Anesthetic considerations for plastic surgery Flashcards
Plastic surgery can be performed under _____ and at the following locations____
local, regional, MAC, & GA
ambulatory or same-day surgery & office-based procedures
______ is the most popular plastic surgery
breast augmentation (although it changed to rhinoplasty during covid)
The most frequent complications of plastic surgery include
DVT & PE*****
For patients undergoing plastic surgery, we are most concerned with
DVT/PE prophylaxis
liposuction guidelines on lidocaine/epinephrine doses
adequate hydration
The most common procedures for women include
breast augmentation>liposuction>blepharoplasty
the most common procedures for men include
liposuction, rhinoplasty, blepharoplasty
For the pre-anesthesia evaluation of the patient presenting for a plastic procedure, it is important to consider
most patients are healthy
low tolerance of errors or side effects
explain anesthetic techniques-risks/benefits
gain patient trust
reduce anxiety
complete H&P b/c plastic surgeon doesn’t always do a good job of this
NPO: 8 hours solid food & 2 hours liquid
Describe the typical patient undergoing plastic surgery.
most patients are 35-50 years of age; facial surgery usually >50 years
most ASA I/II
overweight patients may seek skin removal surgery following bariatric surgery
if patient >50 years, should have clearance by internist
pregnancy testing recommended in women of childbearing age
A concern with medications regarding patients undergoing plastic surgery includes
54% of patients taking herbals that interfere with anesthetics/surgery & 85% are not told to stop before surgery
In regards to the patient history, the patient may have
co-morbidities that are missed by the plastic surgeon
For PONV prophylaxis, it is necessary to
give two or more agents
______ preoperatively has been shown to reduce anxiety, decrease postoperative pain intensity and opioid consumption, improve postoperative sleep quality and reduce postoperative/emergence delirium.
Melatonin 3-10 mg
If the surgery is longer than 4 hours, then
foley catheter should be inserted
Goals for emergence of the plastic patient include
no increase in BP/HR, no bucking and no respiratory complications
____ is often used on eyelids
ophthalmologic lubricant & sterile tape
Regional anesthesia techniques provide for
fewer complications, safer recovery, & better postoperative analgesia
With BIS monitoring, there is a ____ delay from real time
15-30 second
BIS is useful in conjunction with ____ -that monitors electrical activity of frontalis muscle between eyebrows- spikes suggest patient arousal
electromyogram
Risks with general anesthesia include
difficult intubation, failed intubation, kinked/occluded ETT, dental damage, AGM errors, MH
“room air general” - risk of airway fire
LMA is frequently used in plastic surgery
Local anesthesia by plastic surgeon may be used for
blepharoplasty, chin implant, liposuction
Spinal anesthesia can be done for
safe, early discharge, low cost, & rare complications
liposuction, buttocks implants, calf implants, & possibly for breasts
can add adjuvant (clonidine, fentanyl, sufentanil) for surgeries longer than 2 hours
Breast procedures include
breast augmentation
breast reduction
breast lift
Describe the blood supply to the breast
internal mammary artery for the medial aspect
lateral thoracic artery for the lateral aspect
venous drainage- superficial veins under dermis & deep veins that parallel the arteries
lymph drainage via retromammary lymph plexus in the pectoral fascia
Describe the nerve supply for the breast
peripheral nervous system innervation of the anterior and lateral cutaneous branches of the 4th, 5th, and 6th intercostal nerves
thoracic spinal nerve, T4, innervates nipple-areola complex
A breast augmentation can be performed for _____ patients
healthy versus breast cancer
Breast augmentation can be performed under
regional- less PONV, pain, decreased cost
general (VA/IV), cervicothoracic epidural, intercostal block, fascial plane block, tumescent injection with lidocaine
cervicothoracic epidural (C7-T4) better analgesia than general anesthesia
Adjunct: fascial plane blocks- no sympathetic blockade, hemodynamic stability
Describe the incision approaches for breast augmentation.
infra-mammary, peri-areolar, trans-axillary
Describe the implant types & where it is placed for breast augmentation.
implant placed in pocket under mammary gland or pectoralis muscle
silicone or saline implants
Describe the location of postop pain for breast augmentation.
sternum, lateral thorax, middle back
can give NSAIDs, low-dose opioids, & tramadol
The anesthetic changes for breast augmentation include:
position changes: head secured to table, eye protection, arms padded and wrapped to arm boards, extensions on PIV, extension on circuit
-bra placed at end of case
pain management
Complications of breast augmentation include.
capsular contracture, hematoma, infection, wound dehiscence
The most common cancer globally is
breast cancer
1 in 8 women will develop
Ashkenazi Jewish women have high risk d/t BRCA
most common in black women under 45
85% have no family history of breast cancer
Breast surgery can be performed for
excisional biopsy, breast biopsy, & lumpectomy
Describe considerations for breast biopsy
GA, regional, or local with sedation
supine, arms abducted, table turned
outpatient, minimal EBL; 1-1.5 hours
Describe considerations for lumpectomy.
wire guided (radiology- wire inserted under fluoroscopy)–> don’t touch the cup
- GA, regional, local with sedation
- supine
- avoid muscle relaxants b/c of axillary node removal possibility
- <1.5 hours, outpatient procedure
With a sentinel lymph node biopsy,
the axillary node may be dissected- NO relaxation*
used for small, invasive breast cancer
dye injected around breast
wait for pathology (if positive nodes–> axillary dissection)
Gamma probe used to identify tracer in lymph nodes
Transient drop in pulse oximetry, allergic reaction*
Damage to the long thoracic nerve results in
(motor)
winged scapula*** from the paralysis of the serratus anterior muscle
radical mastectomies or with any removal of axillary lymph nodes
Damage to the thoracodorsal nerve
(motor)
results in palsy of the latissimus dorsi muscle*****
Damage to intercostobrachial nerve (sensory)
results in numbness or pain in the lateral aspect of the axilla & medial aspect of upper arm
Intercostobrachial neuralgia causes
post mastectomy pain syndrome
pain in axilla, medial upper arm & anterior chest wall
Lymphedema is a complication of mastectomy and is most common with
axillary dissection + axillary radiation
Nerve damage and complications of mastectomy include
damage to long thoracic nerve damage to thoracodorsal nerve damage to intercostobrachial nerve intercostobrachial neuralgia lymphedema
Anesthetic considerations for mastectomy include
supine, IV/NIBP/pulse ox on opposite arm
EBL 150-500 cc
usually admitted overnight
1.5 hours up to 7 hours if reconstruction
A total or simple mastectomy involves
removes breast only
A modified or partial mastectomy necessitates
postop radiation/chemotherapy
A radical mastectomy involves
removal of breast, pectoral muscle, and axillary lymph nodes
Describe preoperative considerations for mastectomy
respiratory/airway compromise possible if radiation
chemotherapy (cardiomyopathy)
metastasis
anemia with chemotherapy
Describe intraoperative considerations for mastectomy
GA (ETT/LMA) or regional avoid muscle relaxants during axillary dissection** position changes pressure dressings during emergence high incidence of PONV
When performing an immediate breast reconstruction there is
use of either temporary tissue expander or autologous myocutaneous flaps
A relative contraindication to breast reconstruction is
postoperative chest radiation
FLAPS can include
deep inferior epigastric perforator (DIEP)
superficial inferior epigastric artery (SIEA)
Transverse upper gracilis (TUG)
Gluteal (buttocks)
transverse rectus abdominis myocutaneous (TRAM
With a DIEP flap, important considerations include
nO VASOPRESSORS (microvascular case)**** doppler used to check vessels avoid hypertension/fluid overload indocyanine green may be used to check tissue perfusion
Describe risks associated with a DIEP flap,
ICU disposition, risk of graft failure, venous congestion, fat necrosis, bleeding
A DIEP flap is performed
deep inferior epigastric perforator flap
abdominal skin, fat, & deep inferior epigastric vessels are removed and replanted to create new breasts
internal mammary artery and vein are transected suprasternal and anastomosed to epigastric vessels
The latissimus dorsi flap involves
transfer of back tissues (latissimus muscle, fat, blood vessels, and skin) to the mastectomy site
the thoracodorsal artery supplies the flap- left attached to its original supply
Following the mastectomy when performing the latissimus dorsi flap,
the patient is turned lateral or prone
usually requires implant as well
overnight stay in hospital
The TRAM flap involves
Transverse rectus abdominis myocutaneous flap- pedicle or free flap type
“tummy tuck breast reconstruction”
skin, fat, and muscle tunneled from abdomen to chest
With the TRAM flap it is important to
avoid hypotension
use doppler to check perfusion
flap based on superior epigastric vessels
Anesthetic considerations for breast reconstruction involve (type of anesthesia & access)
General anesthesia
keep warm & hydrated (long cases)
vascular access: long procedure time, blood/fluid loss- multiple peripheral IVs
Complications related to chemotherapy and breast reconstruction include
myelosuppresion
cardiomyopathy with adriamycin
pulmonary fibrosis, interstitial infiltrates, pleural effusions with methotrexate, cylcophosphamide, & bleomycin
With breast reconstruction ____ should not be used because it can interfere with healing.
N2O
Anesthetic considerations for breast reconstruction include
ephedrine> phenylephrine for hypotension (vasoconstriction)
-heparin intraoperative
foley catheter
postoperative pain management (regional block)
-Dextran for flap procedures- reduces clot formation in microvasculature, 25-30 mL/h (low molecular weight), monitor for allergic reactions (ARDS)
Preoperative evaluation for breast reduction includes
back pain, skin irritation/infection, skeletal deformities, respiratory disorders
liposuction may be added
Describe the two techniques for breast reduction.
inferior pedicle with long curved horizontal incision across crease beneath breast
inferior pedicle with vertical incision and short horizontal at crease (less scaring and shorter time)
Describe the anesthetic considerations for breast reduction surgery.
general anesthesia frequent position changes longer procedure (3-5+ hours) fluid warmer, bair hugger, foley catheter fluid/volume blood deficits PONV 23 hour stay
Describe the complications of breast reduction surgery
wound dehiscence, infection, seroma, hematoma, skin flap necrosis, loss of sensation, hypertrophic scarring
