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  • Outpatient cosmetic procedures have increased by 457% from 1997 to 2007
  • Of these, 54% are performed in office-based settings, 29% in ambulatory-based settings, and 17% in hospital-based settings

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  • Because of the elective nature of cosmetic surgery, patients tend to be healthy ASA 1 and 2 patients, with no more than a single health problem
  • Patients presenting for an office-based procedure must be medically optimized
  • Preoperative history and physical examination must be within 30 days
  • If the patient has significant comorbid conditions, anesthesiology consultation should be obtained prior to surgery scheduling
  • It is recommended that ASA physical status patients greater than 3 have no more than local anesthesia (with no sedation) in an office-based setting

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  • Standard ASA monitors including EKG, non-invasive blood pressure, pulse oximetry, temperature, and capnography are required for cosmetic surgery procedures. Airways supplies, suction, emergency drugs, and a cardiac defibrillator should also be readily available

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Liposuction

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  • Description
    • Percutaneous cannula aspiration of subdermal fat deposits through strategically placed small incisions
    • Tumescent Liposuction: Rapid pressure subcutaneous infiltration of several liters of wetting solution containing highly diluted lidocaine (0.05–0.10%) and epinephrine (1:1,000,000)
  • Induction
    • A field block or use of tumescent local anesthesia is most commonly used
    • Some patients will request sedation and analgesia to relieve the brief discomfort of needle punctures for subdermal infiltration
    • Epidural and spinal anesthesia in the office setting is discouraged because of the possibility of vasodilation, hypotension, and fluid overload
  • Maintenance
    • Fluid replacement and maintenance of normothermia
    • Improper fluid management in large-volume liposuction may lead to hypovolemic shock at one extreme, and hemodilution progressing to pulmonary edema at the other
    • About 60–70% of wetting solution is absorbed by hypodermoclysis; therefore, as much more wetting solution is infiltrated than fat aspirated, supplemental fluid may not be necessary
    • Avoid hypothermia due to infiltration of large volumes of room-temperature tumescent fluid solution by active warming of the patient intraoperatively
  • Complications (overall rate 0.7%)
    • PE (23%), viscera perforation (14.6%), fat embolization (8.5%), local anesthetic toxicity leading to cardio-respiratory failure (5.4%), or vascular damage leading to hemorrhage (4.6%) by the suction wand
    • The liver drug clearance of lidocaine (estimated at 250 mg/h) is the limiting factor in drug disposition. If liver function is impaired, lidocaine will accumulate in circulation
    • The peak serum levels of lidocaine occur 12–14 hours after injection and decline over subsequent 6–14 hours

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Breast Surgery

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  • Description
    • Augmentation, implant exchanges, breast reduction, and completion of transverse rectus abdominis muscle (TRAM) flaps
  • Induction
    • MAC with paravertebral block using single-level (T4) injection and local anesthesia is being used more frequently in office-based settings
    • However, because of the pain associated with separating the pectoralis muscles from the chest wall during breast augmentation, general anesthesia with either an LMA or ETT is usually preferred
  • Maintenance
    • Anti-emetics and postoperative analgesia
    • For postoperative pain control in first 48 hours, 3 methods have proven successful:
      • Intraoperative bupivacaine 0.25% using 10 mL placed in ...

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