Anesthetic considerations for plastic surgery

Question 1

Plastic surgery can be performed under _____ and at the following locations____

Answer 1

local, regional, MAC, & GA

ambulatory or same-day surgery & office-based procedures

Question 2

______ is the most popular plastic surgery

Answer 2

breast augmentation (although it changed to rhinoplasty during covid)

Question 3

The most frequent complications of plastic surgery include

Answer 3

DVT & PE*****

Question 4

For patients undergoing plastic surgery, we are most concerned with

Answer 4

DVT/PE prophylaxis
liposuction guidelines on lidocaine/epinephrine doses
adequate hydration

Question 5

The most common procedures for women include

Answer 5

breast augmentation>liposuction>blepharoplasty

Question 6

the most common procedures for men include

Answer 6

liposuction, rhinoplasty, blepharoplasty

Question 7

For the pre-anesthesia evaluation of the patient presenting for a plastic procedure, it is important to consider

Answer 7

most patients are healthy
low tolerance of errors or side effects
explain anesthetic techniques-risks/benefits
gain patient trust
reduce anxiety
complete H&P b/c plastic surgeon doesn’t always do a good job of this
NPO: 8 hours solid food & 2 hours liquid

Question 8

Describe the typical patient undergoing plastic surgery.

Answer 8

most patients are 35-50 years of age; facial surgery usually >50 years
most ASA I/II
overweight patients may seek skin removal surgery following bariatric surgery
if patient >50 years, should have clearance by internist
pregnancy testing recommended in women of childbearing age

Question 9

A concern with medications regarding patients undergoing plastic surgery includes

Answer 9

54% of patients taking herbals that interfere with anesthetics/surgery & 85% are not told to stop before surgery

Question 10

In regards to the patient history, the patient may have

Answer 10

co-morbidities that are missed by the plastic surgeon

Question 11

For PONV prophylaxis, it is necessary to

Answer 11

give two or more agents

Question 12

______ preoperatively has been shown to reduce anxiety, decrease postoperative pain intensity and opioid consumption, improve postoperative sleep quality and reduce postoperative/emergence delirium.

Answer 12

Melatonin 3-10 mg

Question 13

If the surgery is longer than 4 hours, then

Answer 13

foley catheter should be inserted

Question 14

Goals for emergence of the plastic patient include

Answer 14

no increase in BP/HR, no bucking and no respiratory complications

Question 15

____ is often used on eyelids

Answer 15

ophthalmologic lubricant & sterile tape

Question 16

Regional anesthesia techniques provide for

Answer 16

fewer complications, safer recovery, & better postoperative analgesia

Question 17

With BIS monitoring, there is a ____ delay from real time

Answer 17

15-30 second

Question 18

BIS is useful in conjunction with ____ -that monitors electrical activity of frontalis muscle between eyebrows- spikes suggest patient arousal

Answer 18

electromyogram

Question 19

Risks with general anesthesia include

Answer 19

difficult intubation, failed intubation, kinked/occluded ETT, dental damage, AGM errors, MH
“room air general” - risk of airway fire
LMA is frequently used in plastic surgery

Question 20

Local anesthesia by plastic surgeon may be used for

Answer 20

blepharoplasty, chin implant, liposuction

Question 21

Spinal anesthesia can be done for

Answer 21

safe, early discharge, low cost, & rare complications
liposuction, buttocks implants, calf implants, & possibly for breasts
can add adjuvant (clonidine, fentanyl, sufentanil) for surgeries longer than 2 hours

Question 22

Breast procedures include

Answer 22

breast augmentation
breast reduction
breast lift

Question 23

Describe the blood supply to the breast

Answer 23

internal mammary artery for the medial aspect
lateral thoracic artery for the lateral aspect
venous drainage- superficial veins under dermis & deep veins that parallel the arteries
lymph drainage via retromammary lymph plexus in the pectoral fascia

Question 24

Describe the nerve supply for the breast

Answer 24

peripheral nervous system innervation of the anterior and lateral cutaneous branches of the 4th, 5th, and 6th intercostal nerves
thoracic spinal nerve, T4, innervates nipple-areola complex

Question 25

A breast augmentation can be performed for _____ patients

Answer 25

healthy versus breast cancer

Question 26

Breast augmentation can be performed under

Answer 26

regional- less PONV, pain, decreased cost general (VA/IV), cervicothoracic epidural, intercostal block, fascial plane block, tumescent injection with lidocaine cervicothoracic epidural (C7-T4) better analgesia than general anesthesia Adjunct: fascial plane blocks- no sympathetic blockade, hemodynamic stability

Question 27

Describe the incision approaches for breast augmentation.

Answer 27

infra-mammary, peri-areolar, trans-axillary

Question 28

Describe the implant types & where it is placed for breast augmentation.

Answer 28

implant placed in pocket under mammary gland or pectoralis muscle silicone or saline implants

Question 29

Describe the location of postop pain for breast augmentation.

Answer 29

sternum, lateral thorax, middle back | can give NSAIDs, low-dose opioids, & tramadol

Question 30

The anesthetic changes for breast augmentation include:

Answer 30

position changes: head secured to table, eye protection, arms padded and wrapped to arm boards, extensions on PIV, extension on circuit -bra placed at end of case pain management

Question 31

Complications of breast augmentation include.

Answer 31

capsular contracture, hematoma, infection, wound dehiscence

Question 32

The most common cancer globally is

Answer 32

breast cancer 1 in 8 women will develop Ashkenazi Jewish women have high risk d/t BRCA most common in black women under 45 85% have no family history of breast cancer

Question 33

Breast surgery can be performed for

Answer 33

excisional biopsy, breast biopsy, & lumpectomy

Question 34

Describe considerations for breast biopsy

Answer 34

GA, regional, or local with sedation supine, arms abducted, table turned outpatient, minimal EBL; 1-1.5 hours

Question 35

Describe considerations for lumpectomy.

Answer 35

wire guided (radiology- wire inserted under fluoroscopy)--> don't touch the cup - GA, regional, local with sedation - supine - avoid muscle relaxants b/c of axillary node removal possibility - <1.5 hours, outpatient procedure

Question 36

With a sentinel lymph node biopsy,

Answer 36

the axillary node may be dissected- NO relaxation*** used for small, invasive breast cancer dye injected around breast wait for pathology (if positive nodes--> axillary dissection) Gamma probe used to identify tracer in lymph nodes Transient drop in pulse oximetry, allergic reaction***

Question 37

Damage to the long thoracic nerve results in

Answer 37

(motor) winged scapula*** from the paralysis of the serratus anterior muscle radical mastectomies or with any removal of axillary lymph nodes

Question 38

Damage to the thoracodorsal nerve

Answer 38

(motor) | results in palsy of the latissimus dorsi muscle*****

Question 39

Damage to intercostobrachial nerve (sensory)

Answer 39

results in numbness or pain in the lateral aspect of the axilla & medial aspect of upper arm

Question 40

Intercostobrachial neuralgia causes

Answer 40

post mastectomy pain syndrome | pain in axilla, medial upper arm & anterior chest wall

Question 41

Lymphedema is a complication of mastectomy and is most common with

Answer 41

axillary dissection + axillary radiation

Question 42

Nerve damage and complications of mastectomy include

Answer 42

``` damage to long thoracic nerve damage to thoracodorsal nerve damage to intercostobrachial nerve intercostobrachial neuralgia lymphedema ```

Question 43

Anesthetic considerations for mastectomy include

Answer 43

supine, IV/NIBP/pulse ox on opposite arm EBL 150-500 cc usually admitted overnight 1.5 hours up to 7 hours if reconstruction

Question 44

A total or simple mastectomy involves

Answer 44

removes breast only

Question 45

A modified or partial mastectomy necessitates

Answer 45

postop radiation/chemotherapy

Question 46

A radical mastectomy involves

Answer 46

removal of breast, pectoral muscle, and axillary lymph nodes

Question 47

Describe preoperative considerations for mastectomy

Answer 47

respiratory/airway compromise possible if radiation chemotherapy (cardiomyopathy) metastasis anemia with chemotherapy

Question 48

Describe intraoperative considerations for mastectomy

Answer 48

``` GA (ETT/LMA) or regional avoid muscle relaxants during axillary dissection** position changes pressure dressings during emergence high incidence of PONV ```

Question 49

When performing an immediate breast reconstruction there is

Answer 49

use of either temporary tissue expander or autologous myocutaneous flaps

Question 50

A relative contraindication to breast reconstruction is

Answer 50

postoperative chest radiation

Question 51

FLAPS can include

Answer 51

deep inferior epigastric perforator (DIEP) superficial inferior epigastric artery (SIEA) Transverse upper gracilis (TUG) Gluteal (buttocks) transverse rectus abdominis myocutaneous (TRAM

Question 52

With a DIEP flap, important considerations include

Answer 52

``` nO VASOPRESSORS (microvascular case)**** doppler used to check vessels avoid hypertension/fluid overload indocyanine green may be used to check tissue perfusion ```

Question 53

Describe risks associated with a DIEP flap,

Answer 53

ICU disposition, risk of graft failure, venous congestion, fat necrosis, bleeding

Question 54

A DIEP flap is performed

Answer 54

deep inferior epigastric perforator flap abdominal skin, fat, & deep inferior epigastric vessels are removed and replanted to create new breasts internal mammary artery and vein are transected suprasternal and anastomosed to epigastric vessels

Question 55

The latissimus dorsi flap involves

Answer 55

transfer of back tissues (latissimus muscle, fat, blood vessels, and skin) to the mastectomy site the thoracodorsal artery supplies the flap- left attached to its original supply

Question 56

Following the mastectomy when performing the latissimus dorsi flap,

Answer 56

the patient is turned lateral or prone usually requires implant as well overnight stay in hospital

Question 57

The TRAM flap involves

Answer 57

Transverse rectus abdominis myocutaneous flap- pedicle or free flap type "tummy tuck breast reconstruction" skin, fat, and muscle tunneled from abdomen to chest

Question 58

With the TRAM flap it is important to

Answer 58

avoid hypotension use doppler to check perfusion flap based on superior epigastric vessels

Question 59

Anesthetic considerations for breast reconstruction involve (type of anesthesia & access)

Answer 59

General anesthesia keep warm & hydrated (long cases) vascular access: long procedure time, blood/fluid loss- multiple peripheral IVs

Question 60

Complications related to chemotherapy and breast reconstruction include

Answer 60

myelosuppresion cardiomyopathy with adriamycin pulmonary fibrosis, interstitial infiltrates, pleural effusions with methotrexate, cylcophosphamide, & bleomycin

Question 61

With breast reconstruction ____ should not be used because it can interfere with healing.

Answer 61

N2O

Question 62

Anesthetic considerations for breast reconstruction include

Answer 62

ephedrine> phenylephrine for hypotension (vasoconstriction) -heparin intraoperative foley catheter postoperative pain management (regional block) -Dextran for flap procedures- reduces clot formation in microvasculature, 25-30 mL/h (low molecular weight), monitor for allergic reactions (ARDS)

Question 63

Preoperative evaluation for breast reduction includes

Answer 63

back pain, skin irritation/infection, skeletal deformities, respiratory disorders liposuction may be added

Question 64

Describe the two techniques for breast reduction.

Answer 64

inferior pedicle with long curved horizontal incision across crease beneath breast inferior pedicle with vertical incision and short horizontal at crease (less scaring and shorter time)

Question 65

Describe the anesthetic considerations for breast reduction surgery.

Answer 65

``` general anesthesia frequent position changes longer procedure (3-5+ hours) fluid warmer, bair hugger, foley catheter fluid/volume blood deficits PONV 23 hour stay ```

Question 66

Describe the complications of breast reduction surgery

Answer 66

wound dehiscence, infection, seroma, hematoma, skin flap necrosis, loss of sensation, hypertrophic scarring