7. Procedure-Specific Anesthesia Guidelines for the Aesthetic Surgery Patient
Anesthesia for Facial Plastic Surgical Procedures (Rhytidectomy, Necklift, etc.)
Patient factors
Usually middle-aged or older
May have increased burden of comorbidities, especially preexisting hypertension
Can have cardiac conditions for which they take antiplatelet, antithrombotic, or anticoagulant medication
Any disruption/resumption in blood thinners should be coordinated with primary care physician or consultant.
Require increased attention to positioning and padding with range of motion limitations, including cervical spine
Often part of multiprocedure combination with duration >4 hours
Consider Foley catheter
DVT mechanical prophylaxis with sequential compression devices
Intermittent position checks to assess extremity and pressure point support and padding
Multiple anesthetic techniques used successfully
IV sedation of varying levels
Total intravenous anesthesia (TIVA) (see Chapter 5)
Balanced technique with inhalational anesthesia
Choice of anesthetic type frequently influenced by surgical preference
Anesthetic Goals
Achieve optimal hemodynamic control.
Hematoma is most common complication of procedure.
Preoperative systolic BP >150 mm Hg has been identified as risk factor for hematoma. 3
Appreciate anxiolysis, antiemesis, and analgesia treatments as components of hemodynamic control.
Preemptively manage changes in surgical stimuli that result in hemodynamic aberration (awareness of procedural components and their sequence).
Be aware of placement, timing, and tolerance of compression head dressings.
Achieve smooth emergence and extubation that prevents coughing and bucking.
Preoperative Management
Continue any home anxiolytic medications.
Add preoperative anxiolysis with midazolam 1–2 mg IV titrated up to 0.7 mg/kg.
Continue any home antihypertensive medications (except diuretics, angiotensinconverting enzymes [ACE-inhibitors], and angiotensin-receptor blockers [ARBs]).
Determine baseline BP and, if known, typical ranges.
Consider use of clonidine: 0.1–0.2 mg PO or 0.1–0.2 mg/d transdermal patch placed preoperatively.
Optimize preoperative PO multimodal analgesia (celcoxib, acetaminophen, gabapentin).
Optimize preoperative antiemesis prophylaxis (aprepitant [Emend], scopolamine patch), especially if history of PONV/PDNV.
Intraoperative Management
Ensure smooth IV induction with propofol.
Continue prophylactic antiemesis regimen (with addition of promethazine, decadron, ondansetron, and/or haloperidol), as determined by Apfel score.
Continue opioid-sparing multimodal analgesia regimen (ketamine, IV acetaminophen).
Provide neuromuscular blockade redosing preemptively for head repositioning or injection stimulation.
Maintain low normotension or modest hypotension during resection.
Generous surgical use of local anesthetic infiltration and nerve blocks
Bolus with shorter-acting synthetic opioids (fentanyl, sufentanil, alfentanil) to blunt:
Hemodynamic effects of laryngoscopy
Periods of intermittent stimulation during local anesthesia injection
Airway stimulation caused by changes in head positioning
Total narcotic use is typically minimal and therefore lessens untoward side effects like postoperative nausea and vomiting (PONV).
Before closing, allow BP return to baseline range to facilitate surgical assessment of oozing.
Judicious use of IV fluids (maintenance amounts) to prevent facial edema
Estimated blood loss (EBL) is minimal.
No appreciable third space losses occur.
Delay emergence until all dressings and wraps are securely in place.
Surgeon or assistant can hold pressure to site during extubation.
Elevate head of bed at least 30 degrees ASAP to minimize postprocedural edema.
Smooth extubation is critical to prevent coughing or bucking that causes increased venous return and increased BP leading to hematoma.
Use lidocaine IV PRN to depress airway reflexes.
Use esmolol IV PRN to quickly control increases in BP.
Timely management of any anxiety, hypertension, pain, or nausea in PACU
In one study, hypertension in the PACU was found to be a statistically significant factor in formation of hematoma. 2
Rhytidectomy is unique in that these components that affect BP need to be strictly controlled to minimize subcutaneous bleeding and hematoma formation.
Airway Management
Endotracheal intubation with controlled ventilation
Provides maximal control of airway during head position changes
Minimizes motion that can occur with spontaneous respiration
Provides closed system for oxygen delivery minimizing fire risk with electrocautery
Decrease FiO2 to lowest level that supports adequate oxygenation.
Secure ET tube in a way to maximize surgeon’s dynamic maneuverability.
Avoid tape by securing ET tube to incisors or canine teeth with suture or floss (inform patient of potential gum irritation, soreness, or bleeding).
Some surgeons prefer to leave ET tube unsecured for ability to move from side to side throughout procedure.
Consider preformed ET tube (oral or nasal RAE).
Bioocclusive dressing can secure ET tube to chin to minimize tape.
Determine level of maintenance muscle relaxation desired by surgeon to prevent unwanted facial laxity.
Supraglottic device (laryngeal mask airway [LMA], I-gel)
Prevents facial distortion, which is less desirable for this reason
Assess anticipated head manipulation to prevent airway irritation or dislodgement intraoperatively.
Good alternative (if no contraindications) in isolated browlift, blepharoplasty, or eyelid procedures because of maintenance of neutral head positioning.
Facilitates smooth emergence because patients less likely to cough or buck
Natural airway with spontaneous ventilation
Tip:
If unsecured, mark the ET tube with an indelible marker at centimeter markings for the teeth or lip so that its position can be continually checked for initial placement depth!
Eye Protection
Sterile ophthalmic ointment (Lacri-Lube) ONLY
CAUTION: DO NOT confuse Lacri-Lube with Surgilube, which, if applied to the cornea, can cause severe ocular damage through probable toxic effects of chlorhexidine gluconate. 4
Corneal protectors
Remember to remove before emergence to avoid unpleasant patient experience and difficulty with removal when awake.
Facial Laser Resurfacing
Use of CO2 laser is painful and usually requires significant analgesia both intraoperatively and immediately after procedure.
Successful use of room air/natural airway/spontaneous ventilation techniques using TIVA have been described.
Need for cardiorespiratory depressants is prevented by using nonopioid analgesics in conjunction with local anesthetic nerve blocks.
Supplemental oxygen and assisted ventilation are avoided, and surgical field is freed.
Drawbacks 6 include eventual need for predischarge rescue opioid analgesics (>70%) and antiemetics (32%).
Balanced technique or TIVA with use of an endotracheal tube 1 , 5 confers ability to:
Treat drug-induced respiratory depression with controlled ventilation
Minimize combustion/fire risk by:
Using closed-circuit oxygen delivery
Using laser-resistant ET tube
Decreasing FiO2 to lowest level that supports adequate oxygenation
Communicating the level of O2 to the surgeon before laser use in a specific laser time-out
ET tube may need repositioning to allow surgeon to work around it, possibly unsecured.
Eye protection with corneal protectors and saline-soaked gauzes pads are needed.
PACU needs can include:
Supplemental narcotic analgesia
Chilled air to face
Application of ointment
Humidified face tent
Rhinoplasty
Well-suited for general anesthesia with controlled airway
Alternative method is moderate-deep sedation with natural airway, although providing supplemental oxygen is more challenging.
Position and secure ET tube over the mandible. Use of tube extenders, armored tube, or oral RAE tube facilitates surgical exposure and maneuverability and prevents crimping or compression.
Supraglottic devices (LMA, I-gel) have also been used successfully.
Caution is needed with osteotomies and bleeding that passively migrates to stomach causing increased incidence of PONV, risk of aspiration, and airway irritation.
Tip:
If LMA is used, consider the type that allows gastric suctioning.
Use of throat packing dampened with saline solution can decrease blood migration but can cause mucosal irritation and postprocedure sore throat.
CAUTION: Use vigilance to make sure throat packing is removed at the end of the procedure! (Add to checklist.)
Patients should be kept anesthetized until splints are contoured and stiffened and dressings are in place.
Emergence entails:
Being awake enough to prevent aspiration or laryngospasm, especially because mask application with positive pressure can cause injury to fresh repair
Being smooth enough to prevent coughing and bucking that increase bleeding
Postoperative pain is usually minimal because of local infiltration by surgeon.
Anesthesia for Breast and Abdominal Procedures
Breast Augmentation
Patients tend to be younger (most <40 years of age).
Younger age, female sex, use of volatile agents and opioids increase Apfel PONV score; thus PONV prophylaxis is often indicated.
Submuscular dissection and placement lends itself to postoperative deep muscular pain and spasm.
Use of multimodal analgesia can include initial doses of acetaminophen, gabapentin, celecoxib or other NSAID.
Can add diazepam (Valium) or carisoprodol (Soma) to regimen to aid pectoralis relaxation 8
Position changes intraoperatively are dynamic and frequent to observe implant location and symmetry.
All positioning should take into account:
Pressure point padding
Angle of arm abduction (≤90 degrees)
Method of securing that allows safe transition between supine and sitting
Testing the bed to sitting position before prep and drape
CAUTION: Hemodynamic and vascular changes can occur with position changes.
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