Anesthesia for Cosmetic Surgery

CME

Peter J. Taub, M.D. Learning Objectives: After studying this article, the participant should be able Sameer Bashey, B.A. to: 1. Recognize the anesthetic choices available to patients undergoing out- Laurence M. Hausman, M.D. patient cosmetic surgery. 2. Identify the various medications selected for use in New York, N.Y. outpatient cosmetic surgery. 3. Understand the complexities of providing safe anesthesia to patients undergoing outpatient cosmetic surgery. Summary: Increasing numbers of plastic surgery procedures are performed in diverse environments, including traditional hospital operating rooms, outpatient surgery centers, and private offices. Just as plastic surgeons develop areas of specialization to better care for their patients, anesthesiologists have special- ized in outpatient plastic surgery, both cosmetic and reconstructive. The methods they utilize are similar to those for other procedures but incorporate specific techniques that aim to better relieve preoperative anxiety, induce and awaken patients more smoothly, and minimize postoperative sequelae of anesthesia such as nausea and vomiting. It is important for plastic surgeons to understand these techniques since they are the ones who are ultimately responsible for their patients’ care and are frequently called on to employ anesthesiologists for their practices, surgery centers, and hospitals. The following is a review of the specific considerations that should be given to ambulatory plastic surgery patients and the techniques used to safely administer agreeable and effective anesthesia. (Plast. Reconstr. Surg. 125: 1e, 2010.)

he American Society of Plastic Surgeons re- impact both the quality and the quantity of recov- cently reported that more than 11 million ery time. Moreover, the anesthetic technique may Tcosmetic procedures were performed last contribute not only to patient safety but also to the year in the United States.1 Many expect this num- overall success of nearly every cosmetic procedure. ber to rise as plastic surgery procedures become It is imperative that not only the anesthesiologist more advanced and less invasive. With the con- but also the surgeon understand the benefits and tinued increase in the number and variety of cos- risks of the various anesthetic options for cosmetic metic procedures performed each year, careful surgery. The following considerations were devel- clinical decision making for the safe and effective oped to highlight some of the basic principles administration of anesthesia for patients under- involved in providing general anesthesia to pa- going cosmetic surgery is imperative. Further- tients undergoing cosmetic surgery in the outpa- more, many cosmetic procedures are performed tient setting. in an office-based setting, in addition to hospitals The plastic surgeon is ultimately responsible or surgery centers, reinforcing the need to con- for managing the patient’s expectations of the sider all factors that ensure patient safety. perioperative period (i.e., “Will I have pain?” “Will Today, patients are discharged home soon af- I be nauseated?” and so on). Therefore, it is im- ter the completion of their procedure without an perative that the surgeon understand and appre- overnight or extended stay.2 It is for this reason ciate some of the anesthetic methods, drugs, that the anesthetic technique is considered as vital and/or possible sequelae. In addition, neither the as the surgery itself. The technique in which the surgical procedure nor the anesthetic delivery oc- various anesthetic agents are administered may curs in a vacuum. Thus, both physicians must understand and appreciate what the other will need From the Division of Plastic and Reconstructive Surgery and the Department of Anesthesia, The Mount Sinai School of Medicine. Received for publication August 1, 2007; accepted February Disclosure: None of the authors has a financial 7, 2008. interest in any of the products, devices, or drugs Copyright ©2009 by the American Society of Plastic Surgeons mentioned in this article. DOI: 10.1097/PRS.0b013e3181c2a268

www.PRSJournal.com 1e Plastic and Reconstructive Surgery • January 2010 to perform the procedure safely. Just as the anes- PREOPERATIVE CARE FOR thesiologist must understand all aspects of the sur- ELECTIVE SURGERY gical procedure to choose the correct anesthetic All patients should be instructed to abstain technique, the surgeon must comprehend the from solid food 8 hours before surgery and clear choices and possible sequelae of different anes- liquids 2 hours before surgery. The history of this thetic techniques for any given procedure. recommendation likely comes from a report published in 1946 by Mendelson, who noted a high incidence of pulmonary aspiration in obstetric pa- PREOPERATIVE DISCUSSION AND tients undergoing general anesthesia. A more con- PATIENT EXPECTATIONS crete recommendation was published by the An anesthetic complication during cosmetic American Society of Anesthesiologists Task Force surgery is rare in part because of the rigorous on Preoperative Fasting in 1999.3 They recom- screening process a patient should undergo be- mend a minimum fasting period for clear liquids fore any elective procedure. The patient should be of 2 hours and a minimum of 6 hours for milk or medically optimized before receiving any type of a light meal. They further recommend a fasting anesthetic ranging from general anesthesia period of 8 hours for patients who have ingested through monitored anesthesia care. In preparing any meal containing fried or fatty foods. Since it is easiest and safest to adopt a single non per os rule a patient for surgery, it is useful to classify him or before elective surgery, 8 hours is the most ap- her by the American Society of Anesthesiologists’ propriate, since it covers all foods and liquids. In Physical Status Score. On this continuum, a pa- most healthy adults undergoing elective cosmetic tient’s physical condition is classified into one of surgery the following morning, there is minimal six categories: inconvenience from an overnight fast. Class I: completely healthy In addition to urging a patient to get plenty of Class II: mild controlled illness or disease with no rest the night before the procedure, the surgeon interference in the patient’s daily life should consider prescribing a medication that Class III: illness or disease of greater than two provides somnolence. It is common for patients to organ systems feel anxiety and apprehension before surgery. A Class IV: uncontrolled illness or disease, which is preoperative benzodiazepine is a suitable choice a constant threat to life because in addition to inducing somnolence, this class of drug is also associated with anxiolysis. In Class V: expected to die within 24 hours with or fact, many plastic surgeons treat preoperative anx- without surgery iety prophylactically. Anxiolytic medications such Class VI: organ donor as Xanax (alprazolam; Pfizer, New York, N.Y.) or Most anesthesiologists would agree that a class Ativan (lorazepam; Biovail, Bridgewater, N.J.) can I or II patient is a suitable candidate for a cosmetic be prescribed to patients 1 to 3 days before the procedure, whereas a class III patient would most procedure in doses of 0.25 to 0.50 mg three times likely need additional assessment before being daily and 2 to 4 mg twice per day, respectively.4 In considered suitable for such procedures. In addi- addition, clonidine, an alpha-2 agonist given in tion to a thorough history and physical examina- doses of 0.1 to 0.2 mg orally the morning of sur- tion, laboratory screenings are often required. gery, has been shown to be dually beneficial by both decreasing blood pressure and providing a Commonly ordered tests include hemoglobin and 5 hematocrit, electrolytes, blood glucose, urinalysis, degree of sedation. Informed consent for the surgical procedure should be obtained in advance of an electrocardiogram, and a pregnancy test for the surgery, and many anesthesiologists do not women within child-bearing age. In fact, any pa- feel that a small dose of a preoperative anxiolytic tient who is menstruating must have a negative will interfere with the patient’s ability to sign con- beta-human chorionic gonadotropin blood test sent for anesthesia. Ultimately, procedures per- within a few days of the surgical procedure. Urine formed on a well-relaxed patient will more than tests are not acceptable. The choice of which test likely be much smoother than those performed on to order should be directed by the history and an irritable and anxious patient.6 physical examination. A specific preoperative visit to the anesthesiologist is not required because the INTRAOPERATIVE CARE primary care physician is able to furnish all of the Upon the patient’s arrival to the hospital, sur- above information. gery center, or office, both the anesthesiologist

2e Volume 125, Number 1 • Cosmetic Anesthesia and cosmetic surgeon should confirm that no in- mia is probably not a likely occurrence in short terval changes have occurred in the patient’s med- cases, a warming blanket is relatively inexpensive ical condition. If a significant change in the pa- compared with other adjunctive devices. tient’s health status occurs immediately before the After the induction of general anesthesia, ev- operation, the entire procedure may need to be ery effort should be made to protect the patient’s delayed. Ostensibly, the paramount concern is pa- eyes from inadvertent injury. Closed eyes should tient safety. always remain closed during surgery, especially in After ensuring that all the required paperwork procedures on the face. With the various surgical and consent forms are in order, the patient may be instruments being passed between the nurse and brought into the operating room. Before the in- surgeon, accidents may occur. To minimize the duction of anesthesia, an intravenous line is in- risk of corneal abrasion, a gentle ophthalmologic serted for administration of medications. Moni- lubricant, with or without antibiotic, should be tors are placed as outlined by standards set forth placed in the lower fornix of each eye at the start from the American Society of Anesthesiology and of the procedure. Sterile tapes are also recom- include a continuous electrocardiogram, a cycling mended to keep the eyelids closed if possible.8 Oint- blood pressure cuff, a pulse oximeter for oxygen ment is not easily washed from the eye, so that unlike saturation, an end-tidal carbon dioxide monitor, tape that may come loose during the procedure, and a temperature probe. Compression boots ointment tends to remain for the duration. should be placed on the calves before the induc- Both patients and surgeons are interested to tion of general anesthesia, as they have been know what role music has in the operating arena. shown to prevent the incidence of deep vein In fact, much has been documented about the use thrombosis in patients.7 A bladder catheter is gen- of music before, during, and after surgical proce- erally advisable for cases longer than 4 hours to dures. Numerous studies have found that patients safely manage fluid resuscitation, or to keep the who listen to music preoperatively and during op- bladder decompressed for abdominal procedures. erations requiring regional anesthesia are calmer For procedures that go beyond the expected time, and less preoccupied with the surgery than their a catheter can be placed temporarily in the oper- counterparts.9 Furthermore, a similar study re- ating room or postoperative care unit. ported a measurable difference in heart and re- Positioning the patient on the operating room spiratory rates as well as blood pressures between table should take into consideration the risk of patients undergoing ambulatory surgery who permanent nerve injury from continuous pres- listened to music compared with those who did sure. The patient’s position must allow the anes- not.10 Additional studies sought to determine the thesiologist to have adequate access to the airway effect of music not just on patients but on the entire in case there is a problem with ventilation. If the operating room, including the staff and the sur- patient’s face is in the operative field and a prob- geons. Not surprisingly, the studies showed that lem arises, the airway should be addressed expe- listening to music allayed preoperative anxiety in ditiously at the temporary expense of sterility be- patients and neither improved nor hindered the fore continuing with the procedure. Finally, the concentration of the surgeons performing the length of all cords of electrical surveillance and procedures.11 Thus, while helping patients mod- patient monitoring systems must be taken into erate their anxiety, the use of music in the oper- account so that they do not cause distractions dur- ating suite seems to simply be a matter of personal ing the surgery. preference and precedent. It is important to note that the temperature of the operating room is a vital consideration when GENERAL ANESTHESIA planning a surgical procedure. Due to the vaso- “General anesthesia is defined as a controlled dilatory nature and the direct inhibition of the state of unconsciousness accompanied by a loss of hypothalamus caused by many anesthetic agents, protective airway reflexes. [In addition to] the all patients are susceptible to hypothermia or loss inability to maintain a patent airway, the patient of body heat during surgery. This may result in will be unresponsive to verbal commands.”12 With platelet dysfunction and bleeding, enzymatic in- this type of anesthesia, the patient may require activity, cardiac dysfunction, or postoperative shiv- respiratory or cardiovascular support. The inser- ering. Hence, the ambient temperature of the op- tion of an endotracheal tube after induction will erating room should be kept at a temperature that allow control of ventilation. Throughout the sur- minimizes body heat loss and a warming blanket gical procedure, the patient is closely monitored be used for longer procedures. While hypother- to note any changes in physiologic status (e.g.,

3e Plastic and Reconstructive Surgery • January 2010 oxygen saturation, blood pressure, heart rate and Dexamethasone (4 to 10 mg intravenously), a ste- rhythm, breathing rate and rhythm, and tempera- roid, and scopalamine, a tropane alkaloid, both ture). General anesthesia can be divided into three may be used to resolve dizziness and nausea. In phases: induction (when the patient loses conscious- addition, metochlopromide (10 mg intrave- ness), maintenance (when unconsciousness is main- nously) and Emend (apripetant; Merck, White- tained during the procedure), and emergence house Station, N.J.), a newer antiemetic, are in- (when the patient regains consciousness). creasingly being used. Combination therapy using It is believed that a patient’s state on induction with several antiemetics is advisable for patients mirrors that of emergence. Accordingly, a smooth who have a high risk for postoperative nausea and induction with minimal hypertension and tachy- vomiting, including young women and nonsmok- cardia is desirable for cosmetic anesthesia. Before ers who have a history of postoperative nausea and induction, the anesthesiologist should consider a vomiting in the past or car-sickness. number of premedications. Midazolam, a short- Various drugs can be used to induce general acting benzodiazepine, can produce sedative-hyp- anesthesia. One commonly used induction agent notic effects or can even induce anesthesia at very is propofol, a short-acting intravenous drug used high doses. It is also characterized by its ability to in adult and pediatric patients. It may also be cause amnesia, hypnosis, and the relaxation of utilized during the procedure for the mainte- muscles with relative celerity. In fact, the onset of nance of anesthesia. Side effects include hypoten- sedation following intravenous administration sion and apnea following induction, as well as pain of midazolam is usually within 3 to 6 minutes, on injection, which can be ameliorated by pre- though there is some degree of patient variability. treatment with intravenous lidocaine.13 Propofol Intravenous midazolam will depress the ventila- is often used for cosmetic procedures because it is tory response to carbon dioxide stimulation, associated with reduced postoperative nausea and which may already be impaired in patients with vomiting and can even be used as an antiemetic. chronic obstructive pulmonary disease. In young, Thiopental is another induction agent. Thiopen- healthy patients, intravenous sedation with mida- tal is a barbituate that affects fine motor skills and zolam in small doses does not appear to adversely is notorious for producing a heavy “hangover” affect respiration. As far as cardiac sensitivity is effect and significant postoperative nausea and concerned, the use of midazolam is associated vomiting.6 Midazolam and ketamine can also be with decreases in mean arterial pressure, cardiac used for induction, although they are associated output, stroke volume, and systemic vascular resis- with a longer recovery time postoperatively. Ket- tance. Consequently, midazolam is contraindicated in amine, a phencyclidine derivative, is an anesthetic patients with acute pulmonary insufficiency or severe agent approved for human and veterinary use chronic obstructive pulmonary disease. Nevertheless, whose popularity in the outpatient arena has in- studies have reported that the administration of cer- creased over the past several years. Its effects in- tain barbiturate and benzodiazepam drugs by an clude analgesia and sedation with minimal to no anesthesiologist preoperatively may “reduce the respiratory depression. However, hallucinations, overall anesthetic requirements [of the procedure hypertension, increased intracranial pressure, itself], thereby improving recovery time [later].”6 and salivation have limited its appeal. It has been Postoperative nausea and vomiting is a major used successfully with propofol and midazolam for concern with any anesthetic procedure. Preoper- cosmetic procedures, since it may be used without ative antiemetics should be used to prevent post- the need for endotracheal intubation, supplemen- operative nausea and vomiting following the use tal oxygen, or narcotics.14,15 of numerous anesthetic agents, including narcot- General anesthesia requires control of the pa- ics and nitrous oxide. Many anesthesiologists tient’s airway. The drugs used to induce uncon- avoid narcotics altogether to minimize the inci- sciousness are associated with muscle weakness, dence of nausea and vomiting. Alternative anal- alkalosis, and the loss of many autonomic reflexes, gesics include local anesthetics, ketamine, and ke- including the ventilatory response to carbon di- torolac. Others advocate the use of narcotics for oxide and hypoxia.16 Thus, patients under general heavy pain cases and use a variety of available anesthesia often require mechanical ventilation. antiemetics to minimize postoperative nausea and Adequate airway control may be achieved either vomiting. Granisitron (0.2 to 1 mg intravenously) with a traditional endotracheal tube that passes and ondansetron (1 to 4 mg intravenously) are beyond the vocal cords or with a laryngeal mask serotonin antagonists that reduce the autonomic airway that is inflated above the vocal cords at the neuroactivity in the vomiting center of the brain. laryngeal aperture. As with all considerations in

4e Volume 125, Number 1 • Cosmetic Anesthesia cosmetic surgery, the means of securing the airway The choice of drugs used to maintain anes- depends on the procedure being performed. For thesia is also important to minimize postoperative procedures that do not involve frequent head nausea and vomiting and to allow for a rapid re- turning, the laryngeal mask airway provides a safe covery process. Nitrous oxide is commonly used as alternative to the endotracheal tube because it an inhalational agent to maintain anesthesia. Its does not risk vocal cord injury and has less of an use reduces the need for higher concentrations of incidence of postoperative laryngeal irritation and the volatile inhalational agents for maintenance of “bucking on the tube.”17 However, since the la- anesthesia. It is, however, associated with postop- ryngeal mask airway does not occlude the trachea, erative nausea and vomiting and should be limited patients at high risk for aspiration should still use to concentrations under 50%, especially in pa- a traditional endotracheal tube. tients with evident coronary disease.18 The device itself may be secured to the face in Isoflurane is one of a number of volatile in- various ways. For procedures not involving the halation agents commonly used for maintenance face, adhesive tape is most often used to secure of anesthesia. Desflurane is shorter-acting mem- the tube to the lower jaw. For facial procedures, ber of this class of drugs and may be more suitable the tube may be prepped into the field or covered for cosmetic surgery. Its quick recovery time re- with sterile plastic or stockinet to maintain steril- sults from a higher vapor pressure. However, des- ity. Of paramount importance is that the surgeon flurane often causes postoperative respiratory ir- and anesthesiologist weigh surgical exposure ver- ritation and coughing largely due to its pungent sus sterility and always respect the need for emer- smell. Sevoflurane is better tolerated than desflu- gent visualization of the numerous connections rane because it lacks a characteristic odor. As a result within the patient’s anesthetic circuit should prob- of the lower solubility of these newer volatile agents, lems with ventilation arise. Because surgical prep- cognitive functions return to baseline more rapidly aration of the face often dislodges the tape hold- when compared with inhaled isoflurane. Continuous intravenous anesthetics are com- ing the tube, it may be advisable to place a suture monly employed in cosmetic surgery. Propofol, around the tube and then around the teeth in the remifentanil, dexmetatomidine, and ketamine are midline. Of course, this is impractical in patients among the most commonly used. Propofol was with dental restoration, such as a bridge or an discussed earlier as a drug of choice for induction, implant. but it can also be used as a continuous infusion (75 After the induction of general anesthesia, the to 150 ␮g/kg per minute) to maintain anesthesia. anesthesiologist must vigilantly monitor changes Remifentanil may be used just before induction to in the patient’s cardiovascular status, including suppress the autonomic responses to intubation alterations in oxygen saturation, blood pressure, and during maintenance to suppress other auto- heart rate and rhythm, respiratory rate, and tem- nomic responses to surgical stimuli. Because it is perature, while continuously administering anes- also a short-acting narcotic, it is ideal for the end thetics for the duration of the operation. To accom- of the procedure, since it is a potent cough sup- plish this, the anesthesiologist carefully administers pressant. However, as with all narcotics, it can a combination of drugs while closely assuring that cause postoperative nausea and vomiting.19 Last, the patient’s heart rate and blood pressure are well ketamine, like propofol, can be used for both in- controlled. duction and maintenance, though it is often as- A constant stable blood pressure in the low- sociated with an increase in blood pressure and normal range for the duration of the cosmetic salivation, as well as bad hallucinations. Fortu- procedure is desirable to minimize blood loss and nately, it is not associated with postoperative nau- bleeding into the tissues, which contributes to pro- sea and vomiting. longed postoperative ecchymosis and edema. More severe consequences of prolonged hyper- EMERGENCE tension include cardiopulmonary-hepatic conges- Emergence should be a well-planned event. tion or anasarca, and possibly even heart or renal The ideal emergence from anesthesia following failure. If the blood pressure drops too low, the cosmetic surgery has no increases in blood pres- patient will not adequately perfuse vital organs sure or heart rate, no “bucking” from irritation of and can develop circulatory collapse. Keeping the the endotracheal tube, and no respiratory blood pressure constant at a level that ensures complications.20 While the concentration of inha- adequate perfusion without the aforementioned lational and intravenous anesthetics are lowered complications cannot be overemphasized. to allow the patient to regain consciousness, ad-

5e Plastic and Reconstructive Surgery • January 2010 ditional medications are administered to restore maintain an airway independently and continu- muscle activity and allow the patient to breathe ously and to respond to physical stimuli and verbal spontaneously to permit extubation. Maneuvers commands.”6,21 This anesthetic technique is often that are particularly stimulating, such as nasogas- referred to as “conscious sedation,” and the pa- tric decompression or suctioning, are done while tient will be sedated so as to not feel any pain or the patient is still deeply sedated to prevent hy- have any keen sense of environmental awareness. pertension. Gagging at the conclusion of any pro- However, unlike in general anesthesia, where un- cedure is undesirable because it raises blood pres- consciousness is induced and spontaneous respi- sure and may trigger subcutaneous bleeding. The ration is depressed, patients will continue to prevention of nausea and vomiting is important to breathe on their own. minimize fluctuations in blood pressure. Patients Monitored anesthetic care has been shown to be should be reminded as they emerge from anes- effective and safe in large study populations.22–24 Typ- thesia that they may have blurred vision due to the ically, a combination of two or more medication ointment and should be prevented from attempt- types is used to achieve the desired level of seda- ing to rub their eyes. tion and analgesia. Commonly used agents include rapid-acting opioids, such as fentanyl, and POSTOPERATIVE CARE sedatives, such as midazolam and propofol.25,26 Anesthetic care does not end once the endo- In certain patients, the administration of tracheal tube has been removed and the patient is enough medication will cause the patient to lose restored to consciousness. Patients must be closely protective airways reflexes and move into a state of monitored postoperatively for signs and symptoms general anesthesia. In some instances, this will of hypoxia, hypertension, pain, nausea and vom- require securing the airway, while in others it may iting, and even unconsciousness. This is an im- require decreasing the dose of the anesthetic portant part of the continuum of anesthesia care. agents to allow the patient to regain spontaneous A patient may be discharged once an Assessment respiration. For this reason, monitored anesthesia of Home Readiness test is conducted.6 In this eval- care has all of the same requirements as general uation, patients are closely observed to ensure that anesthesia. Patients should be screened preoper- their vital signs are stable, to make sure they are atively, vigilantly monitored intraoperatively, and environmentally aware, and to make sure they can meet the same discharge criteria. walk without falling or becoming excessively dizzy. Patients are also evaluated for pain, nausea and GENERAL ANESTHESIA COMPARED vomiting, and bleeding at the surgical site. Most WITH MONITORED CARE ANESTHESIA delays in discharge are due to pain, postoperative Each of the aforementioned anesthetic tech- nausea and vomiting, hypotension, and dizziness niques has both advantages and disadvantages, upon ambulating.6 All patients require analgesia thus the selection of one method over the other postoperatively and some may require stronger truly depends on the nature of the surgical pro- medications than acetaminophen or nonsteroidal cedure and the comfort level of the anesthesiol- anti-inflammatory drugs as part of their postop- ogist and surgeon alike. erative regimen. For shorter, less complicated procedures, either method may be used. For difficult and time- MONITORED ANESTHETIC CARE consuming procedures, general anesthesia is TECHNIQUES often more appropriate. In the monitored anes- The choice of anesthetic technique for cos- thesia care model, the patient drifts in and out of metic surgery varies based on the discretion of the consciousness during the procedure and may anesthesiologist, the surgeon, and the procedure. become more anxious, irritable, and emotional Most patients associate surgery with general anes- than patients undergoing general anesthesia.6 thesia, but other forms of anesthesia exist along Postoperative nausea and vomiting, however, the spectrum of choices for intraoperative seda- may be reduced. tion/analgesia and are effectively utilized for such It should be noted that the administration of procedures. Monitored anesthesia care may be both types of anesthesia in an ambulatory setting offered to patients undergoing compatible pro- is safe. Largely due to the meticulous preoperative cedures. In this technique, a combination of local screening and technological advancements in an- anesthetic and intravenous analgesic and sedative esthesia, morbidity and mortality resulting from drugs produces a “minimally depressed level of outpatient anesthesia are rare.6 A recent study consciousness that retains the patient’s ability to reported no significant differences between either

6e Volume 125, Number 1 • Cosmetic Anesthesia form of anesthetic technique employed as it re- 11. Sa´rma´nyJ,Ka´lma´n R, Staud D, Salacz G. Role of the music lates to patient recovery time, sensitivity to pain, in the operating theatre. Orv Hetil. 2006;147:931–936. and safety.27 A joint study conducted by Yale Uni- 12. Nique TA. Ambulatory office general anesthesia. In: Anes- thesia for Facial Plastic Surgery. New York: Thieme Medical versity and the State University of New York at Publishers; 1993. Stony Brook evaluated the safety of outpatient 13. Piper SN, Rohm KD, Papsdorf M, Maleck WH, Mattinger P, anesthesia for plastic surgery procedures on the Boldt J. Dolasetron reduces pain on injection of propofol [in face. The study reported no deaths or severe com- German]. Anasthesiol Intensivmed Notfallmed Schmerzther. 2004; plications among the 1200 cases retrospectively 37:528–531. reviewed.28 14. Friedberg BL. Facial laser resurfacing with the propofol- ketamine technique: Room air, spontaneous ventilation Patients undergoing cosmetic surgery are gen- (RASV) anesthesia. Dermatol Surg. 1999;25:569. erally well informed regarding the nature of the 15. Friedberg BK. Propofol-ketamine technique: dissociative an- procedure and the reputation of their surgeon, esthesia for office surgery (a five year review of 1,264 cases). but overlook the importance of the anesthetic Aesthet Plast Surg. 1999;23:70. technique needed to effectively perform the pro- 16. Knill RL, Clement JL. Variable effects of anesthetics on the cedure. A successful cosmetic procedure involves ventilatory response to hypoxia in man. Can Anaesth Soc J. 1982;29:93–99. both a skilled plastic surgeon and a knowledgeable 17. Cork RC, Depa MC, Standen JR. Prospective comparison of anesthesiologist. Cosmetic surgeons realize the use of the laryngeal mask airway an endotracheal tube during importance of this and often choose to work with ambulatory anesthesia. Anesth Analg. 1994;79:719–727. one or more select anesthesiologists with whom 18. Moffitt EA, Sethna DH, Gary RJ, Raymond MJ, Matloff JM, they have developed a rapport and a tacit under- Bussell JA. Nitrous oxide added to halothane reduces coronary flow and myocardial oxygen consumption in patients standing of what is needed before, during, and with coronary disease. Can Anaesth Soc J. 1983;30:5–9. after surgery. 19. Egan TD, Lemmens HJ, Fiset P, et al. The pharmacokinetics of the new short-acting opiod remifentanil (G197084B) in Peter J. Taub, M.D. healthy adult male volunteers. Anesthesiology 1993:79:881– Division of Plastic and Reconstructive Surgery 892. The Mount Sinai School of Medicine One Gustave L. Levy Place 20. Koga K, Asai T, Vaughan RS, Latto IP. 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