Plastic Surgery Flashcards
1
Q
most frequent complications of plastic surgery
A
-DVT and PE
2
Q
other common complications of plastic surgery
A
- postop pain
- nausea
- vomiting
3
Q
most common plastic surgery procedure
A
breast augmentation
4
Q
other common plastic surgery procedures
A
- liposuction
- nose reshaping
- eyelid surgery
- facelift
5
Q
patient history
A
- make sure to get a thorough patient history
- plastic surgeon may not get quite as thorough a history so you must!!
- consult with internist/specialist for disease states
6
Q
preop medications for plastics
A
- benzos (midaz esp useful for short procedures)
- melatonin 3-10 mg preop
- two or more agents for PONV prophylaxis
- pre-emptive analgesia = mag, NSAIDs, gabapentinoids, ketamine
7
Q
melatonin preop
A
- reduce anxiety
- decrease postop pain intensity and opioid consumption
- improve post-op sleep quality
- reduce post op/emergence delirium
- may also reduce oxidative stress and anesthetic requirements
8
Q
goals for emergence with plastics
A
- no increase in BP/HR
- no bucking
- no respiratory complications
9
Q
BIS monitor
A
- used a lot in plastics
- useful for patients receiving propofol-ketamine anesthesia
- delay of 15-30 seconds from real time
- useful in combo with EMG
10
Q
electromyogram (EMG)
A
monitors electric activity of frontalis muscle between eyebrows
spikes suggestive of patient arousal
11
Q
goals of GA for plastics
A
- rapid induction
- adequate operative conditions
- hemodynamic stability
- fast recovery
- absence of side effects
- good control of pain and emesis
12
Q
three breast procedures
A
- breast augmentation
- breast reduction
- breast lift
13
Q
blood supply to breast
A
- internal mammary artery for the medial aspect
- lateral thoracic artery for lateral aspect
- venous drainage = superficial veins under dermis and deep veins that are parallel to arteries
- lymph drainage = retromammary lymph plexus in pectoral fascia
14
Q
nerve supply to breast
A
- PNS innervation of anterior and lateral cutaneous branches of 4th, 5th, and 6th intercostal nerves
- thoracic spinal nerve, T4, innervates nipple-areola complex
15
Q
breast augmentation
A
- healthy vs breast cancer
- general, cervicothoracic epidural, intercostal block, fascial plane block, tumescent injection with lidocaine
- regional = less PONV + pain and decreased cost
- cervicothoracic epidural (C7-T4) = better analgesia than general
- adjunct = fascial plane block, no sympathetic blockade and better hemodynamic stability
16
Q
breast augmentation epidural level
A
C7-T4
17
Q
incisions in breast augmentation
A
- infra-mammary
- peri-areolar
- trans-axillary
18
Q
implant placement in breast augmentation
A
- in pocket under mammary
- under pectoralis muscle
19
Q
type of implant
A
silicone (800 cc max)
saline
20
Q
post op pain in breast augmentation
A
-can extend to sternum, lateral thorax, middle back
21
Q
anesthetic considerations for breast augmentation
A
- 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
22
Q
complications of breast augmentation
A
- capsular contracture (common)
- hematoma
- infection
- wound dehiscence
23
Q
breast surgery
A
- excisional biopsy
- breast biopsy
- lumpectomy
24
Q
breast biopsy anesthetic considerations
A
- GA, regional, or local with sedation
- supine, arm abducted, table turned
- outpatient, minimal EBL
- 1-1.5 hours
25
lumpectomy anesthetic considerations
- wire guided (need to go to radiology before to insert wire under fluoro)
- GA, regional, Local with sedation
- supine
- avoid muscle relaxants
- <1.5 hours, outpatient
26
sentinel lymph node biopsy anesthetic considerations
- for small, invasive breast cancer
- axillary node dissection, NO RELAXATION
- sentinel lymph node is first node to drain the afferent lymphatics from the area of the lesion
- dye injected around breast (transient drop in pulse ox, allergic rxn)
- gamma probe used to ID tracer in lymph nodes
- wait for pathology (if positive nodes --> axillary dissection)
27
damage to long thoracic nerve
- motor
- radical mastectomies or with any removal of axillary lymph nodes
- WINGED SCAPULA (scapula alata) from paralysis of serratus anterior muscle
28
damage to thoracodorsal nerve
- motor
| - results in palsy of the latissimus dorsi muscle
29
damage to intercostobrachial nerve
- sensory
| - numbness or pain in lateral aspect of axilla and medial aspect of upper arm
30
intercostobrachial neuralgia
- aka post mastectomy pain syndrome
| - pain in axilla, medial upper arm, and anterior chest wall
31
lymphedema
- occurs when lymph vessels are not able to drain lymph fluid --> result is swelling
- most common with axillary dissection or axillary radiation
32
types of mastectomy
- modified or partial - usually chemo or radiation after
- total or simple - breast only
- radical - removal of breast, pectoral muscle and axillary lymph nodes
33
anesthetic considerations for mastectomy
- supine
- IV, NIBP, pulse ox on opposite arm
- EBL 150-500 mL
- usually admitted overnight
- 1.5 up to 7 hours if reconstruction
34
preoperative considerations for mastectomy
- respiratory/airway compromise possible if radiation
- chemo = potential for complications like cardiomyopathy
- metastasis
- anemia with chemo
35
intraoperative considerations for mastectomy
- GA (ETT/LMA) or regional
- avoid muscle relaxants during axillary dissection so can monitor nerves
- position changes
- pressure dressing during emergence
- high incidence of PONV
36
breast reconstruction
- immediate = use a temporary tissue expander and autologous myocutaneous flaps
- post op chest radiation is relative contraindication
- FLAPS
37
FLAPS in breast reconstruction
- deep inferior epigastric perforator
- superficial inferior epigastric artery
- transverse upper gracilis
- gluteal
- transverse rectus abdominis myocutaneous
38
DIEP flap
- deep inferior epigastric perforator flap
- abdominal skin, fat and deep inferior epigastric vessels removed and replanted to create new breasts
- internal mammary artery and vein transected suprasternal and anastomosed to epigastric vessels
- NO VASOPRESSORS (microvascular area)
- doppler to check vessels
- avoid hypertension/fluid overload
- indocyanin green may be used to check tissue perfusion
- ICU disposition, risk of graft failure, venous congestion, fat necrosis, bleeding
39
latissimus dorsi flap
- transfer of back tissues (latissmis muscle, fat, blood vessels and skin) to mastectomy site
- thoracodorsal artery supplies flap - left attached to its original supply
- following mastectomy, patient turned lateral or prone
- usually requires implant as well
- overnight stay
40
TRAM flap
- transverse rectus abdominis myocuteanous flap (pedicle free flap type)
- tummy tuck breast reconstruction
- skin, fat, and muscle tunneled from abdomen to chest
- avoid hypotension
- doppler to check perfusion
- flap based on superior epigastric vessels
41
anesthetic considerations for breast reconstruction
- vascular access (long procedure with blood loss so multiple PIVs)
- complications r/t chemo
- general anesthesia
- keep warm and hydrated
- ephedrine > phenyl for hypotension
- heparin intraop
- foley
- post op pain management (regional is nice)
- dextran for flaps (reduces clot formation in microvasc)
- NO Nitrous (can interfere with healing)
42
adriamycin
cardiomyopathy
43
breast reduction preop eval
- back pain
- skin irritation/infection
- skeletal deformities
- respiratory disorders
44
two techniques of breast reduction
- inferior pedicle with long curved horizontal incision across crease beneath breast
- inferior pedicle with vertical incision and short horizontal at crease (less scarring and shorter time)
- lipo may be added
45
breast reduction anesthetic considerations
- GA
- frequent position changes
- longer procedures (3-5+ hrs)
- fluid warmer, bair hugger, foley
- fluid/blood volume deficits
- PONV
- 23 hour stay
46
breast reduction complications
- wound dehisence
- infection
- seroma
- hematoma
- skin flap necrosis
- loss of sensation
- hypertrophic scarring
47
abdominal plastics surgeries
- liposuction
- abdominoplasty
- abdominal muscle repair
- 360 degree liposuction
- mommy makeover
- tummy tuck
48
liposuction
- second most common
- HIGHEST morbidity and mortality
- remove fat from unwanted areas
49
preop eval for lipo
assess for cardiomyopathy, pulmonary disease, pulmonary embolus, thrombophilia
50
dry technique of lipo
- aspiration cannula inserted into space where fat will be removed
- EBL 25-45% of aspirated volume
- not recommended, not done as much
51
wet technique of lipo
- 200-300 mL of solution injected into each area to be treated
- EBL 4-30% of volume aspirated
52
superwet technique of lipo
- infiltrated solution = amount of fat to be removed 1:1 ratio
- EBL 1% of volume aspirated
53
tumescent method of lipo
- large amount of solution (3-4 mL per mL of expected aspirate) injected into fatty tissue
- EBL 1% of volume aspirated
54
tumescent solution
- removal of SQ fat under anesthesia infiltrated with large volumes of saline solution with lido and epi
- definition excludes use of another type of anesthetic
- currently this one with another type of anesthesia
55
klein's solution
- 50mL 1% lido (500 mg)
- 1 mL 1:1000 epi
- 12.5 mL 8.4% NaH2CO3
- 1000 mL NS
56
hunstad solution
- 1000 mL LR
- 50 mL 1% lido
- 1 mL 1:1000 epi
57
lido max per FDA for tumescent solution
35 mg/kg of total body weight
58
total epi max for tumescent solution
50 mcg/kg
59
why bicarb in tumescent solution?
increases pH
helps reduce pain
favors faster entry into nerve cell where the lido acts
60
if tumescent solution is used, what must the anesthetist have?
- monitoring
- cardiac resuscitation
- ventilatory support
- recovery under anesthesia care
61
why LR vs NS?
no burning
| less sodium load
62
complications of lipo
- LAST
- hypothermia
- fat embolism/DVT/PE
- acute anemia
- pulmonary edema
- fluid overload
- electrolyte imbalance
- death
63
how much does 1:200,000 epi reduce absorption of SQ lido?
by 50%
64
total volume of fat removed in lipo not to exceed....
- <5 L
| - not to exceed 5% of body weight
65
high fat volumes removed in lipo associated with...
- hypovolemia
- bleeding
- electrolyte disturbances
66
IVF management with lipo
- <4 L = maintenance only
- >4 L = maintenance + 0.25 mL/mL removed after 4L
- goal = maintain normal intravascular volume with postanesthetic Hct > 30% and albumin > 3g
67
abdominoplasty
- surgery of abdominal wall
- resection of excess skin
- semi-fowler position (during emergence and extubation to prevent strain on suture line)
- can be combined with lipo
- can be combined with plication of rectus abdominis muscle
- common in patients who have had multiple pregnancies or those who have lost a lot of weight or after bariatric procedures
68
abdominoplasty anesthetic considerations
- 2-5 hrs
- post gastric bypass, ensure stable weight for at least 6 months
- labs = CBC, CMP, EKG, liver fxn
- O/N monitoring if comorbidities
- GA
- Fluid warmer, bair hugger, foley, PIV, abx
- need to flex table for closure (semi-fowlers) to prevent strain on suture line)
- emergence = smooth, anitemetics, binder, semi-fowlers
- PCA +/- epidural for postop pain mgmt
69
complications of abdominoplasty
- ileus
- infection
- dehisence
- fat embolus
- DVT
70
procedures in mommy makeover
- breast augmentation
- breast lift
- buttock augmentation
- lipo
- tummy tuck
- vaginal rejuvenation
71
autologous fat grafting
- transfer for fat from one or more areas to other areas in order to improve body contour
- natural filler
- unpredictable percentage of reabsorption
- most frequent areas = hips, buttocks, breast, face, and hands
72
3 phases of autologous fat graft
- harvest adipose tissue
- processing of lipoaspirate
- reinjection into receptor site
73
types of cosmetic facial surgery
- rhytidoplasty
- rhinoplasty
- blepharoplasty
- buccal fat removal
- lip lifts
- chin implants
- eyebrow lift
74
rhytidoplasty
- face lift
- local anesthesia (subcutaneous and nerve blocks) can be combined with conscious sedation
- pre-anesthetic medication for sedation, anxiolysis, preventative analgesia
- most common complication = hematoma
- no paralysis for facial nerve monitoring
- smooth emergence
75
brow lift and blepharoplasty
- brow lift = resuspection of brows; hair-line incision with flap
- blepharoplasty = lid lift; manipulation of periorbital fat can result in retrobulbar hematoma and blindness
- local anesthesia and IV sedation
- possible laser use
76
occulocardiac reflex
- Aschner phenomenon, Aschner reflex, or Aschner–Dagnini reflex
- a decrease in pulse rate associated with traction applied to extraocular muscles and/or compression of the eyeball
77
anesthetic considerations for brow, face and lid lifts
- supine, table turned away from AGM
- LA with epi
- abx
- steroids
- 1-2 hour procedure length
- outpatient
- occulocardiac reflex (decreased HR and BP)
- LA with sedation so patient can open and close eyes during procedure
78
rhinoplasty
- surgical manipulation of nasal form for aesthetic and or functional improvement
- find out diagnosis/indication for billing
- septorhinoplasty includes septum repair
- augmentation with silicon, gortex, synthetic material, cadaveric or autologous tissue (rib, cranium, iliac crest)
- surgery may be open, closed or both
- splint with nasal packing at end
- outpatient
79
rhinoplasty anesthetic considerations
- MAC with infraorbital/nasalcillary block
- GA (regular or oral rae ETT; OGT to remove blood in belly, nasal packing, smooth emergence)
- table turned away from AGM
80
burns surgical approaches
- tangential excision - slices of eschar shaved sequentially until healthy wound bed developed; large blood loss so need epi and tourniquet
- fascial excision - removes eschar and underlying tissues down to muscle fascia; more rapid and less blood loss than tangential; cosmetic deformities and functional loss may occur
81
anesthetic considerations for burns
- PRBCs in room
- warm everything
- room temp 82-100
- position
- caution with epi use
- abx/asepsis
- ICU
- pain management
82
rule of 9's
- used to estimate severity of burns
| - 18-40% mortality (correlates with area of burn)
