Plastics part 2 Flashcards
Describe the possible abdominal surgeries.
liposuction abdominoplasty abdominal muscle repair 360 degree liposuction "mommy makeover" tummy tuck
______ has the highest morbidity & mortality
Liposuction****
Liposuction involves
removing fat from unwanted areas
abdomen, hips, waist, torso, neck, extremities, pectoral region
With liposuction, the preop evaluation should assess for
cardiomyopathy, pulmonary disease, pulmonary embolus, thrombophilia
Describe the possible techniques for liposuction.
dry technique
wet technique
super wet technique
tumescent method
Describe the dry technique for liposuction.
aspiration cannula inserted into space where fat will be removed
EBL 20-45% of aspirated volume
not recommended
Describe the wet technique for liposuction.
200-300 mL of solution injected into each area to be treated
EBL 4-30% of volume aspirated
Describe the super wet technique.
Infiltrated solution= amount of fat to be removed (1:1 ratio)
EBL 1% of volume aspirated
Describe the tumescent method.
large amount of solution (3-4 mL per mL of expected aspirate) injected into fatty tissue
EBL 1% of aspirated volume
The Tumescent solution is the
removal of SQ fat under anesthesia** infiltrated with large volumes of saline solution with epinephrine & lidocaine
-definition excludes the use of another type of anesthesia
Describe the composition of Klein’s solution:
50 mL of 1% lidocaine + 1 mL 1:1000 epinephrine + 12.5 mL 8.4% NaH2Co2+ 1000 NS****
The lidocaine max according to the FDA is
35 mg/kg of total body weight
total adrenaline max 50 mcg/kg
The Hunstead solution is
another form of tumescent solution
1000 LR + 50 mL of 1% lidocaine + 1 mL 1:1000 epinephrine
no burning sensation with LR (sodium load is also reduced)
The bicarb within Tumescent solution works to
increase the pH, quicken the onset, and help reduce pain
The complications of liposuction include
LAST hypothermia fat embolism/DVT/PE acute anemia pulmonary edema fluid overload electrolyte imbalances death
Describe the lidocaine max dosing.
dermatology/plastic surgery says 55 mg/kg of weight
anesthesiology says 5 mg/kg of weight
lido w/ epi max dose is 500 mg
Epinephrine 1:200,000 reduces absorption of SQ lidocaine by 50%
With liposuction, the total volume of fat removal
should be <5 L in single session or not to exceed 5% of body weight
When removing higher volumes with liposuction, it can lead to
hypovolemia, bleeding, & electrolyte disturbances
Describe the IVF management for liposuction.
for < 4 L= maintenance only
for >4 L= maintenance + 0.25 mL/mL removed after 4L
Goal: maintain normal intravascular volume with postanesthetic Hct >30% and albumin >3 g
The anesthetic considerations for liposuction include
GA+ SCDs
if large volume lipo, need foley, bair hugger, fluid warmer
incision sites are closed with sterile dressings
compression garment
pain related to amount of fat removed
tissue trauma from suctioning
Complications of liposuction include
PE, fat embolus, fluid overload, LAST, epinephrine toxicity, hemorrhage, nerve damage
Describe the fluid status with liposuction.
60% of solution infused remains in tissues
third spacing into surgical cavities
over/under estimation of fluid shifts can lead to pulmonary edema or hypovolemic shock**
360 degree liposuction is
liposuction of the entire truncal midsection
Goal is to complete curvier contour from every angle
can be combined with dermolipectomy, plication of the rectus abdominis muscle, umbilicoplasty, or gluteal fat grafting
Abdominoplasty is the
surgery of the abdominal wall- umbilicus circumcised and blood supply preserved
resection of skin excess (pubis to costal margin)
can be combined with liposuction or plication of the rectus abdominis muscle
Abdominoplasty positioning is the
semi-fowler position
Abdominoplasty is common in patients who have had
multiple pregnancies, or those who lost a lot of weight or after bariatric procedures
Anesthetic considerations for abdominoplasty include
2-5 hour procedure length
post gastric bypass, ensure patients have stable weight for six months prior to surgery with stable health status
labs: CBC, CMP, EKG, liver function
GA
overnight monitoring if comorbidities & extent of surgery
fluid warmer, bair hugger, foley, PIV, abx
Describe emergence & postop considerations for abdominoplasty.
NEED TO FLEX TABLE FOR CLOSURE*** to reduce tension on suture lines
emergence: smooth emergence, antiemetics, binder placement, semi-fowler
PCA +/- epidural for postoperative pain management
Complications of abdominoplasty include:
ileus, infection, dehiscence, fat embolus, DVT
The goal of the mommy makeover is to
restore shape and appearance after childbearing
It is important to prevent______ with mommy makeovers
DVT, PE, infections, postoperative pain
Possible procedures included in a mommy makeover include
breast augmentation, breast lift, buttock augmentation, liposuction, tummy tack, vaginal rejuvenation
typically performed as a single-stage procedure
Abdominal contour surgeries require a spinal block up to
T4
need to prolong anesthetic time up to 5 hours or longer
Autologous fat grafting is the
transfer of fat from one or more areas to other areas in order to improve body contour
natural filler so available and easy to obtain
unpredictable percentage of reabsorption
The most frequent areas of autologous fat grafting include
hips, buttocks, breast, face, and hands
With autologous fat grafting, _____ has benefits over ______
spinal anesthesia over general anesthesia
The 3 phases of autologous fat grafting include
harvesting adipose tissue, processing of lipoaspirate, reinjection into receptor site
Cosmetic facial surgery include
rhytidoplasty rhinoplasty blepharoplasty buccal fat removal lip lifts chin implants eyebrow lift
Rhytidoplasty is a
face lift
local anesthesia (subcutaneous & nerve blocks) can be combined with conscious sedation
requires smooth emergence
The most common complication of rhytidoplasty is
hematoma
The biggest consideration with rhytidoplasty is
NO paralysis**** for facial nerve monitoring
Describe a browlift
resuspension of brows- hair line incision with flap
Describe a blepharoplasty
lid lift
-manipulation of periorbital fat can result in retrobulbar hematoma & blindness
Occulocardiac reflex—> decreased HR & BP***
Brow lifts & blepharoplasty involve
local anesthesia & IV sedation
possible laser use
Anesthetic considerations for brow, face, & lid lifts include.
supine, table turned away from AGM LA with epinephrine ABx steroids (?) 1-2 hour procedure length outpatient occulocardiac reflex--> decreased HR & BP LA with sedation so patient can open & close eyes during procedure
Maintenance of rhytidoplasty includes
ketamine+ midazolam, ketamine+ propofol, dexmedetomidine + opioid
Anesthetic considerations for rhytidoplasty includes:
nasal oxygen to maintain normal O2 saturation
corneal protection
GA should be avoided & reserved for complex patients who cannot tolerate/cooperate with conscious sedation
- no need for muscle relaxation
-avoid coughing on extubation due to bleeding at surgical site
A rhinoplasty is the
surgical manipulation of the nasal form for aesthetic and/or functional improvement
-important to find out diagnosis/indication for billing
Septorhinoplasty includes
septum rpair
A rhinoplasty can be performed
open, closed or both
outpatient procedure
Rhinoplasty augmentation is with
silicon, gortex, synthetic material, cadaveric, or autologous tissue (rib, cranium, iliac crest)
Describe MAC considerations with rhinoplasty
MAC with infraorbital/nasocillary block
- vasoconstrictor-soaked packs placed prior to incision
- if increased amount of blood pooling, safer to use GA
Describe general anesthesia considerations with rhinoplasty.
regular ETT 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
-table turned away from AGM (positioning, access, etc.)
Describe postoperative pain control for plastics cases
multiple neural ending injuries in liposuction, tummy tuck, & breast implants
start analgesia in pre-anesthetic phase with preemptive strategies
NSAIDs + opioids most commonly used
some agents used include: celecoxib, tramadol, ketorolac, acetaminophen, pregabalin, gabapentin, ketamine, esmolol on induction
Describe discharge for plastic cases
outpatient or short-stay procedures
admission to hospital/unit most frequently due to uncontrolled pain, nausea, vomiting or urinary retention
Each ASC/hospital has its own discharge criteria
Deaths with plastic cases are related to
bronchospasm, deep sedation, illicit drug use, and thromboembolism
-office based deaths occur, many of which are related to plastic surgery and general anesthesia
_______ are the most common errors or incidents that cause severe neurological damage or death
cardiopulmonary events
Preventing poor outcomes involves appropriate
pre-anesthetic evaluation, informed consent, appropriate monitoring, appropriate anesthesia, and postanesthetic care
______ are the most common complications related to plastic surgery
DVT & PE
Ensuring appropriate DVT & PE prophylaxis includes
compression stockings, intermittent pneumatic compression tools, venous foot pumps, low molecular weight hepair
Longer anesthesia time leads to increased risk of complications including
bleeding, atelectasis, DVT, PE, & immune response
The most common and most unfavorable complication after plastic surgery is
PONV
PONV leads to increased
bleeding, delayed discharge and increased cost of care
- dexamethasone + ondansetron useful and low cost
- 10 mg propofol at end of case has antiemetic effect
Non-aesthetic conditions treated by plastic surgery include:
congenital abnormalities oculoplastic conditions hand surgery malignancy burns facial palsy wound management vascular malformations
The surgical approach for burns includes
tangential excision
-facial excision
Burns utilize wound coverage with
autograft or synthetic/biological dressing
require early & frequent eschar removal
Describe the tangential excision approach for burns
slices of eschar are shave sequentially until healthy wound bed is developed
large blood loss- epinephrine & tourniquet
Facial excision involves
removal of eschar and underlying tissues down to muscle fascia
more rapid and less blood loss than tangential excision
cosmetic deformities and functional loss may occur
Anesthesia for burns is scheduled once
patient is fluid resuscitated
- performed every 2-3 days
- endpoint: operative time> 3 hours, core temp <35 C, blood loss >10 unit PRBC
Anesthetic considerations for burns include:
PRBCs in room warm everything*** (room temp 82-100 deg F) position caution with epinephrine use antibiotics/antisepsis ICU Pain management***
The rule of 9’s is used to
estimate severity of burn
18-40% mortality (correlates with area of burn)
Preoperative anesthetic considerations for burns include:
respiratory exam (upper or lower airway involvement)*
cardiac-hypermetabolism
MSK- increased acetylcholine receptor density- decreased sensitivity to NDMR*, potentially fatal elevation of K+ with succinylcholine
-coagulopathies- H&H, coags
Access- PIV vs. central line
Intraoperative anesthetic considerations for burns include:
high-dose narcotics
- GETA (no LMA due to airway edema)- may need to suture
- induction with ketamine/etomidate
- > 30% TBSA burn need to increase intubating dose of NDMR
Describe maintenance anesthetic considerations for burns
respiratory compromise + hypermetabolic state–> increased minute ventilation, high inspiratory pressures, PEEP
- warm fluid, room, patient
- prepare for large, fast blood loss
- large bore IV x2, cordis, CVC
- blood loss- 200 mL/1% BSA excised and grafted
Describe the emergence anesthetic considerations for burns.
narcotic use and fluid resuscitation- may need to remain intubated
transport with monitor, emergency meds/airway, PEEP
monitor labs
