Chapter 84. Cosmetic Surgery

• 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

• 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

• 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

• 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

Breast Surgery

• 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 ...