Plastics Flashcards
Most common plastic surgery complications are _____ & _____
DVT & PE
Other common plastic surgery complications include:
Postop pain, nausea, & vomiting
Plastic Surgery
Anesthetic Considerations
1° patient safety
DVT/PE prophylaxis
Liposuction guidelines on Lidocaine/Epi doses
Adequate hydration
Most common plastic surgery procedure
Breast augmentation
Followed by liposuction, rhinoplasty, blepharoplasty, rhytidectomy (face lift)
Preanesthesia Evaluation
CBC, BMP, coags, HFP, HIV, Hep B/C, HCG
Assess current medications - NSAIDs, vitamin E, contraceptives, weight loss, illegal drug use, prescriptions
Thyroid hormones, antidepressants, vitamins/minerals, herbals
Potential anticoagulant, antiplatelet, procoagulant effects, & effect on anesthetics
What supplements have anticoagulant effects?
Alfalfa Dong quai Anise Saffron Bromelain Castanea sativa Ginseng Arnica Kelp Horseradish Red clover Asiatic ginseng
What supplements have antiplatelet effects?
Fish oil Garlic Dong quai Celery Onion Clove Chili pepper Gingko biloba Black cohosh Licorice root Turmeric Vitamin E Asiatic ginseng
Alternative preop medication to reduce anxiety
Melatonin 3-10mg ↓postop pain ↓opioid consumption Improve postop sleep quality ↓postop/emergence delirium ↓oxidative stress & anesthetic requirements
Regional Anesthesia
Advantages
Fewer complications
Safer recovery
Improved postop analgesia
BIS
Delay 15-30 seconds
General Anesthesia
Risks include difficult or failed intubation, kinked/occluded ETT, dental damage, anesthesia gas machine errors, malignant hyperthermia
LMA frequently utilized
Room air general d/t airway fire risk
Breast Blood Supply
Medial aspect = internal mammary artery
Lateral aspect = lateral thoracic artery
Venous drainage = superficial veins under dermis & deep veins parallel the arteries
Lymph drainage = retromammary lymph plexus in the pectoral fascia
Breast Nerve Supply
Peripheral nervous system anterior & lateral cutaneous branches innervation 4th, 5th, & 6th intercostal nerves
Thoracic spinal nerve T4 innervates nipple-areola complex
Breast Augmentation
Anesthetic Considerations
Healthy vs. breast cancer
General or regional
Cervicothoracic epidural or intercostal/fascial plane block
Position changes - secure head & arms to bed, eye protection, PIV extension tubing
Bra/binder place at end
Cervicothoracic Epidural
C7-T4
Analgesia > general
Fascial Plane Blocks
Adjunct block
No sympathetic blockade
Hemodynamic stability
Breast Augmentation Incisions
- Infra-mammary
- Peri-areolar
- Trans-axillary
Implants
Silicone or saline
Place in pocket under mammary gland or pectoralis muscle
Breast Augmentation
Complications
Capsular contracture
Hematoma
Infection
Wound dehiscence
Breast Surgery Lumpectomy
Wire-guided (radiology wire inserted under fluoroscopy)
Avoid muscle relaxants
< 1.5hrs
Outpatient procedure
Sentinel Lymph Node Biopsy
Small, invasive breast cancer Axillary node dissection - NO relaxation Sentinel lymph node = 1st node to drain afferent lymphatics from lesion area Dye injected around breast Transient ↓SpO2 Pathology + nodes → axillary dissection
Long Thoracic Nerve Damage
Motor
Winged scapula (scapula alata) d/t serratus anterior muscle paralysis
Complication from radical mastectomy or w/ axillary lymph node removal
Thoracodorsal Nerve Damage
Motor
Results in latissimus dorsi muscle palsy
Intercostobrachial Nerve Damage
Sensory
Numbness or pain in axilla lateral aspect & medial aspect upper arm
Intercostobrachial Neuralgia
Post-mastectomy pain syndrome
Numbness
Axilla, medial upper arm,& anterior chest wall pain
Lymphedema
Most common w/ axillary dissection & radiation
Mastectomy
Modified or partial - postop radiation/chemo
Total or simple - removes breast only
Radial - removes breast, pectoral muscle, & axillary lymph nodes
Mastectomy
Anesthetic Considerations
Supine Pox, PIV, & NIBP on opposite arm or LE EBL 150-500mL Admit overnight 1.5hrs Reconstruction up to 7hrs
Avoid what medications during axillary dissection?
Muscle relaxants
Chemotherapy Complications
Cardiomyopathy Anemia Pulmonary fibrosis Interstitial infiltrates Pleural effusion Myelosuppression
Radiation Complications
Respiratory or airway compromise possible
Breast Reconstruction
Immediate - temporary tissue expander or autologous myocutaneous flaps
Flaps = DIEP/SIEA/TUG/TRAM
Breast reconstruction relative contraindication:
Postop chest radiation
DIEP Flap
Deep inferior epigastric perforator flap
Abdominal skin, fat, & deep inferior epigastric vessels are removed & replanted to create new breasts
Internal mammary artery & vein are transected suprasternal & anastomosed to epigastric vessels
NO VASOPRESSORS
Avoid HTN or fluid overload
Indocyanine green to check tissue perfusion
ICU dispo, graft failure risk, venous congestion, fat necrosis, bleeding
Latissimus Dorsi Flap
Transfer back tissues (latissimus muscle, fat, blood vessels, & skin) to the mastectomy site
Thoracodorsal artery supplies the flap - left attached to its original supply
Turn patient lateral or prone
Overnight hospital admission
AVOID PHENYLEPHRINE
TRAM Flap
Transverse rectus abdominis myocutaneous - pedicle or free flap
Tummy tuck breast reconstruction
Skin, fat, & muscle tunneled from abdomen to chest
Avoid hypotension
Doppler to check perfusion
Flap based on superior epigastric vessels
AVOID PHENYLEPHRINE
Breast Reconstruction
Anesthetic Considerations
Vascular access MAP 85-100 Ephedrine > Phenylephrine Avoid direct vasoconstriction Heparin intraop Foley catheter Regional block postop pain management NO nitrous oxide (interferes w/ healing)
Dextran
Flap procedures
Reduces clot formation in microvasculature
25-30mL/hr (low molecular weight)
Monitor allergic reactions ARDS
Breast Reduction
Reduction mammoplasty
Inferior pedicle w/ long curved horizontal incision across crease beneath breast
Inferior pedicle w/ vertical incision & short horizontal at crease (less scaring & shorter time)
+/- liposuction
Breast Reduction
Anesthetic Considerations
General Frequent position changes 3-5hrs + Fluid warmer Bair hugger Foley catheter Fluid/blood volume deficits PONV 24hr stay
Breast Reduction
Complications
Wound dehiscence Infection Seroma Hematoma Skin flap necrosis Loss sensation Hypertrophic scarring
Abdominal Surgeries
Liposuction 360° liposuction Abdominoplasty Tummy tuck Abdominal muscle repair Mommy makeover
Liposuction
2nd most common plastic surgery procedure
Removes fat from unwanted areas
Potential fat redistribution
Abdomen, hips, waist, torso, neck, extremities, pectoral region
Preop assess for cardiomyopathy, pulmonary disease, pulmonary embolus, thrombophilia
Relatively low risk procedure
Do not exceed 5% body weight (total volume < 5L)
Hypervolemia → hypovolemia, bleeding, electrolyte disturbances
What plastic surgery procedure has the highest morbidity & mortality?
Liposuction
Liposuction
Dry Technique
Not recommended
Aspiration cannula inserted into space where fat will be removed
EBL 20-45% volume aspirated
Liposuction
Wet Technique
200-300mL solution injected into each area to be treated
EBL 1% volume aspirated
Liposuction
Super-Wet Technique
Infiltrated solution = amount fat to be removed 1:1 ratio
EBL 1% volume aspirated
Liposuction
Tumescent Method
3-4mL solution per mL expected aspirate injected into fatty tissue
EBL 1% volume aspirated
Tumescent Solution
Removal SQ fat under anesthesia infiltrated w/ saline solution w/ Epi & Lidocaine
Used w/ general, spinal, or epidural
Requires monitoring, cardiac resuscitation, ventilatory support, recovery under anesthesia care
Klein’s Solution
1% Lidocaine 50mL
1:1,000 Epi 1mL
8.4% NaH2CO2 12.5mL
1,000mL NS
Hunstad Solution
1,000mL LR (no burning sensation d/t reduced Na+ load)
1% Lidocaine 50mL
1:1,000 Epi 1mL
NO bicarbonate
Lidocaine Maximum Dose
FDA 35mg/kg (total body weight) Dermatology or plastic surgery 55mg/kg Anesthesiology 5mg/kg Lidocaine w/ Epi 500mg Epi 1:200,000 ↓SQ lidocaine absorption 50%
Total Adrenaline Maximum
50mcg/kg
Bicarbonate
↑pH
Helps to reduce pain
Facilitates faster entry into nerve cell where lidocaine acts therefore quicker onset
Liposuction
Complications
LAST Hypothermia Fat embolism DVT/PE Acute anemia Pulmonary edema Fluid overload Hemorrhage Electrolyte imbalances Nerve damage Epi toxicity Death
Liposuction
IVF Management
< 4L = maintenance only
> 4L = MIVF + 0.25mL per mL removed after 4L
Goal to maintain normal intravascular volume w/ post-anesthetic Hct > 30% & albumin > 3g
Liposuction
Anesthetic Considerations
General anesthesia SCDs DVT/PE prophylaxis Foley, Bair hugger, fluid warmer Close incision sites w/ sterile dressings Compression garment (binder) Postop pain r/t amount fat removed Tissue trauma d/t suctioning
360° Liposuction
Entire truncal midsection
Goal to complete curvier contour from every angle
Combination w/ dermolipectomy, rectus abdominis muscle plication, umbilicoplasty, or gluteal fat grafting
Abdominoplasty
Abdominal wall surgery
Umbilicus circumcised & blood supply preserved
Resect excess skin (pubis to costal margin)
Semi Fowler position on emergence & extubation
Combined w/ liposuction → lipoabdominoplasty
Abdominoplasty
Anesthetic Considerations
2-5hr
Post gastric bypass ensure patients have stable weight 6mos prior to surgery
CBC, BMP, EKG, HFP
General anesthesia
Fluid warmer, Bair hugger, Foley, PIV, antibiotics
Prevent tension on suture lines (flexed table during surgical closure)
Postop PCA
Abdominoplasty
Complications
Ileus Infection Dehiscence Fat embolism DVT
Mommy Makeover
Goal to restore shape & appearance after childbearing
Typically performed as single-stage procedure
Breast augmentation or lift, buttock augmentation, liposuction, tummy tuck, vaginal rejuvenation
Prevent DVT/PE, infections, postop pain
Abdominal contour surgeries consider spinal block up to T4
Autologous Fat Grafting
Transfer fat from one or more areas to other areas in order to improve body contour
Natural filler
Available & easy to obtain
Unpredictable % reabsorption
Most frequent areas = hips, buttocks, breast, face, & hands
Spinal > general anesthesia
Autologous Fat Grafting
Phases
- Harvesting adipose tissue
- Processing lipoaspirate
- Reinjection into receptor site
Cosmetic Facial Surgeries
Rhytidoplasty Eyebrow lift Rhinoplasty Blepharoplasty Buccal fat removal Lip lifts Chin implants
Rhytidoplasty
Face lift
Local anesthesia (subcutaneous & nerve blocks) + conscious sedation
Pre-medication (Melatonin, Lorazepam, Clonidine, Morphine, Fentanyl)
PONV prophylaxis
NO paralysis
Smooth emergence
Most common complication associated w/ rhytidoplasty:
Hematoma
Eyebrow Lift
Brow resuspension
Hair-line incision w/ flap
Possible laser use
Blepharoplasty
Lid lift
Periorbital fat manipulation
Possible laser use
Blepharoplasty Complications
Retrobulbar hematoma & blindness
Occulocardiac reflex → bradycardia & hypotension
Facial Surgery
Anesthetic Considerations
Brow, face, & lid lifts
Supine w/ HOB rotated away LA w/ Epi Antibiotics Steroids 1-2hr procedures Outpatient Occulocardiac reflex → bradycardia & hypotension LA w/ sedation - patient able to open & close eyes during procedure
Rhytidoplasty
Corneal protection
Nasal oxygen
Maintenance w/ Ketamine, Midazolam, Propofol, Dexmedetomidine, & opioids
Avoid general anesthesia (reserve for complex patients unable to tolerate/cooperate w/ conscious sedation)
Muscle relaxation not needed
Avoid coughing on extubation d/t bleeding at surgical site
Rhinoplasty
Nose surgical manipulation - aesthetic and/or functional improvement
Find out diagnosis/indication (billing)
Septorhinoplasty includes septum repair
Augmentation w/ silicon, gortex, synthetic material, cadaveric or autologous tissue (rib, cranium, iliac crest)
Open and/or closed surgery
Splint w/ nasal packing
Outpatient procedure
Rhinoplasty
Anesthetic Considerations
MAC w/ infraorbital/nasocillary block
- Vasocontrictor-soaked packed placed prior to induction
- Safer to use general when ↑blood pooling
General anesthesia
- Regular ETT or oral RAE
- OG tube to remove blood in stomach
- HOB elevated
- Nasal packing (educate patient to breath through mouth)
- Smooth emergence
- PONV prophylaxis
Rotate HOB away from anesthesia gas machine (consider positioning & vascular access)
COMPLICATIONS & DEATH
Bronchospasm
Deep sedation
Illicit drug use
Thromboembolism
How to prevent poor outcomes?
Appropriate pre-anesthetic evaluation
Informed consent
Appropriate monitoring
Appropriate anesthesia & postanesthetic care
DVT/PE Prophylaxis
Compression stockings
Intermittent pneumatic compression tools SCDs
Venous foot pumps
Low molecular weight heparin
What contributes to anesthesia complications?
Longer anesthesia times
↑complication risk
Bleedings, atelectasis, DVT/PE, immune response
PONV Complications
Most common & unfavorable complication after surgery
↑bleeding, delayed discharge, $$$
PONV Treatment
Dexamethasone & Ondansetron useful & low cost 10mg Propofol (1-2cc)
Burns
Wound coverage w/ autograft or synthetic/biological dressing
Early & frequent eschar removal
Debridement every 2-3 days
Tangential Excision
Eschar slices are shaved sequentially until healthy wound bed developed
Epi & tourniquet per surgeon to prevent & ↓blood loss
Facial Excision
Removes eschar & underlying tissues down to the muscle fascia
More rapid & less blood loss than tangential excision
Cosmetic deformities & functional loss may occur
Burn
Anesthetic Considerations
Surgery scheduled once patient fluid resuscitated
Performed every 2-3 days
Endpoint = OR time > 3hrs, core temp < 35°C, blood loss > 10 units PRBCs
Type & screen w/ PRBCs present in room & on hold
Room temp 82-100°F
Caution w/ Epi
Antibiotics & antisepsis
ICU
Pain management
Rule of 9s
Estimate burn severity
18-40% mortality correlates w/ burn area
Head 9% Anterior chest 18% Posterior chest 18% Arms 9% each Legs 18% each Perineal 1%
Burns Preop
Assess respiratory involvement (upper or lower airway)
Inhalational smoke/burns → airway edema
Cardiac hypermetabolism
nAChR up-regulation ↓sensitivity to NDMR ↑K+ w/ Succinylcholine
Hct/Hgb & coags
PIV vs. central line
Burns Intraop
OPIOIDS/NARCOTICS
GETA (no LMA d/t airway edema)
Potentially suture ETT when facial burns present
Induction w/ Ketamine or Etomidate
> 30% total body surface area burns ↑NDMR dose
Burns Maintenance
Respiratory compromise + hypermetabolic state → ↑minute ventilation, inspiratory pressures, PEEP
Warm room & IV fluids
Prepare for blood loss
- Large bore PIVs x2, cordis, and/or CVC
- Blood loss 200mL per 1% body surface area excised & grafted
Burns Emergence
Narcotic use & fluid resuscitation - remain intubated
Transport w/ monitor, emergency meds/airway, PEEP
Monitor labs
