Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ Outpatient cosmetic procedures have increased by 457% from 1997 to 2007Of these, 54% are performed in office-based settings, 29% in ambulatory-based settings, and 17% in hospital-based settings ++ 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 problemPatients presenting for an office-based procedure must be medically optimizedPreoperative history and physical examination must be within 30 daysIf the patient has significant comorbid conditions, anesthesiology consultation should be obtained prior to surgery schedulingIt is recommended that ASA physical status patients greater than 3 have no more than local anesthesia (with no sedation) in an office-based setting ++ 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 +++ Liposuction ++ DescriptionPercutaneous cannula aspiration of subdermal fat deposits through strategically placed small incisionsTumescent 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)InductionA field block or use of tumescent local anesthesia is most commonly usedSome patients will request sedation and analgesia to relieve the brief discomfort of needle punctures for subdermal infiltrationEpidural and spinal anesthesia in the office setting is discouraged because of the possibility of vasodilation, hypotension, and fluid overloadMaintenanceFluid replacement and maintenance of normothermiaImproper fluid management in large-volume liposuction may lead to hypovolemic shock at one extreme, and hemodilution progressing to pulmonary edema at the otherAbout 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 necessaryAvoid hypothermia due to infiltration of large volumes of room-temperature tumescent fluid solution by active warming of the patient intraoperativelyComplications (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 wandThe 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 circulationThe peak serum levels of lidocaine occur 12–14 hours after injection and decline over subsequent 6–14 hours +++ Breast Surgery ++ DescriptionAugmentation, implant exchanges, breast reduction, and completion of transverse rectus abdominis muscle (TRAM) flapsInductionMAC with paravertebral block using single-level (T4) injection and local anesthesia is being used more frequently in office-based settingsHowever, 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 preferredMaintenanceAnti-emetics and postoperative analgesiaFor postoperative pain control in first 48 hours, 3 methods have proven successful:Intraoperative bupivacaine 0.25% using 10 mL ... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth