Angeline F. Lim MD
Surgeon
David M. Kahn MD
Surgeon
George W. Commons MD1
Surgeon
Lindsey Vokach-Brodsky MB, ChB, FFARCS
Anesthesiologist
Bruce D. Halperin MD1
Anesthesiologist
1Liposuction
P.1084
Augmentation Mammoplasty
Surgical Considerations
Description: Augmentation mammoplasty is accomplished through the use of saline or silicone gel-filled breast implants. The surgery may be performed under GA or local anesthesia with sedation. The patient is positioned either with the arms abducted at 90° or with the hands on the abdomen. Local anesthetic (± epinephrine) is infiltrated into the skin at the incision site and under the glandular tissue. Implant insertion can be done through inframammary, periareolar, transaxillary, or transumbilical incisions. The implant is placed in a pocket that is created either beneath the mammary gland (subglandular), under the pectoralis muscle (submuscular), partially subglandular and partially submuscular (dual-plane), or beneath the pectoralis fascia (subfascial), depending on the surgeon's preference and the amount of tissue available. An endoscope may be used to assist with dissection of the pocket. When the implant is placed in the submuscular position, the pectoralis muscle is divided from its insertion along the inframammary fold and sometimes along the sternal insertion to allow the muscle to drape over the implant. Regardless of the location of the pocket, the surgical wound is carefully irrigated and inspected for hemostasis. Sizers, either predetermined volumes of silicone gel or adjustable saline- or air-filled temporary implants, may be used to help determine the appropriate final volume and placement. The patient may be placed in the seated position to assess the size, shape, and symmetry of the breasts. The sizers are then replaced with the permanent prostheses. If permanent saline implants are used, they are filled with saline until the desired volume is reached; gel-filled implants do not have alterable volumes. The wounds are closed, and dressings are applied (Fig. 11.2-1).
Augmentation mammoplasty usually is performed as an outpatient procedure, although some patients may want an overnight stay for pain management and antiemetics. PONV is not uncommon, and all efforts should be made to decrease its frequency.
|
Figure 11.2-1. Breast augmentation. Implants may be placed in a subglandular or subpectoral position. (Reproduced with permission from Spear SL: The Breast: Principles and Art. Lippincott-Raven: 1998.) |
P.1085
Variant procedure or approaches: The endoscopic transumbilical approach is used much less frequently.
Preop Diagnosis: Hypomastia, breast ptosis
Summary of Procedures
|
Position |
Supine |
|
Incision |
Inframammary; periareolar; transaxillary; or transumbilical |
|
Antibiotics |
Cefazolin 1 g iv |
|
Unique considerations |
May place patient in sitting position during procedure. |
|
Surgical time |
1 h |
|
Closing considerations |
May need patient in sitting position for application of dressings. |
|
EBL |
Minimal |
|
Postop care |
Outpatient procedure |
|
Mortality |
Rare |
|
Morbidity |
Prosthesis failure: 5% |
|
Pain score |
3–4 |
Patient Population Characteristics
|
Age range |
Typically 17–45 yr, but also may be done on the contralateral breast in a patient undergoing breast reconstruction. |
|
Incidence |
329,396 performed in the United States in 2006; the most common cosmetic surgical procedure |
|
Etiology |
Developmental; involution after breast feeding; age-related atrophy or ptosis |
|
Associated conditions |
Not common, but can be seen with Poland's syndrome. |
Anesthetic Considerations
See Anesthetic Considerations following Mastopexy/Breast Lift, p. 1089.
Suggested Readings
P.1086
Reduction Mammoplasty
Surgical Considerations
Description: Breast reduction surgery can be done as an outpatient procedure or with an overnight stay. One might choose to admit the patient overnight in a hospital setting to monitor for hematoma formation and evidence of decreased blood supply to the nipple-areola complex. For these patients, the pain from this procedure is relatively low; therefore, PONV tends to be the greater issue in the immediate postoperative period.
The traditional type of breast reduction performed in the U.S. is the inferior pedicle technique using a Wise pattern (“anchor-type” scar) for the skin excision (Fig. 11.2-2). Markings are made with the patient upright in the preoperative holding area. The areola is marked circumferentially with an areola sizer and incised. The remaining incision lines are scored with a scalpel. Next, the inferior pedicle, which contains the neurovascular supply to the nipple-areola complex, is deepithelialized. Excess skin and breast tissue are excised, preserving the pedicle of tissue that will compose the breast mound. The resected tissue from each breast, which can range from 200–1,000 g, is weighed as an adjunctive method of ensuring symmetry. Temporary skin closure with staples allows the patient to be placed in a sitting position so that the breasts can be evaluated for symmetry. When the surgeon is satisfied with the appearance of the breasts, they are closed with sutures. Drains may be placed, depending on surgeon preference (Fig. 11.2-2). After the skin has been closed, the location of the nipple and areola is marked and excised, and the nipple-areola complex is delivered and sutured into position. Soft, supportive dressings are placed.
A technique that has gained in popularity recently is the vertical reduction mammoplasty, which shares the fundamental principles of excision of excess breast tissue and preservation of blood flow to the nipple-areola complex, but differs in choice of skin incision and pedicle. Relatively more time is spent performing the tissue excision and pedicle shaping, but wound closure time is greatly decreased (resulting in a “lollipop-type” scar) compared with the traditional Wise-pattern technique.
|
Figure 11.2-2. Reduction mammoplasty using an inferior pedicle technique. A: The skin and breast tissue on the medial and lateral sides of the pedicle are resected. B: The medial and lateral skin envelopes are sutured at the midline, leaving an inverted-T shaped scar. (Reproduced with permission from Spear SL: The Breast: Principles and Art. Lippincott-Raven: 1998.) |
P.1087
Variant procedure or approaches: Liposuction may be used in combination with this procedure. Reduction mammoplasty using liposuction alone has increased in popularity.
Preop diagnosis: Macromastia, gigantomastia, mammary hypertrophy
Summary of Procedures
|
Position |
Supine, arm abducted 90° |
|
Incision |
Marked preop. Most have circumareolar incision with an inferior anchor-shaped extension (Fig. 11.2-2) or a short vertical component (“lollipop” scar). |
|
Antibiotics |
Cefazolin 1 g iv |
|
Unique considerations |
May place patient in sitting position during procedure to assess symmetry; Foley catheter; SCDs |
|
Surgical time |
2–5 h, depending on volume of reduction and technique |
|
Closing considerations |
May place patient in sitting position for application of dressings. |
|
EBL |
100–200 mL |
|
Postop care |
Outpatient or 24–h stay for pain/nausea management. Avoid the use of Toradol in the first 24 h because of the large, raw surface created between the skin flaps and breast tissue. |
|
Mortality |
Minimal |
|
Morbidity |
Dehiscence: 5% |
|
Pain score |
3–4 |
Patient Population Characteristics
|
Age range |
25–65 yr |
|
Incidence |
104,455 performed in the United States in 20061 |
|
Etiology |
Developmental; child-bearing; obesity |
|
Associated conditions |
None common |
Anesthetic Considerations
See Anesthetic Considerations following Mastopexy/Breast Lift, p. 1089.
Suggested Readings
P.1088
Mastopexy/Breast Lift
Surgical Considerations
Description: Mastopexy procedures reduce the volume of the skin envelope to match the volume of the breast gland. Depending on the degree of ptosis (“droopy breasts”) and the wishes of the patient, the ptosis may be treated by augmentation alone to increase the volume of the breast, by skin excision alone to reduce the skin envelope appropriately, or by a combination of a mastopexy and an augmentation.
The operation itself resembles a reduction mammoplasty, except that breast tissue is generally excised minimally or not at all, and an implant may be added (mastopexy/augmentation). The patient is marked before surgery in the upright position. After the induction of anesthesia, the arms are positioned either on the abdomen or abducted 90°. The procedure begins with the areola being marked circumferentially with an areola sizer, and then incised. Next, the skin flaps are elevated. The breast tissue is moved to a higher position on the chest wall, and the skin is redraped and tailor-tacked closed. The patient is placed in a sitting position to assess for symmetry and nipple location. The nipple-areola complex is then brought out into its new position, and dressings are applied.
Preop diagnosis: Breast ptosis
Summary of Procedures
|
Position |
Supine |
|
Incision |
Circumareolar ± inferior vertical extension or complete anchor |
|
Antibiotics |
Cefazolin 1 g iv |
|
Unique considerations |
May place patient in sitting position during procedure. |
|
Surgical time |
2–4 h |
|
Closing considerations |
May place patient in sitting position for application of dressings. |
|
EBL |
> 100 mL |
|
Postop care |
Outpatient or 24-h stay |
|
Mortality |
Minimal |
|
Morbidity |
Wound healing: 5% |
|
Pain score |
3–4 |
Patient Population Characteristics
|
Age range |
35–65 yr |
|
Incidence |
103,788 performed in the United States in 2006 |
|
Etiology |
Age-related ptosis; involution after breastfeeding; weight loss |
|
Associated conditions |
None common |
P.1089
Anesthetic Considerations for Mammoplasty/Mastopexy
Preoperative
Typically, three patient populations present for mammoplasty: (a) healthy individuals, for breast reduction/augmentation/lift or removal of an implant; (b) morbidly obese, for breast reduction; (c) breast cancer patients, for reconstruction after mastectomy. (For preop considerations in the morbidly obese patient, see Anesthetic Considerations for Abdominoplasty, p. 1094.) Breast cancer patients undergoing mastectomy with immediate reconstruction will not have had either chemotherapy or radiation. The following considerations are for breast cancer patients undergoing delayed reconstruction postchemotherapy.
|
Respiratory |
Pulmonary fibrosis may complicate chemotherapy. Alkylating agents (e.g., cyclophosphamide and melphalan), used to treat breast cancer, have some pulmonary toxicity. Consider pulmonary fibrosis in a patient reporting dyspnea, nonproductive cough, and fever. |
|
Cardiovascular |
Cardiomyopathy and CHF may result from chemotherapy, especially doxorubicin (Adriamycin) > 550 mg/m2. |
|
Neurologic |
Note any previous damage to long thoracic nerves, as evidenced by winged scapula deformity. |
|
Musculoskeletal |
Avoid iv and BP cuff on mastectomy side. |
|
Hematologic |
Leukopenia, thrombocytopenia, and anemia from chemotherapy may be present. |
|
Renal/Hepatic |
Methotrexate can produce some renal and hepatic dysfunction. |
|
Laboratory |
Other tests as indicated from H&P, prior chemotherapy, obesity. |
|
Premedication |
Midazolam 1–2 mg iv immediately preop. Surgeon may want to mark the patient's skin preop, with patient standing. Delay premedication until this has been done. |
Intraoperative
Anesthetic technique: GETA
|
Induction |
Standard induction (see p. B-2). [check mark] with surgeons regarding use of a nerve stimulator during dissection (and the need to avoid muscle relaxants). Consider LTA to minimize coughing during position changes. |
|
|
Maintenance |
Standard maintenance (see p. B-2). Surgeons may want patient sitting for part of the procedure. Pneumothorax should be considered with any change in lung inflation pressure, O2 sat, or BP. |
|
|
Emergence |
During some of the procedure and for application of dressing, patient may be moved to sitting position, with consequent coughing, bucking, etc. (Rx: deeper anesthesia, e.g., propofol 0.5 mg/kg or lidocaine 1 mg/kg.) Watch BP carefully and treat orthostatic hypotension if it occurs, usually with a fluid bolus if the patient is not fluid sensitive (Hx of CHF or renal failure). |
|
|
Blood and fluid requirements |
IV 16–18 ga × l |
Minimal blood loss for simple reconstruction, augmentation, or reduction; larger blood losses anticipated for combined procedures (e.g., mastectomy with immediate reconstruction or flap reconstruction). |
|
Monitoring |
Standard monitors (p. B-1) |
Arterial line in the morbidly obese |
|
Positioning |
Patient may need to be sitting for application of dressing. |
Avoid HTN, bucking, and straining; these may cause or exacerbate bleeding at reconstruction site. Careful padding and unwrapping of arms to protect them during position change. |
P.1090
Postoperative
|
Complications |
Pneumothorax |
|
Pain management |
PCA (see p. C-3) |
Suggested Readings
Brachioplasty
Surgical Considerations
Description: Brachioplasty is performed as outpatient surgery for patients who note “flabbiness” or a “bat-wing” appearance of their upper arms. Markings are done in the preoperative holding area with the patient upright, arms abducted and flexed. An incision is made starting along the chest wall or in the axilla, extending onto the upper arm and stopping before the elbow. Excess skin and soft tissue are excised, and the incision is closed, sometimes over a drain. Dressings are applied, often followed by a compression garment or ACE wraps.
Usual preop diagnosis: Upper arm laxity or redundancy, lipodystrophy.
Summary of Procedures
|
Position |
Supine, arms abducted |
|
Incision |
From chest/axilla, extending along lower inner arm |
|
Unique considerations |
Both arms must be mobile and prepped circumferentially; SCDs |
|
Antibiotics |
Cefazolin 1 g iv |
|
Surgical time |
1–2 h |
|
EBL |
Minimal |
|
Postop care |
Avoid ketorolac first 24–48 h |
|
Mortality |
Minimal |
|
Morbidity |
Seroma: 10% |
|
Pain score |
3–4 |
P.1091
Patient Population Characteristics
|
Age range |
20–65 yr |
|
Male:Female |
1:50 |
|
Incidence |
14,886 performed in the United States in 2006 |
|
Etiology |
Overweight; aging; massive weight loss |
|
Associated conditions |
Obesity |
Anesthetic Considerations
Preoperative
Patients presenting for brachioplasty have often undergone gastric bypass surgery with massive weight loss. If morbidly obese an appropriate preoperative work up should be performed. IV access may be difficult. Consider need for IV access in lower limb or neck due to bilateral arm surgery. (See Anesthesia considerations in morbid obesity, p. 502.)
Intraoperative
Anesthetic technique: GETA, routine monitors
Procedure may be combined with other plastic procedures, necessitating position changes.
|
Induction |
Standard induction (see p. B-2) for healthy patients. Special considerations for the morbidly obese include prophylaxis for aspiration, followed by rapid-sequence induction in an appropriately positioned patient (seeFig. 7.2-6). If mandibular and cervical mobility are decreased by excessive soft tissue, plan awake fiber optic intubation (see p. B-5) with the patient sitting. Anticipate rapid O2 desaturation during periods of hypoventilation, even with adequate preoxygenation. |
|
Maintenance |
Standard maintenance (see p. B-2). Calculate drug dosage on basis of lean body mass. In the obese, controlled ventilation with large TV and high inspired O2 concentration is recommended. Positioning may be difficult and care must be taken to give adequate padding and support. |
|
Emergence |
Give antiemetics (ondansetron 4 mg) 20 min before conclusion of surgery. |
|
Blood and fluid requirements |
Minimal blood loss, 18 ga × 1 |
|
Monitoring |
Standard monitors |
P.1092
Postoperative
|
Pain Management |
PCA |
|
Tests |
As indicated by patient condition |
Suggested Readings
Abdominoplasty
Surgical Considerations
Description: Patients who present for abdominoplasty have laxity in the abdominal wall musculature and excess skin and adipose tissue. This laxity may be associated with rectus muscle diastasis. Liposuction often is performed before abdominoplasty to remove additional adipose tissue and improve contour.
Incision lines are marked on the patient preoperatively in the upright position (Fig. 11.2-3). The umbilicus is circumscribed, with care taken to preserve its blood supply. An incision is made above the pubic hairline and extended
P.1093
bilaterally to each anterior superior iliac spine. Electrocautery is used to raise a flap of skin, subcutaneous tissue, and fat at the level of the abdominal wall fascia. The dissection extends cephalad to the costal margin. The operating table is flexed to place the patient in the semi-Fowler position. The elevated flap is pulled down to overlap the inferior incision, and the redundant soft tissue is excised in a tailor-tack fashion (Fig. 11.2-4). The surgical area is inspected for hemostasis and irrigated. Sutures may be placed to plicate the abdominal wall musculature if there is laxity. Fibrin sealant may be sprayed to aid in hemostasis. The wound is closed over drains, and the umbilicus is brought out through a new incision. Dressings, which may include an abdominal binder, are applied. The patient is maintained in the semi-Fowler position during transfer from the operating table. The patient may elect to have the procedure as an outpatient or with an overnight stay in a monitored facility.
|
Figure 11.2-3. Abdominoplasty, markings for incisions. (Reproduced with permission from Aston SJ, Beasley RW, Thorne CHM: Grabb & Smith's Plastic Surgery, 5th edition. Lippincott-Raven: 1997.) |
|
Figure 11.2-4. After the lower incision has been made and the abdominal flap has been elevated, the flap is pulled down to overlap the inferior incision, and the redundant soft tissue is excised in a tailor-tack fashion. (Reproduced with permission from Aston SJ, Beasley RW, Thorne CHM: Grabb & Smith's Plastic Surgery, 5th edition. Lippincott-Raven: 1997). |
Variant procedure or approaches: Patients who require additional width reduction may have a fleur de lis abdominoplasty (vertical midline extension of incision and scar). Panniculectomy (simple resection of overhanging skin and soft tissue) can be performed alone without the fascial plication, particularly in the case of morbidly obese patients. Mini-abdominoplasty may be performed in those patients who require less extensive dissection.
Usual preop diagnosis: Abdominal wall laxity; rectus diastasis; lipodystrophy; redundant skin and soft tissue
Summary of Procedures
|
Position |
Supine |
|
Incision |
Extended Pfannenstiel's; periumbilical; vertical midline extension if needed |
|
Unique considerations |
Foley catheter; SCDs |
|
Antibiotics |
Cefazolin 1 g iv |
|
Surgical time |
1.5–4 h |
|
Closing considerations |
Flex table to facilitate closure; patient must subsequently remain in semi-Fowler position. |
|
EBL |
~100 mL, not including blood contained in specimen. |
|
Postop care |
Maintain flexed position; avoid ketorolac in the first 24–48 h. |
|
Mortality |
0–1% |
|
Morbidity |
Ileus: 10% |
|
Pain score |
4–6 |
P.1094
Patient Population Characteristics
|
Age range |
20–65 yr |
|
Male:Female |
1:25 |
|
Incidence |
146,240 performed in the United States in 2006; fifth most common cosmetic surgical procedure. |
|
Etiology |
Overweight; laxity of skin after pregnancy; massive weight loss |
|
Associated conditions |
Obesity |
Anesthetic Considerations
Preoperative
Typically, there are two patient populations for abdominoplasty: the generally healthy, and the morbidly obese. Some patients have Hx of amphetamine, cocaine, or thyroid hormone abuse, and ↑ incidence of hiatal hernia. The following considerations focus on the morbidly obese patient (body weight ≥ 2 × ideal weight. Ideal body weight can be estimated by subtracting 100 (male) or 105 (female) from height in cm).
|
Respiratory |
In the morbidly obese patient, findings include: ↑ O2 consumption, ↑CO2 production, restrictive lung disease, ↓ FRC, ↓ ERV, ↓ VC,↓ IC, and ↓ PaO2. These changes are exacerbated by the supine position. Younger patients may show alveolar hyperventilation in response to hypoxemia; older patients may not, and may retain CO2. Patients may have obesity hypoventilation syndrome (Pickwickian syndrome) and sleep apnea; with intermittent airway obstruction, hypoxemia, and hypercarbia during sleep, which may → pulmonary HTN. Obese patients are at ↑ risk of pulmonary aspiration due to ↑ incidence of hiatal hernia, GERD, and ↑ gastric volumes (typically > 25 mL with pH < 2.5). See Premedication, below, for aspiration prophylaxis. |
|
Cardiovascular |
↑ CO and ↑ blood volume → LVH. Chronic hypoxia and pulmonary compromise may produce right heart failure, ↓↓ exercise tolerance, ↑ risk of CAD, and pulmonary systemic HTN. Patients with LVH may have ↑dysrhythmias. Some patients may have previously taken fenfluramine alone or in combination with phentermine for weight loss. Those patients should be evaluated for pulmonary HTN (e.g., dyspnea, central cyanosis, right axis deviation, and CXR changes) and valvular heart disease. |
|
Metabolic |
Increased incidence of diabetes, hypercholesterolemia, hypertriglyceridemia, liver abnormalities, ↓ plasma folate, B12, ↑ incidence of cholelithiasis, nephrolithiasis. Determine whether electrolyte abnormalities are present in patient S/P ileojejunal bypass. |
|
Hematologic |
Polycythemia suggests chronic hypoxemia (see Respiratory, above). |
|
Laboratory |
Other tests as indicated from H&P. |
|
Premedication |
Sedative premedication is avoided in the morbidly obese due to their pulmonary compromise. Aspiration prophylaxis is essential: ranitidine 100 mg po or iv the evening before, and 60–90 min before surgery, plus nonparticulate antacid (Na citrate 0.3 M, 30 mL po) preinduction. Additionally, metoclopramide 10 mg iv may be given, although it has not been shown to be more effective in combination with an H2-blocker than the H2-blocker alone. For the healthy outpatient, midazolam 1–2 mg iv immediately preop may lessen anxiety. |
P.1095
Intraoperative
Anesthetic technique: GETA. Morbidly obese patients may not tolerate the supine position for an extended period of time. Consider placement of thoracic epidural for postop pain control.
|
Induction |
Standard induction (see p. B-2) for healthy patients. Special considerations for the morbidly obese include prophylaxis for aspiration (see above), followed by rapid-sequence induction in an appropriately positioned patient (see Fig. 7.2-6). If mandibular and cervical mobility are decreased by excessive soft tissue, plan awake fiber optic intubation (see p. B-5) with the patient sitting. Anticipate rapid O2 desaturation during periods of hypoventilation, even with adequate preoxygenation. |
||
|
Maintenance |
Standard maintenance (see p. B-2). Calculate drug dosage on basis of lean body mass. In the obese, increased plasma fluoride concentrations are found after anesthesia with halothane and enflurane; controlled ventilation with large TV and high inspired O2 concentration is recommended. Because epinephrine infiltration generally is used to decrease blood loss, isoflurane is recommended as the least dysrhythmogenic of the inhalation agents in the presence of epinephrine. *NB: Midazolam has a prolonged half-life in obese patients, but awakening times from inhalational or narcotic-based anesthetics are comparable to those of nonobese patients. |
||
|
Emergence |
Smooth emergence with minimal bucking, coughing, or retching to minimize tension on the suture line; give antiemetics (metoclopramide 10 mg and ondansetron 4 mg) 20 min before conclusion of surgery. Maintenance of flexed position will minimize tension on suture line. Small additional doses of narcotic (e.g., meperidine 10 mg) may be titrated to RR if patient is allowed to resume spontaneous respiration before the end of the case. |
||
|
Blood and fluid requirements |
Moderate blood loss |
||
|
Monitoring |
Standard monitors (see p. B-1). |
Additional monitoring for the morbidly obese patient may include arterial and CVP lines. |
|
|
Positioning |
Flexed position |
Flexed position minimizes tension on suture line. Morbidly obese may require two OR tables side-by-side. Supine position may be poorly tolerated; monitor ventilation closely. |
|
|
Complications |
Fat emboli |
More common during liposuction. |
|
P.1096
Postoperative
|
Complications |
Patients may have postop ileus of 1–2 d duration. |
The morbidly obese should not be outpatients; they have an ↑ incidence of wound infection, DVT, PE, and postop pulmonary complications. Provide supplemental O2 for the first 2 d postop. Keep patient in semisitting or flexed position to avoid undue stress on wound. |
|
Pain management |
Epidural narcotics or PCA may be used (p. C-3). |
Monitor patient for postop respiratory depression. |
|
Tests |
Pulse oximetry |
Maximum reduction of arterial saturation may occur on postop day 2–3. |
Suggested Readings
Body Lifts
Surgical Considerations
Description: With heightened awareness of the importance of nutrition and exercise as well as the advent of improved gastric bypass and restriction techniques, more patients with massive weight loss are presenting to plastic surgeons for treatment of the resultant skin excess and laxity. Patients frequently have multiple areas of concern, from the face (seeFacelifts) to the breasts (see Mastopexy) to the abdomen and thighs. Often patients will require circumferential torso plasty (combining Abdominoplasty with a modified buttocks lift), and/or extensive lower body work (medial and lateral thigh lifts). All of these body lift procedures may be combined with liposuction for additional contouring.
The patient is marked in the standing position in the preoperative holding area. Depending on surgeon preference, the initial operative position may begin supine, lateral decubitus, or prone. Incisions are made, and the marked excess skin and soft tissues are elevated and excised. The patient's position is changed as needed to allow for access to all of the surgical areas. Drains are placed. During wound closure, care is taken to close in several layers, beginning with the strength layer of the superficial fascial system. Dressings are applied, and compression garments or ACE wraps may also be used. The patient may elect to have the procedure as an outpatient but frequently choose to stay overnight in a monitored facility.
Usual preop diagnosis: Thigh and buttock laxity; lipodystrophy; redundant skin and soft tissue
P.1097
Summary of Procedures
|
Position |
Multiple: supine, lateral decubitus, prone |
|
Incision |
Depending on the combination of procedures; may include circumferential waistline, transverse groin crease, possible medial thigh vertical extension |
|
Unique considerations |
Foley catheter; knee-high SCDs; appropriate pressure point padding |
|
Antibiotics |
Cefazolin 1 g iv |
|
Surgical time |
2–6 h |
|
EBL |
50–100 mL, not including blood contained in specimen |
|
Postop care |
Avoid ketorolac in the first 24–48 h; maintain semi-Fowler position for any procedures involving abdominoplasty |
|
Mortality |
Minimal |
|
Morbidity |
Seroma: 1–16% |
|
Pain score |
4–6 |
Patient Population Characteristics
|
Age range |
20–65 yr |
|
Male:Female |
1:4 |
|
Incidence |
Thigh lift: 12,295 performed in the United States in 2006 |
|
Etiology |
Overweight; massive weight loss |
|
Associated conditions |
Obesity |
Anesthetic Considerations
Patients may have had massive weight loss, or may be morbidly obese. (See anesthetic considerations for abdominoplasty, p. 1094). Body lift procedures may be combined with liposuction. (See anesthetic considerations, see p. 1099.)
Suggested Readings
P.1098
Liposuction
Surgical Considerations
Description: Liposuction remains the most commonly performed cosmetic surgical procedure in the United States. The surgical technique has changed since the introduction of the procedure in the late 1970s. For example, the preaspiration injection of epinephrine-containing wetting solution into the adipose tissue has expanded the use of the surgical procedure. Patients who desire a more dramatic cosmetic surgical result may now have larger volumes of fat removed safely, without losing large quantities of blood during surgery. All members of the surgical team must function in a coordinated fashion to avoid the many pitfalls associated with liposuction. Complications such as PE, fat emboli, fluid overload, toxicity from local anesthetics, and body-cavity perforation from both the wetting solution cannula and the suctioning cannula have been reported.
The current standards for performance of liposuction involve the use of an epinephrine-containing wetting solution injected into the subcutaneous tissue prior to aspiration. Most wetting solutions contain 1 L of LR, to which 1 mg of epinephrine and 200–500 mg of lidocaine are added. Epinephrine in the 1/1,000,000 concentration will provide excellent vasoconstriction in the adipose tissue before suctioning. The concentration of lidocaine depends on the primary anesthetic modality. For patients having GA or regional anesthesia, the lower concentration of local anesthetic will provide satisfactory postop analgesia. Higher concentrations of local anesthetic are needed for patients having liposuction under local anesthesia/MAC. Following administration of the wetting solution to the surgical region, 10–20 min is allowed for vasoconstriction to take place before suctioning. The large volume of local anesthetic and epinephrine-containing solution represents substantial risk to the patient (local anesthetic toxicity, HTN, cardiac arrhythmia, coronary insufficiency), along with the risk of perforation with the cannula.
Ultrasonic liposuction may be used to liquefy fat in the surgical region prior to or simultaneously with its removal. Power-assisted liposuction utilizes pressurized gases or an electrical motor to power the tip of the lipo cannula to improve the efficiency of the procedure. Complications reported during the use of the new technologies include seroma formation, increased blood loss, and increased risk of body cavity perforation.
Following completion of the surgery, incision sites are closed and sterile dressings are applied. Compressive garments may be worn by the patient for several d or wk, depending on the extent of the surgery. Discomfort in the surgical regions varies greatly from patient to patient, but may last from several d to several wk. Ultrasonic liposuction is now being used for the treatment of axillary osmidrosis (hyperhydrosis). Ultrasonic energy applied in the superficial planes of the skin of the axilla has successfully treated hyperhydrosis in a large number of patients. The procedure may be performed under local or general anesthesia.
Usual preop diagnosis: Obesity
Summary of Procedures
|
Position |
According to body region (repositioning often required). |
|
Incision |
Incisions may be hidden in skin folds. The use of long injection and lipo cannulas will reduce the number of incisions. |
|
Special instrumentation |
Cannulas, aspirating machine; ultrasonic or power-assisted machinery |
|
Antibiotics + other meds |
Cefazolin 1 g. Dexamethasone 8 mg may be given during surgery. |
|
Surgical time |
2–7 h, depending on volume of resection and number of surgical sites |
|
EBL |
2–8% of total aspirate volume when using wetting solution before aspiration |
|
Postop care |
PACU for small-volume liposuction; hospitalization or postop monitoring for large-volume resection (> 5,000 mL) |
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Mortality |
19.1/100,000 |
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Morbidity |
Pulmonary emboli |
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Unique considerations |
Wetting solution must be warmed before use to prevent hypothermia. Foley catheter monitoring is used for larger volume surgeries. TEDs, SCDs used on all cases. |
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Pain score |
4–6 |
P.1099
Patient Population Characteristics
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Age range |
Teens–70 yr |
|
Male:Female |
< 1:9 |
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Etiology |
Quest for eternal youth |
Anesthetic Considerations
Preoperative
Patients considering liposuction should be in ASA category I or II. The ideal candidate for surgery should be physically active and have maintained a stable weight Hx for 6 mo–1 yr. Preop consultation with the surgical team is necessary for finalizing the anesthetic plan. Current techniques use the injection of wetting solution to reduce blood loss and to deliver local anesthetics for postop analgesia. Most wetting solutions contain lidocaine 200–500 mg/L combined with epinephrine 1 mg/L (1/1,000,000). Typically, 1 mL of wetting solution will be used for each l mL of anticipated fat resection. Because of the demand for more dramatic results, larger fat resections (large-volume liposuction > 5,000 mL) are being performed. These large-volume procedures may require postop hospitalization for patient monitoring (fluid shifts, ↓ Hct, pulmonary edema). Large volumes of wetting solution often are used in these procedures and require limiting iv fluids during surgery. In contrast, small-volume liposuction often requires larger volumes of iv fluid administration because of the small volumes of wetting solution that would be available for postop hydration.
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Respiratory |
Postop discomfort following chest, upper back, and upper abdomen liposuction may interfere with respiration. Restrictive compression garments applied to the chest or upper abdomen also may restrict breathing. Patients with respiratory impairment may not be candidates for this procedure. |
|
Cardiovascular |
Patients with Hx of CHF or those with MVP may not be candidates for high-volume liposuction. Fluid management is based on volume status and the quantity of tumescent fluid injected during surgery. Tumescent solution injected into the subcutaneous tissue is absorbed over 48 h. Postop pulmonary edema has been reported 2° fluid overload in patients receiving larger volumes of tumescent injection. Some patients may have previously taken fenfluramine alone or in combination with phentermine for weight loss. Those patients should be evaluated for pulmonary HTN (e.g., dyspnea, central cyanosis, right axis deviation and CXR changes) and valvular heart disease. All weight control drugs should be D/C'd at least 2 wk before surgery. |
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Neurologic |
Preop neurologic exam should be normal. Local anesthetic administration during tumescent injection may cause areas of numbness postop. |
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Hematologic |
Vasoconstriction from epinephrine-containing wetting solutions greatly reduces blood loss to 2–8% of the total aspirate volume. Blood transfusion is rarely needed, even in larger volume resections. |
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Laboratory |
Other tests as indicated from H&P. |
|
Premedication |
Midazolam 1–2 mg or oral benzodiazepine (e.g., lorazepam 1 mg po 1–2 h preop) |
P.1100
Intraoperative
Anesthetic technique: Local anesthesia may be suitable for smaller volume liposuction. Regional anesthesia (spinal, epidural) may be used when the surgical regions are appropriate for this type of anesthetic. Concerns have been raised because of vasodilation →↑ blood loss +↑ fat embolization with regional anesthesia. GA ensures patient comfort and allows liposuction to be done on all body regions. Airway and ventilation control also provides safety during the surgery. SCDs or foot/ankle compression devices are used for all patients to reduce the risk of PE.
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Induction |
Standard induction (see p. B-2). Steroids (dexamethasone 8 mg) may be used to reduce postop swelling and may be of benefit in the event of fat embolism. |
|
|
Maintenance |
Standard maintenance (see p. B-2) with volatile anesthetics or propofol infusion. Neuromuscular blockade as appropriate. GA is maintained during application of compression garments. |
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|
Emergence |
Antiemetic prophylaxis with metoclopramide (10–20 mg) and ondansetron (4 mg) is appropriate. Careful monitoring of respiratory function is necessary when surgery has been performed on the chest, back or upper abdomen, since compression garments may limit respiration. |
|
|
Blood and fluid requirements |
IV: 18 or 20 ga × 1 |
NS/LR volume determined by the needs of the case. Transfusion rarely needed, diuretics (e.g., furosemide 5–10 mg) may be needed for patients receiving large volumes of wetting solution. Larger intravenous fluid volumes are needed during smaller volume liposuction and restriction of IV fluid may be needed during large volume liposuction because of absorption of large volumes of wetting solution into the circulation. |
|
Monitoring |
Standard monitors (seep. B-1). |
UO monitoring mandatory on all large-volume lipo cases. Careful temperature monitoring. |
|
Positioning |
[check mark] and pad pressure points. |
Frequent intraop position checks are needed as patient position may change during surgery → potential for peripheral nerve injury. Documentation of avoidance of external ocular pressure Q 15 minutes while patients are in the prone position. |
|
Complications |
Local anesthetic toxicity |
Lidocaine 35–55 mg/kg has been shown to produce safe serum levels when used in a highly dilute solution (0.05–0.1%) with epinephrine for tumescent injection during liposuction. Peak plasma lidocaine level occurs 10–12 h after infusion. Peak epinephrine levels occur 5–6 h after infusion and leads to increases in cardiac index, heart rate. |
|
Hypothermia |
Vigorous efforts needed to maintain body temperature (e.g., fluid warmer, Bair-Hugger). |
|
P.1101
Postoperative
|
Complications |
Hypoxemia |
Consider fluid overload, fat embolism, pneumothorax or pulmonary edema in differential diagnosis (DDx). |
|
HTN |
Consider fluid overload and epinephrine effect in DDx. |
|
|
Respiratory compromise |
May be 2° compression garments and pain. |
|
|
Pain management |
PO analgesics |
Patients often will be comfortable 2° residual local anesthesia, which may persist for 8–24 h. Oral analgesics are usually satisfactory for postop pain control. |
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Tests |
Hct |
[check mark] Hct |
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