© Springer Science+Business Media New York 2015
Paul K. Sikka, Shawn T. Beaman and James A. Street (eds.)Basic Clinical Anesthesia10.1007/978-1-4939-1737-2_5454. Cosmetic Surgery
(1)
Department of Anesthesiology, University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA 15213, USA
(2)
Department of Anesthesiology, Magee-Women’s, Hospital of UPMC, 300 Halket Street, Pittsburgh, PA 15213, USA
Keywords
Plastic surgeryLocal anesthesia toxicityLiposuctionBreast surgeryPostoperative nausea and vomitingThe American Society of Plastic Surgery recently reported that more than 11 million cosmetic procedures were performed in the United States per year. This number is expected to rise as plastic surgery procedures become more advanced and less invasive. With this continued increase, careful clinical decision making for the safe and effective administration of anesthesia for patients undergoing cosmetic surgery is imperative. Furthermore, many cosmetic procedures are performed in diverse environments, including traditional hospital operating rooms, outpatient surgery centers, and private offices, reinforcing the need to consider all factors that ensure patient safety.
Preanesthetic Assessment
The preanesthetic evaluation of the cosmetic patient is one of the most important functions for the anesthesiologist. In general, ASA physical status I and II indicate patients who are good candidates for these elective procedures. Usual preoperative concerns should be adhered to. The number of patients with a variety of severe medical conditions (ASA 3 and 4) undergoing cosmetic surgery, however, continues to increase. Specific considerations to focus upon include obesity, diabetes mellitus, immunocompromised states, advanced age, hypertension, hepatic disease, smoking, cardiovascular disease, obstructive sleep apnea, thyroid disease, coagulopathy, and psychiatric disease. In addition, the drugs with interactions that may affect the metabolism of lidocaine (those that inhibit cytochrome P450 isoenzyme system) must be evaluated during the preoperative assessment and possibly suspended.
Intraoperative Management
Choice of Anesthetic Method
Anesthesia for patients undergoing cosmetic surgery must accomplish a number of important goals. These include anxiolysis, intraoperative and postoperative analgesia, and rapid recovery with the absence of postoperative side effects. Techniques most commonly used are intravenous anesthesia, regional anesthesia, and general inhalation anesthesia.
Total intravenous anesthesia (TIVA) using short-acting hypnotics and opioids has emerged as an attractive alternative to inhaled anesthesia in the setting of ambulatory cosmetic procedures. It allows for rapid control of intraoperative stresses in a variety of surgical procedures and for faster recovery with less toxicity, than when the individual drugs are used alone in higher doses. Several different combinations of hypnotic-analgesic agents have been used for TIVA, notably propofol-remifentanil-midazolam, propofol-ketamine-fentanyl-midazolam (PKFM), and dexmedetomidine with PKFM.
Regional anesthesia, which includes both central neuraxial techniques as well as peripheral nerve blocks, minimizes requirements for additional anesthetic, analgesic, or sedative agents, thereby reducing side effects such as postoperative nausea, vomiting, and sedation. Spinal anesthesia provides rapid-onset, bilateral surgical anesthesia for cosmetic procedures from the abdomen to the lower extremities. Epidural anesthesia provides similar advantages (thoracic epidurals for surgery involving the breast and thorax; thoracolumbar epidurals for lower body regions) with the addition of extended postoperative analgesia. Unfortunately, spinal and epidural anesthesia have a risk of post-dural puncture headache as a side effect, and intrathecal or epidural narcotics such as morphine require prolonged postoperative observation. Peripheral paravertebral nerve blocks can offer intraoperative anesthesia and prolonged postoperative analgesia with rare side effects.
Local Anesthetic Toxicity
Lidocaine toxicity has accounted for a significant proportion of patient morbidity and mortality regarding cosmetic procedures. Surgeons and anesthesiologists attempt to calculate the “maximal safe dose” of lidocaine. Still prolonged surgical cases involving liposuction, rhinoplasty, and/or breast augmentation can create complex physiologic scenarios in which determination of the “cutoff” level of safe lidocaine dosing can be a difficult calculation.
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