Anesthesia for cosmetic surgery

Propofol Dexmedetomidine Total Intravenous Anesthesia with Tumescent Anesthesia in Aesthetic surgery

BACKGROUND

Total intravenous anesthesia (TIVA) is commonly performed in ambulatory aesthetic surgery centers. The authors compared combination of TIVA and tumescent anesthesia for safety and efficacy in prolonged and successive multiple aesthetic procedures.

METHODS

A retrospective review of patients who underwent aesthetic surgery procedures under TIVA from 2016 through 2024 at the authors' aesthetic surgery center was conducted. Patients were included if they fulfilled ASA 1 or 2 staging, BMI < 45 and were of age between 12 and 80 years. Perioperative drug dosages, time under anesthesia and patient vitals were recorded.

RESULTS

Of the 307 patients assessed, 301 completed surgery under TIVA and 6 were converted to GA. No major morbidity was recorded and all 307 cases were discharged from Anesthesia Recovery at 6 hours post-surgery. Average duration of anesthesia time was highest for lipoabdominoplasty (278 min, range 170-360 min). Average dose of tumescent anesthesia was highest in excisional body contouring (2967 ml). No surgical morbidity, e.g., skin necrosis, hematoma and blood transfusion, was reported. No anesthetic morbidity, e.g., deep vein thrombosis, fat embolism and lignocaine toxicity, was reported. Mean arterial pressure and SpO2 were maintained in safe normal range (70-100 mm Hg and > 95%, respectively) up to 6 hours postoperative. Aldrete score for postoperative recovery was > =9 at 10 min for 80% cases (n= 245).

CONCLUSIONS

The analysis of 307 total intravenous anesthesia with tumescent anesthesia cases demonstrated the overall safety and efficacy of the propofol-dexmedetomidine protocol under deep sedation. The study underscores the importance of complete preoperative assessments, vigilant anesthetist-guided drug infusions and monitoring for complications.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Conscious Sedation Methods for Blepharoplasty in Day Surgery

Midazolam and fentanyl, in combination, are the most commonly used medications for conscious sedation in day aesthetic surgeries. Dexmedetomidine is popularly used in the sedation protocol of our hospital due to its reduced respiratory depression. However, its sedation benefits in facial aesthetic surgeries, like blepharoplasty, have not been well-evaluated. We retrospectively compared individuals sedated with midazolam and fentanyl bolus injection (N = 137) and those sedated with dexmedetomidine infusion (N = 113) to determine which is more suitable for blepharoplasty with a mid-cheek lift. The total amount of local anesthetic (p < 0.001), postoperative pain (p = 0.004), ketoprofen administration (p = 0.028), and the number of hypoxia episodes (p < 0.001) and intraoperative hypertension (p = 0.003) were significantly lower in the dexmedetomidine group. Hypoxia severity (p < 0.001) and minor hematoma formation (p = 0.007) were also significantly lower in the dexmedetomidine group. Sedation with dexmedetomidine infusion is associated with less hematoma formation than sedation with midazolam and fentanyl bolus pattern due to hemodynamic stability and analgesic effects. Dexmedetomidine infusion may be a good alternate sedative for lower blepharoplasty.

Enhanced Recovery After Aesthetic Breast Surgery Under Sedation, Intercostal Block and Tumescent Anaesthesia: A Prospective Cohort Study of the Early Postoperative Phase

BACKGROUND

Comfort and recovery are major concerns of patients seeking aesthetic surgery. This study aimed to assess postoperative pain and recovery after outpatient breast surgery under sedation, intercostal block, and local anaesthesia.

METHODS

This prospective cohort study included all consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022. Epidemiological data, anaesthesia, pain, and patients' satisfaction were systematically assessed with standardized self-assessment questionnaires.

RESULTS

Altogether, 48 patients [median (IQR) age: 30 (36-25)] were included. The most frequent surgery was mastopexy. 69% of surgeries involved additional procedures. The mean intercostal block and local anaesthesia time was 15 min. Patients received a median (IQR) of 19 (34-2) mg/kg lidocaine and 2.3 (2.5-2.0) mg/kg ropivacaine. The median (IQR) consumption of propofol and alfentanil was, respectively, 4.89 (5.48-4.26) mg/kg/h and 0.27 (0.39-0.19) µg/kg/min. No conversion to general anaesthesia or unplanned hospital admission occurred. Patients were discharged after a median (IQR) of 2:40 (3:43-1:58) hours. Within the first 24 postoperative hours, 17% required once an antiemetic medication and 38% an opioid. Patients were very satisfied with the anaesthesia and 90% of the patients had not wished more analgesia in the first 24 h.

CONCLUSIONS

Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia can safely be performed as an ambulatory procedure and is associated with minimal intra- and postoperative opioid consumption and high patient satisfaction. These data may be used to inform patients and clinicians and improve the overall quality of care.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Perioperative Management of the Facelift Patient

In this article, the authors set out to lay a foundation for successful perioperative management of the facelift patient. They describe the changes of normal facial aging in an attempt to help one recognize the universal way the face is affected by aging. Having a clear understanding of these factors may help to guide the physician with procedures necessary to offer the patient for a desired outcome. Also, the authors emphasize the preoperative assessment and postoperative care necessary to ensure a successful, low-risk operation with minimal downtime and beautiful results, meeting the patient's expectations.

Facial Aesthetic Surgery: The Safe Use of Oral Sedation in an Office-Based Facility

BACKGROUND

The desire for efficient and safe office-based facial plastic surgery procedures has continued to rise. Oral sedation is a safe and effective method to provide anesthesia for facial aesthetic surgery.

OBJECTIVES

This study reviewed private practice anesthesia-related outcomes using oral sedation combined with local anesthesia for office-based facial aesthetic surgery procedures.

METHODS

A retrospective chart review was performed on all patients who underwent office-based facial plastic surgery procedures from July 2008 to July 2014. Patient demographic data including age, gender, body mass index (BMI), past medical history, social history, surgical history, allergies, and medications were collected. Anesthesia-related data were also collected including: American Society of Anesthesia (ASA) class, type of procedure, medications administered, and major complications related to sedation were assessed.

RESULTS

There were 199 patients (23 males and 176 females) who underwent 283 facial aesthetic surgical procedures. Mean age was 49.8 years (range, 29 to 80 years). There were 195 patients in ASA class I and 4 patients were in ASA class II. Patients underwent 44 upper blepharoplasty procedures, 35 lower blepharoplasty procedures, 5 browlifts, 43 upper blepharoplasty-browpexy, 46 facelifts, 38 neck lifts/lower facelifts, 54 fat grafting, 3 tip rhinoplasties, and 15 minor revision cases. During the study period, there were no major complications and no sedation issues.

CONCLUSIONS

Facial aesthetic surgical procedures can be performed safely and comfortably in the office-based setting under oral sedation in appropriately selected patients. LEVEL OF EVIDENCE 4: Therapeutic.

Refining the anesthesia management of the face-lift patient: lessons learned from 1089 consecutive face lifts

BACKGROUND

The importance of anesthetic technique is often underappreciated in face-lift procedures and is sparsely written about in the literature. Appropriate control of blood pressure, anxiety, pain, and nausea is essential for reducing the complications of face lift, primarily, hematoma risk. This study discusses the standard anesthetic protocol provided at the authors' institution and describes the preoperative, intraoperative, and postoperative management of face-lift patients resulting in low hematoma and complication rates.

METHODS

One thousand eighty-nine patients who underwent face-lift procedures performed by a single surgeon (R.J.R) were included in a retrospective chart review following institutional review board approval. Patient demographics, operative data including additional ancillary procedures, and the anesthesia regimen were recorded. In addition, postoperative complications and reoperation rates were documented.

RESULTS

Between 1990 and 2013, 1089 face-lift procedures were performed. Of these, 10 patients developed postoperative hematomas. Benzodiazepines were commonly administered preoperatively to reduce anxiety level. Intraoperatively, a specific regimen and combination of inhalation agents, neuromuscular blockers, antiemetics, antihypertensives, and narcotics was given to control the ease of induction and emergence from anesthesia. Postoperatively, nausea, vomiting, anxiety, pain, and hypertension were treated as needed.

CONCLUSIONS

The described protocol is safe and has been instituted at the authors' facility for approximately 20 years. The benefit of this regimen is related to the synergy of combination therapy. It is successful in reducing patient anxiety and pain, controlling blood pressure and postoperative emesis, and subsequently results in a reduced risk of hematoma.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Anaesthetic complications in plastic surgery

Anaesthesia related complications in plastic surgeries are fortunately rare, but potentially catastrophic. Maintaining patient safety in the operating room is a major concern of anaesthesiologists, surgeons, hospitals and surgical facilities. Circumventing preventable complications is essential and pressure to avoid these complications in cosmetic surgery is increasing. Key aspects of patient safety in the operating room are outlined, including patient positioning, airway management and issues related to some specific conditions, essential for minimizing post-operative morbidity. Risks associated with extremes of age in the plastic surgery population, may be minimised by a better understanding of the physiologic changes as well as the pre-operative and post-operative considerations in caring for this special group of patients. An understanding of the anaesthesiologist's concerns during paediatric plastic surgical procedures can facilitate the coordination of efforts between the multiple services involved in the care of these children. Finally, the reader will have a better understanding of the perioperative care of unique populations including the morbidly obese and the elderly. Attention to detail in these aspects of patient safety can help avoid unnecessary complication and significantly improve the patients’ experience and surgical outcome.

Prevention of perioperative and anesthesia-related complications in facial cosmetic surgery

Although office-based anesthesia for facial cosmetic surgery remains remarkably safe, no anesthesia or sedation performed outside the operating room should be considered minor. Proper organization, preparation, and patient selection, close collaboration with the surgeon, and expert and effective anesthesia care will increase patient safety and improve perioperative outcomes and patient satisfaction. This article presents a comprehensive overview of anesthesia in terms of facial plastic surgery procedures, beginning with a broad review of essentials and pitfalls of anesthesia, followed by details of specific anesthetic agents, their administration, mechanism of action, and complications.