Plastic Surgery Flashcards
most frequent complications of plastic surgery
-DVT and PE
other common complications of plastic surgery
- postop pain
- nausea
- vomiting
most common plastic surgery procedure
breast augmentation
other common plastic surgery procedures
- liposuction
- nose reshaping
- eyelid surgery
- facelift
patient history
- 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
preop medications for plastics
- 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
melatonin preop
- 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
goals for emergence with plastics
- no increase in BP/HR
- no bucking
- no respiratory complications
BIS monitor
- 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
electromyogram (EMG)
monitors electric activity of frontalis muscle between eyebrows
spikes suggestive of patient arousal
goals of GA for plastics
- rapid induction
- adequate operative conditions
- hemodynamic stability
- fast recovery
- absence of side effects
- good control of pain and emesis
three breast procedures
- breast augmentation
- breast reduction
- breast lift
blood supply to breast
- 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
nerve supply to breast
- PNS innervation of anterior and lateral cutaneous branches of 4th, 5th, and 6th intercostal nerves
- thoracic spinal nerve, T4, innervates nipple-areola complex
breast augmentation
- 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
breast augmentation epidural level
C7-T4
incisions in breast augmentation
- infra-mammary
- peri-areolar
- trans-axillary
implant placement in breast augmentation
- in pocket under mammary
- under pectoralis muscle
type of implant
silicone (800 cc max)
saline
post op pain in breast augmentation
-can extend to sternum, lateral thorax, middle back
anesthetic considerations for breast augmentation
- 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
- capsular contracture (common)
- hematoma
- infection
- wound dehiscence
breast surgery
- excisional biopsy
- breast biopsy
- lumpectomy
breast biopsy anesthetic considerations
- GA, regional, or local with sedation
- supine, arm abducted, table turned
- outpatient, minimal EBL
- 1-1.5 hours
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
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)
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
damage to thoracodorsal nerve
- motor
- results in palsy of the latissimus dorsi muscle
damage to intercostobrachial nerve
- sensory
- numbness or pain in lateral aspect of axilla and medial aspect of upper arm
intercostobrachial neuralgia
- aka post mastectomy pain syndrome
- pain in axilla, medial upper arm, and anterior chest wall
lymphedema
- occurs when lymph vessels are not able to drain lymph fluid –> result is swelling
- most common with axillary dissection or axillary radiation
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
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
preoperative considerations for mastectomy
- respiratory/airway compromise possible if radiation
- chemo = potential for complications like cardiomyopathy
- metastasis
- anemia with chemo
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
breast reconstruction
- immediate = use a temporary tissue expander and autologous myocutaneous flaps
- post op chest radiation is relative contraindication
- FLAPS
FLAPS in breast reconstruction
- deep inferior epigastric perforator
- superficial inferior epigastric artery
- transverse upper gracilis
- gluteal
- transverse rectus abdominis myocutaneous
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
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
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
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)
adriamycin
cardiomyopathy
breast reduction preop eval
- back pain
- skin irritation/infection
- skeletal deformities
- respiratory disorders
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
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
breast reduction complications
- wound dehisence
- infection
- seroma
- hematoma
- skin flap necrosis
- loss of sensation
- hypertrophic scarring
abdominal plastics surgeries
- liposuction
- abdominoplasty
- abdominal muscle repair
- 360 degree liposuction
- mommy makeover
- tummy tuck
liposuction
- second most common
- HIGHEST morbidity and mortality
- remove fat from unwanted areas
preop eval for lipo
assess for cardiomyopathy, pulmonary disease, pulmonary embolus, thrombophilia
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
wet technique of lipo
- 200-300 mL of solution injected into each area to be treated
- EBL 4-30% of volume aspirated
superwet technique of lipo
- infiltrated solution = amount of fat to be removed 1:1 ratio
- EBL 1% of volume aspirated
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
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
klein’s solution
- 50mL 1% lido (500 mg)
- 1 mL 1:1000 epi
- 12.5 mL 8.4% NaH2CO3
- 1000 mL NS
hunstad solution
- 1000 mL LR
- 50 mL 1% lido
- 1 mL 1:1000 epi
lido max per FDA for tumescent solution
35 mg/kg of total body weight
total epi max for tumescent solution
50 mcg/kg
why bicarb in tumescent solution?
increases pH
helps reduce pain
favors faster entry into nerve cell where the lido acts
if tumescent solution is used, what must the anesthetist have?
- monitoring
- cardiac resuscitation
- ventilatory support
- recovery under anesthesia care
why LR vs NS?
no burning
less sodium load
complications of lipo
- LAST
- hypothermia
- fat embolism/DVT/PE
- acute anemia
- pulmonary edema
- fluid overload
- electrolyte imbalance
- death
how much does 1:200,000 epi reduce absorption of SQ lido?
by 50%
total volume of fat removed in lipo not to exceed….
- <5 L
- not to exceed 5% of body weight
high fat volumes removed in lipo associated with…
- hypovolemia
- bleeding
- electrolyte disturbances
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
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
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
complications of abdominoplasty
- ileus
- infection
- dehisence
- fat embolus
- DVT
procedures in mommy makeover
- breast augmentation
- breast lift
- buttock augmentation
- lipo
- tummy tuck
- vaginal rejuvenation
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
3 phases of autologous fat graft
- harvest adipose tissue
- processing of lipoaspirate
- reinjection into receptor site
types of cosmetic facial surgery
- rhytidoplasty
- rhinoplasty
- blepharoplasty
- buccal fat removal
- lip lifts
- chin implants
- eyebrow lift
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
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
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
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
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
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
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
anesthetic considerations for burns
- PRBCs in room
- warm everything
- room temp 82-100
- position
- caution with epi use
- abx/asepsis
- ICU
- pain management
rule of 9’s
- used to estimate severity of burns
- 18-40% mortality (correlates with area of burn)
