates the nipple areola complex

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58
Q

What are two populations of individuals receiving breast augmentations?

A

healthy vs breast cancer

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59
Q

What anesthetic techniques can be performed for a breast augmentation?

A 
General
cervicothoracic epidural
intercostal block
fascial plane block
tumescent injection with lidocaine
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60
Q

Is the cervicothoracic epidural better or worst analgesia than general anesthesia?

A

better analgesia

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61
Q

What does the cervicothoracic epidural cover?

A

C7-T4

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62
Q

What is an adjunct to breast augmentation?

A

fascial plane blocks
no sympathetic blockade
hemodynamic stability

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63
Q

What are the three possible incisions for a breast augmentation?

A

infra mammary
peri areolar
transaxillary

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64
Q

Where is the implant placed for a breast augmentation?

A

in pocket under mammary gland or pectoralis muscle

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65
Q

Where can post-operative pain extend to in an breast augmentation?

A

sternum, lateral thorax, middle back

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66
Q

What medications are good for postoperative pain management?

A

NSAIDs, low dose opioids and tramadol

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67
Q

What are anesthetic considerations for a breast augmentation?

A

Position changes
bra placed at end of case
pain managemnet

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68
Q

What are the position changes encountered in breast augmentation surgery?

A 
head secured to table
eye protection
arms padded and wrapped to arm boards
extension on PIV
extensions on circuit
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69
Q

What are possible complications with breast augmentation surgery?

A

capsular contracture
hematoma
infection
wound dehiscence

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70
Q

What is an capsular contracture?

A

Capsular contracture is a local complication thought to occur due to an excessive fibrotic foreign body reaction to the implant. It is thought to be an inflammatory reaction which causes fibrosis through the production of collagen [3], leading to excessively firm and painful breasts [6].

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71
Q

What is the most common cancer globally?

A

breast cancer

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72
Q

What ethnicity is breast cancer more common in women under 45?

A

black women

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73
Q

What ethnicity has the highest risk of BRCA?

A

Ashkenazi Jewish women

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74
Q

What % of breast cancer is linked to genetics?

A

5-10%

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75
Q

What % of breast cancer has no family history? How does this occur?

A

85%

genetic mutations due to aging process and life

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76
Q

What are three different breast surgeries? (smaller)

A

excisional biopsy
breast biopsy
lumpectomy

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77
Q

How can a breast biopsy be completed?

A

GA regional or with local sedation
outpatient, minimal EBL,
1-1.5 hours

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78
Q

What is the positioning for a breast biopsy?

A

supine
arm abducted
table turned

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79
Q

How can a lumpectomy be performed?

A

GA
regional
local with sedation
<1.5 hours, outpatient procedure

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80
Q

What is the positioning for a lumpectomy?

A

supine

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81
Q

What needs to avoided in a lumpectomy? Why?

A

muscle relaxants to watch axillary nodes

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82
Q

What is a lumpectomy?

A

Nonpalpable lesions are usually discovered on routine screening mammography or on diagnostic workup using breast
ultrasound or breast MRI. Microcalcifications, masses, densities, and architectural distortion fall into the category
of potentially malignant lesions. Breast ultrasound can identify complex cystic or solid masses, and MRI can show
areas of abnormal vascular enhancement. In these instances, the breast usually feels and looks normal. Typically, the
radiologist places one or more percutaneous hookwires in close proximity to the lesion, using local anesthesia. Later,
in the operating room, the surgeon then uses the hookwire(s) as an anatomical guide to locate and excise the area of
abnormality. These procedures are referred to as wire-localization breast biopsies or lumpectomies. In the OR,
the surgeon removes the breast tissue surrounding the wire and confirms the removal of the wire and target lesion
on specimen radiography and/or ultrasound. Bracket wire localization refers to placement of multiple hookwires
to mark the periphery of a larger lesion or multiple lesions so tissue can be removed between the bracketing wires

– JAFFEE

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83
Q

What is a sentinel lymph node biopsy for?

A

small, invasive breast cancer

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84
Q

What is dissected in the sentinel lymph node biopsy?

A

axillary node

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85
Q

Is their relaxation in a sentinel node biopsy?

A

no

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86
Q

What is the sentinel lymph node?

A

first node to drain the afferent lymphatics from the area of the leison

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87
Q

What is injected around the breast in a sentinel node biopsy?

A

dye

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88
Q

When dye is inject in a sentinel node biopsy what may or may not happen to the patient?

A

transient drop in pulse oximetry

allergic reaction

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89
Q

What probes are placed to identify lymph node in a sentinel node biopsy?

A

gamma probe

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90
Q

What are you waiting for in a sentinel node biopsy?

A

pathology
if positive
axillary dissection

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91
Q

What nerve damage can occur in breast surgery?

A 
long thoracic nerve (motor)
thoarcodorsal  nerve (motor)
intercostobrachial nerve (sensory)
intercostobrachial neurgalgia (post mastectomy pain syndrome)
lymphedema
92
Q

If damage to long thoracic nerve what can be seen?

A

winged scapula (scapula alata) from paralysis of the serratus anterior muscle

93
Q

What surgeries can damage to the long thoracic nerve occur?

A

radical mastectomies or with any removal of axillary lymph nodes

94
Q

What results in thoarcodorsal nerve damage?

A

palsy of the latissimus dorsi muscle

95
Q

What results in damage to the intercostobrachial nerve?

A

numbness or pain in the lateral aspect of the axilla and medial aspect of the upper arm

96
Q

What results in intercostobrachial neurgalgia (post mastectomy pain syndrome)?

A

pain in axilla, medial upper arm and anterior chest wall

97
Q

When is lymphedema most common?

A

axillary dissection and axillary radiation

98
Q

What are two types of mastectomies?

A

modified or partial

total or simple or radical

99
Q

What is a radical mastectomy?

A

removal of breast, pectoral muscle, and axillary lymph nodes

100
Q

What is a total/simple mastectomy?

A

removal of breast only

101
Q

What are general anesthetic considerations for mastectomy? (4)

A

supine, IV/NIBP/Pulse ox on opposite arm
EBL 150-500
usually admitted overnight
1.5-7 hours of reconstruction

102
Q

What are preoperative considerations for mastectomies?

A

respiratory/ airway compromise possible if radiation
chemotherapy (cardiomyopathy)
metastasis
anemia or chemotherapy

103
Q

What are intra-operative considerations for mastectomies?

A 
GA (ETT/LMA) or regional
avoid muscle relaxants during axillary dissection
position changes
pressure changes during emergence
high incidence of PONV
104
Q

What are immediate interventions for breast reconstruction?

A

temporary tissue expander

autologous myocutaneous flap

105
Q

What is relative contraindication to breast reconstruction?

A

postoperative chest radiation

106
Q

What are the five flaps for breast reconstruction?

A

Deep Inferior Epigastric perforator (DIEP)
superifical inferior epigastric artery (SIEA)
transverse upper gracilis (TUG)
gluteal (buttocks)
transverse rectus abdominis myocutaneous (TRAM)

107
Q

What the most common flaps for breast reconstruction?

A

TRAM

DIEPs

108
Q

Describe the DIEP flap

A

deep inferior epigastric perfortator flap
abdominal skin, fat and deep inferior epigastric vessels are removed and replanted to create new breasts
internal mammary artery and vein are transected suprasternal and anastmosed to epigastric vessels

109
Q

What is avoided with DIEP flaps?

A

vaspressors (microvascular case)
doppler used to check vessels
avoid hypertension/ fluid overload

110
Q

What can be used to check tissue perfusion with a DIEP flap?

A

indocyanine green

111
Q

What are complications to the DIEP flap?

A 
ICU disposition
risk of graft failure
venous congestion
fat necrosis 
bleeding
112
Q

What blood pressure medication is preferred in DIEP flaps and why?

A

ephedrine because indirect MOA

Albumin is preferred for fluid administration and expansion

113
Q

Describe a latissimus dorsi flap

A

transfer of back tissues (latissimus muscle, fat, blood vessels on skin) to the mastectomy site
thoracodorsal artery supplied the flap and left attached to its original supply

114
Q

When is the patient turned prone for the latissimus dorsi flap?

A

following (after) the mastectomy

115
Q

What is required for a latissimus dorsi flap?

A

implants

overnight stay in hospital

116
Q

Describe a TRAM flap

A

transverse rectus abominis myocutaneous flap (pedicl or free flap type)

117
Q

What is a TRAM flap also known as

A

tummy tuck breast reconstruction

118
Q

What do you want to avoid in a TRAM flap?

A

hypotension

119
Q

What is the TRAM flap based on?

A

superior epigastric vessels

120
Q

What is more painful a TRAM or DIEP flap? Why?

A

TRAM is more painful and stimulating because the muscle is utilized

121
Q

What are anesthetic considerations for breast reconstruction?

A 
long procedure time
blood/fluid loss
multiple peripheral IVs
General anesthesia
Keep warm and hydrated
foley catheter
postoperative pain management (regional block)
122
Q

What are complications to breast reconstruction that are related to chemotherapy?

A

pulmonary fibrosis, interstitial infiltrates, pleural effusions with methotrexate, cyclophosphamide, bleomycin
cardiomyopathy with adriamycin
myleosuppression

123
Q

What are some medications considerations for breast reconstruction?

A

ephedrine > phenylephrine for hypotension (avoids vasoconstriction)
heparin intraoperative
dextran for flap procedures

124
Q

What is avoid in breast reconstruction surgeries?

A

No N20

125
Q

Why dextran for flap procedures?

A

reduces clot formation in microvasculature

126
Q

What do you need to monitor for with dextran?

A

allergic reactions (ARDS)

127
Q

What rate is dextran run?

A

25-30ml/h (low molecular weight)

128
Q

What are necessary as pre-operative evaluation with mammoplasty reduction?

A

back pain
skin irritation/ infection
skeletal deformities
respiratory disorders

129
Q

What are the techniques for reduction mamoplasty?

A

inferior pedicle with long curved horizontal incision across crease beneath breast
inferior pedicle with vertical incision and short horizontal at crease (less scarring and short time)

130
Q

Can reduction mammoplasty be completed with an LMA?

A

yes

131
Q

If liposuction is added to the reduction mammoplasty what complication does the anesthesia provider need to be aware of?

A

lung puncture

132
Q

What are anesthetic considerations for breast reduction? (7)

A 
general anesthesia
frequent position changes
longer procedure (3-5)+
fluid warmer/bair hugger/ foley catheter
fluid/ blood volume deficits
PONV
23 hour stay
133
Q

What are complications to a breast reduction?

A 
wound dehiscence
infeciton
seroma
hematoma
skin flap necrosis
loss of sensation
hypertrophic scarring
134
Q

What are 7 abdominal surgeries?

A 
liposuction
abdominoplasty
abdominal muscle repair
360 degree liposuction
body sculpting
"mommy makeover"
tummy tuck
135
Q

What surgery has the highest morbidity and mortality in plastic surgery?

A

liposuction

136
Q

What is the second most common plastic surgical procedure?

A

liposuction

137
Q

What is liposuction?

A

removing fat from unwanted areas

abdomen, hips, waist, torso, neck, extremities, pectoral region

138
Q

What are some pre-operative considerations for patients coming for liposuction?

A

assess for cardiomyopathy
pulmonary disease
pulmonary embolus
throbmbophilia

139
Q

What are the 4 methods to perform liposuction?

A

dry technique
wet technique
super wet technique
tumescent method

140
Q

What is dry technique?

A

aspiration cannula inserted into space where fat will be removed

141
Q

What is the EBL in dry technique liposuction?

A

24-40% of aspirated volume

142
Q

What is wet technique?

A

200-300 ml of solution injected into each area to be treated

143
Q

What is the EBL of wet technique liposuction?

A

4-30% of volume aspirated

144
Q

What is super wet technique?

A

infiltrated solution= amount to be removed

1:1 ration

145
Q

What is the EBL of super wet technique liposuction?

A

EBL is 1% of volume aspirated

146
Q

What is the tumescent method?

A

large amount of solution (3-4ml per ml of expected aspirate) injected into fatty tissue

147
Q

What is the EBL of tumescent method liposuction?

A

1% of aspirated volume

148
Q

Describe tumescent solution

A

removal of SQ fat UNDER ANESTHESIA infiltrated wiht large volumes of saline solution with epinephrine and lidocaine

149
Q

What is klein’s s solution?

A

50 ml of 1% lidocaine + 1 ml 1:1000 epinephrine + 12.5ml 8.4% NaH2CO3 + 1000 NS

150
Q

What is hunstad solution?

A

1000LR + 50ml of 1% lidocaine + 1ml of 1:1000 epinephrine

151
Q

What is the lidocaine max for liposuction procedures?

A

35mg/kg of TBW

being injected into lipid cells/SQ tissue therefore very slow absorption into the systemic system

152
Q

What is the total epinephrine max for liposuction procedures?

A

50mcg/kg

153
Q

What is the purpose of bicarbonate in the tumescent solution (Klein’s)?

A

increased pH and helps reduce pain

favors faster entry into nerve cell where lidocaine acts

154
Q

What solution lacks a burning sensation?

A

Hunstad

LR ( sodium load is also reduced)

155
Q

What is required for liposuction procedures?

A

monitoring, cardiac resuscitation, ventilatory support, recovery under anesthesia care
ie adequate PACU needed

156
Q

What are the possible complications of liposuction?

A 
LAST 
hypothermia
fat embolism, DVT, PR
acute anemia
pulmonary edema
fluid overload
electrolyte imbalances
death
157
Q

What does of epi reduces the absorption of SQ lidocaine by 50%?

A

1:200,000

158
Q

What is the max dose of lido with epi/max?

A

500mg

159
Q

What is the max total volume allowed to be removed in a single session of liposuction?

A

<5L or 5% of body weight

160
Q

What do higher volumes of fat removal in liposuction lead to?

A

hypovolemia, bleeding, electrolyte disturbances

161
Q

Describe IVF management in Liposuction for < 4L

A

maintenance fluid only

162
Q

Describe IVF management in Liposuction for >4L

A

maintenance + 0.25ml/ml removed after 4L

163
Q

What is the goal of IVF management in liposuction?

A

maintain normal intravascular volume with postanesthestic Hct> 30% and albumin >3g

164
Q

What are anesthetic considerations for liposuction?

A 
GA SCDs
compression garnment
incision sites are closed with sterile dressings
pain related to amount of fat removed
tissue trauma from suctioning
165
Q

If large volumes of liposuction are taken, monitors required are

A

foley
bair hugger
fluid warmer

166
Q

What are complications for liposuction?

A 
PE
fat embolus
fluid overload
LAST
epinephrine toxicity
hemorrhage
nerve damage
167
Q

Describe the fluid status throughout liposuction

A

60% of solution infused remains in tissues (and will be absorbed)
third spacing into surgical cavity

168
Q

What can Over/under estimation of fluid shifts can lead to

A

PE or hypovolumic shock

169
Q

What is 360 degree liposuction?

A

liposuction of the entire tuncal midsection

170
Q

What is the goal of 360 degree liposuction?

A

complete curvier contour from every angle

171
Q

What can 360 degree liposuction be combined with?

A

dermolipectomy, plication of the rectus abdominis muscle, umbilicoplasty or gluteal fat grafting

172
Q

What is an abdominoplasty?

A

surgery of the abdominal wall
umbilicus circumcised and blood supply preserved
resection of skin excess (pubis to costal margin)

173
Q

What position are patients in for abdominoplasty?

A

semi-fowlers position

174
Q

What is lipoabdominoplasty?

A

abdominoplasty + liposuction

175
Q

Who is an abdominoplasty common?

A

patients who have had multiple pregnancies, or those who have lost alot of weight or after bariatric procedures

176
Q

What can be combined with abdominoplasty?

A

plication (folding) of the rectus abdominis muscle

177
Q

What are anesthetic considerations for the abdominoplasty?

A

2-5 hours procedure length
post gastric bypass, ensure patients have stable weight for six months prior to surgery with stable health status
overnight monitoring of comorbidities and extent of surgery
GA
fluid warmer, bair hugger, foley, PIV, antibiotics
PCA +/- epidural for postoperative pain management

178
Q

What are possible labs for a abdominoplasty?

A

CBC, CM, EKG, liver function

179
Q

Describe the emergence for an abdominoplasty?

A

smooth emergence, antiemetics, binder placement, semi-fowler

180
Q

What are complications for abdominoplasty?

A

ileus, infection, dehiscence, fat embolus, DVT

181
Q

What needs to happed for closure after an abdominoplasty?

A

flex the table to reduce tension on suture lines

182
Q

What is a mommy makeover?

A

breast augmentation, breast lift, buttock augmentation, liposuction, tummy tuck, vaginal rejuvenation

183
Q

What is the goal of a mommy makeover?

A

to restore shape and appearance after childbearing

184
Q

What block is appropriate for abdominal contour surgeries?

A

spinal block up to T4

need to prolong anesthetic time up to 5 hours or longer

185
Q

What should be prevented in mommy makeovers?

A

DVT
PE
infections
Postoperative Pain

186
Q

What is autologous fat grafting?

A

transfer of fat from one or more areas to other areas in order to improve body contour
natural filler, available and easy to obtain
unpredictable % of reabsorption

187
Q

What are the frequent areas for autologous fat grafting?

A

hip buttocks

breast face and hands

188
Q

What are the three phases of autologous fat grafting?

A

harvesting adipose tissue, processing of lipoaspirate, reinjection into receptor site

189
Q

What anesthesia is better for autologous fat grafting?

A

spinal anesthesia

190
Q

What are 7 cosmetic facial surgeries?

A 
rhytidoplasty
rhinoplasty
blepharoplasty
buccal fat removal
lip lifts
chin implants
eyebrow lift
191
Q

What is rhytidoplasty?

A

face lift

192
Q

What anesthesia can be used for rhytidoplasty

A

local anesthesia (subcutaneous and nerve blocks) can be combined with conscious sedation

193
Q

What is the most common complication of rhytidoplasty?

A

hematoma

194
Q

What are pre-anesthetic considerations for rhytidoplasty?

A

10 mg oral melatonin + 2 mg sublingual lorazepam + 0.1-0.2 mg oral clonidine 1 hour prior to surgery
+ 5-10mg mophrine/ 25-50 mcg fentanyl + PONV prophylxis

195
Q

What is avoided in rhytidoplasty?

A

no paralysis for facial nerve monitoring

196
Q

What is needed for rhytidoplasty?

A

smooth emergence

197
Q

What is a brow lift?

A

resuspension of brows

hair line incision with flap

198
Q

What is a blepharoplasty?

A

lid lift

manipulation of periorbital fat can result in retrobulbar hematoma and blindess

199
Q

What reflex do you have to be conscious of in blepharoplasty

A

occulocardiac reflex

decreased HR and BP

200
Q

What anesthesia can be administered for blepharoplasty?

A

local anesthesia and IV sedation

201
Q

What is possible in blepharoplasty?

A

laser use

202
Q

What are anesthetic considerations for brow, face and lid lifts?

A 
supine table turned away
LA with epinephrine
antibiotics
steroids
1-2 hours
outpatient
LA with sedation so patient can open and close eyes during procedure
corneal protection
203
Q

What medications can be used for maintenance for a rhytidoplasty?

A

ketamine + midazolam
Ketamine + propofol
dexmedetomidine + opioid

204
Q

How is oxygen delivered to maintain normal O2 saturation in rhytidoplasty?

A

nasal cannula

205
Q

What anesthetic should avoided in rhytidoplasty?

A

GA
only for complex patients who cannot tolerate/ cooperate with conscious sedation
no need for muscle relaxation
avoid coughing and bucking on extubation due to bleeding at surgical site

206
Q

What is a septorhinoplasty?

A

face lift with septum repair
outpatient
open closed or both

207
Q

What is a rhinoplasty?

A

surgical manipulation of the nasal form for aesthetic and/or functional improvement

208
Q

What do they augment with in rhinoplasties?

A

silion, gortex, synthetic material, cadaveric or autologous tissue (rib, cranium, iliac crest)

209
Q

What happens at the end of a rhinoplasty?

A

splinting with packing at end

210
Q

Anesthetic considerations for rhinoplasty?

A

MAC with infraorbital/nasocillary block
GA
table turned away from AGM

211
Q

What are implications of MAC with infraorbital/nasocillary block or a rhinoplasty?

A

vasoconstrictor-soaked packs placed prior to incision

if increased amount of blood pooling, safer to use GA

212
Q

What are implications of GA for a rhinoplasty?

A 
regular ET or Oral RAE
OG tube at end of surgery to remove blood in stomach
HOB elevated at end of case
nasal packing
smooth emergence
PONV prophylaxis
213
Q

What are strategies for postoperative pain control?

A

multiple neural ending injuries in liposuction, tummy tuck and breast implants
start analgesia in pre-anesthetic phase with pre-emptive strategies
NSAIDs + opioids most commonly used
celecoxib, tramadol, ketorlac, acetaminophen, pregabalin, gabapentin, ketamine, esmolol on induction

214
Q

Why are patients admitted to hospital after plastic surgery?

A

uncontrolled pain, nausea, vomiting or urinary retention

215
Q

Discharge criteria for outpatient or short-stay procedures depends on

A

ASC/ hospital requirements

216
Q

What are the most common errors or incidents that cause severe neurological damage or death?

A

cardiopulmonary events

217
Q

What are the poor outcomes related to?

A

facilities, type of surgery, and/or surgeon, physical status of patient, quality of anesthetic care

218
Q

What are plastic surgical deaths related too?

A

bronchospasm, deep sedation, illicit drug use, thromboembolism, fluid shifts

219
Q

What are the 5 requirements for plastic surgery procedures?

A

appropriate pre-anesthetic evaluation, informed consent, appropriate monitoring, appropriate anesthesia and post anesthetic care

220
Q

What are the most common complications to plastic surgery?

A

DVT and PE

221
Q

What is appropriate prophylaxis for DVT and PE?

A

compression stockings
intermittent pneumatic compression tools
venous foot pumps
low molecular weight heparin

222
Q

What increases the risk of complications?

A

longer anesthesia time

223
Q

What is the most common and most unfavorable complication after plastic surgery?

A

PONV

224
Q

What does PONV lead to?

A

increased bleeding, delayed discharge adn increased cost of care

225
Q

What medication can be given as antiemetic effect?

A

10 mg of propofol

226
Q

What are eight non-asethetic conditions treated by plastic surgery?

A 
congenital abnormalities
oculoplastic conditions
hand surgery
malignancy
burns
facial palsy
wound management
vascular malformations

N931 Advanced Principles (14 decks)

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