Week 8 - Anesthesia for Elective Plastic Surgery Flashcards
What are the advantages and disadvantages of an open approach Rhinoplasty?
Advantages:
- allows full exposure
- precise diagnosis and correction of deformities
- direct control of bleeding
Disadvantages:
- external incision
- prolonged operative time
- delayed wound healing
What are the advantages and disadvantages of a closed approach Rhinoplasty?
Advantages:
- limits dissection to areas needing modification (shorter operative time/rapid recovery)
- no external scar
Disadvantages:
- experience
- no direct visualization
- greater reliance on accurate preop diagnosis
What are anesthetic considerations for a Rhinoplasty?
- GETA (some utilize local anesthesia with IV sedation)
- Surgical Time = 1-2.5 hrs
- EBL = 50-100mL
- Nose often packed after surgery (unable to place nasal cannula)
- Blood in stomach – antiemetic prophylaxis, consider OG tube
What is a Blepharoplasty? What are the indications?
Improves appearance of upper/lower eyelids
Indications:
- loose or sagging skin (may impair vision)
- bags under eyes
- excess fatty deposits or puffiness
- droopiness of the lower lids
What are the anesthetic considerations of a Blepharoplasty?
- General Anesthetic without intubation
- Surgical Time = 30-90 min
- EBL = negligible
- Monitor for oculocardiac reflex
- Surgeon may want patient to wake up to open their eyes to assess
What are the indications and limitations of a traditional face lift (Rhytidectomy)?
Useful for generalized skin laxity
Limitations:
-not a treatment for minor wrinkles, sun damage, most creases or irregular pigmentation
What is endoscopic face life? What are the benefits?
Fiberoptic lens placed through several small incisions in mouth and temple (Less Invasive)
- useful for limited corrections
- generally midface and cheek areas
Benefits:
-No visible incisions, minimal scarring, less bleeding, no hair loss, minimal numbness, much quicker recovery
What are the anesthetic considerations of a face lift?
- GETA - reinforced ETT (some utilization of IV sedation and local anesthesia)
- Surgical Time = 4-6 hours
- EBL = 100-250 mL
- Blood pressure maintained at 100 systolic (to avoid excessive bleeding)
- Planned hypertension at end of procedure (assess for bleeding)
What age are silicone breast implants approved for by the FDA?
22 years or older
What are the benefits of silicone breast implants?
More natural appearance
Softer than saline
Less rippling
What age are saline breast implants approved for by the FDA?
18 years of older
What are benefits of saline breast implants?
Very low spontaneous deflation rate
Fixed volume vs adjustable volume
What are the different incisional sites for breast implant procedures?
Inframammary
Periareolar
Axillary
Transumbilical (higher complication rate)
What does the method for inserting and positioning implants depend on?
- Type of implant
- Degree of enlargement desired
- Body type of patient
- Surgeon’s recommendations
What are the benefits and disadvantages of placing breast implants over the muscle?
Benefits:
- Many women prefer rounded, less natural look
- Ease of surgery
- Reduced post op pain
- Allows for insertion of oversized implants
Disadvantages:
- Interference with mammograms
- Visible rippling of skin
- Higher rates of capsule contracture
What are benefits and disadvantages of placing breast implants under the muscle?
Benefits:
- Natural breast shape
- No rippling
- Very low mammography interference
- Good internal support
- Minimal scarring
Disadvantages:
- Technically difficult surgery
- Post op discomfort
What are anesthetic implications for breast implant surgery?
- GETA
- Surgical Time = 1-2 hours
- EBL = negligible
-Patient often is sat up during surgery (make sure pt positioning is proper and secure)
What are anesthetic implications of breast reduction surgery?
- GETA
- Surgical Time = 3-5 hours
- EBL = 100-250 mL
-Postop pain management
What are the indications of an Abdominoplasty?
Indicated for patients with laxity of skin in the lower trunk
Generally related to massive weight loss
Goals: flat abdominal contour, eliminate abdominal wall laxity and enhance waist definition
What are complications of Abdominoplasty?
- Wound healing
- Infection
- Hematoma/Bleeding
- Tissue necrosis
- Abdominal binder limits mobility (DVT/PE)
- Large scar and contour asymmetry
What are the anesthetic implications for an Abdominoplasty?
GETA
Surgical Time = 2-4 hours
EBL = 100mL not including blood contained in the specimen removed
What are the characteristics of Dry Liposuction?
Requires general anesthesia
Limited by blood loss
Aspirate contains 25-40% blood
*generally healthy patients with limited comorbidities
What are the characteristics of Wet Liposuction?
Injection of 200-300 mL fluid
Blood loss reduced to 4-30% of aspirate
What are the characteristics of Superwet Liposuction?
1 mL of fluid infiltrated for each mL of fat removed
Infiltrate contains epinephrine +/- lidocaine
Blood loss is reduced to 1% of aspirate
What are the characteristics of Tumescence Liposuction?
- Infiltration of 3-4mL of fluid for each mL of aspirate
- Contains local anesthetic 0.05 - 0.1% lidocaine mixed with epinephrine
- No other anesthetic necessary (done without general anesthetic)
- Evolved into an office based procedure (50% performed by non-surgeons)
*Max dose = 50 mg/kg
accepted infiltrate concentration is 35-50mg/kg
What are the characteristics of Ultrasound Assisted Liposuction?
Ultrasound heats and liquefies fat
- reduces surgeon effort
- can cause thermal injury
- cannot be used with dry technique
What is considered Large Volume Liposuction?
Greater than 5L
- fluid resuscitation is necessary
- should be done in acute care setting (NOT the office)
- 23 hour monitoring
Often split into serial procedures to reduce risk
What are complications of liposuction?
- Lidocaine toxicity (beware of tissue vascularity, peak time = 12 hours)
- Fluid imbalances (large amount of infiltrate (50-70% left behind)
- Pulmonary Embolism (#1 cause of death)
- Fat embolus (small fat droplets become loosened and embolized to the lungs)
- Hypothermia (infiltrate is at room temp or refrigerated)
What is the fluid replacement recommendations for liposuction?
Small Volume (<5L)
- maintenance fluid = replaces deficit
- infiltrate
Large Volume (>5L)
- maintenance fluid = replaces deficit
- infiltrate
- 0.25 mL of crystalloid for each mL of aspirate over 5 liters
What is the only absolute contraindication for liposuction?
Hepatic disease
*many relative contraindications
What are anesthetic considerations for liposuction?
General anesthesia vs MAC
Minimal postop pain
Tight binders – impede mobility, compromise respiratory function
What are the types of flap reconstruction?
- Pedicled + Tram Flap: Traverse Rectus Myocutaneous Flap
- Free Flap
- DIEP Flap: Deep inferior epigastric artery perforator flap
- SIEA Flap: Superficial epigastric artery flap
- Difference is related to blood vessels that supply the flaps
- There are also reconstructions with thigh and buttocks flaps
*Long cases, waves of stimulation, go light on fluid to prevent issues with anastomosis
