CME Anesthesia for Cosmetic Surgery 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, outpa- tient 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 meth- ods 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 un- derstand 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 pub- lished 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 sur- gical 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.