19 Plastic surgery

Breast reduction 518

Breast augmentation 520

Correction of prominent ears 521

Facelift (rhytidectomy)  522

Free flap surgery 524

Liposuction 528

Skin grafting 530

Other plastic surgical procedures 532

Monitoring. ECG leads, the pulse oximeter probe, and blood pressure cuff may all be difficult to position adequately.

Vascular access. Position cannulae away from the operative field. Use femoral vessels or the foot if necessary. Long extension sets may be required.

Patients recovering from head and neck procedures are often surprisingly comfortable despite extensive surgery.

Major body cavities and abdominal musculature are usually not involved. The pain experienced after abdominoplasty is significantly less than pain following laparotomy.

Plastic surgery procedures seldom involve new fractures of long bones.

The gastrointestinal tract is usually unaffected. The oral route for drugs is frequently available which may make dosing and administration of analgesics simpler.

Blood loss. Ensure blood has been crossmatched. The initial dissection is usually the period of most blood loss and a moderate hypotensive technique may help to limit this. Thereafter losses may be insidious and ongoing. Aim to keep track by swab weighing, visual estimation, regular haemoglobin or haematocrit estimations.

Fluid balance. Urinary catheterisation is essential. Ensure careful monitoring of fluid balance, especially in children and patients with poor cardiorespiratory function.

Body temperature. Monitor core temperature (e.g. rectal, nasopharyngeal, oesophageal). Maintain temperature by using low fresh gas flows, a heat-moisture exchange (HME) filter, warmed IV fluids, a warm ambient theatre temperature (e.g. 24°C), a heated mattress, or external warming blankets (e.g. ‘Bair Hugger^®’). Take care not to overheat.

Positioning. Ensure that structures such as the cervical spine and brachial plexus are not in positions of stress. Take care with pressure areas. Make liberal use of cotton wool padding (‘Gamgee’) over bony prominences. Raise the heels off the table using foam pads or boots.

DVT prophylaxis. Venous thromboembolism is often initiated during surgery. All patients should receive daily low molecular weight heparin, thromboembolism (‘TED’) stockings, and intermittent calf compression whilst in theatre.

Nasogastric tube. Consider emptying the stomach. Children are especially prone to gastric distension during prolonged procedures.

Eye care. Lightly tape and pad the eyes for protection. Avoid excessive padding, since this may negate the natural protection afforded by the bony orbit. Prophylactic antibiotic ointment is unnecessary. Do not allow corneal abrasion to develop from surface drying.

ET tube cuff pressure. Cuff pressure will gradually increase if N₂O is used. Where possible, recheck the cuff pressure at intervals during the case if possible.

Postoperative care. Discuss the preferred site of postoperative care with the nursing staff and surgical team. Surgeons often prefer patients to return to the plastic surgery ward where wound care and nursing observation may be more attuned to the specifics of the operation. Closer patient observation, invasive monitoring, and regular blood gas estimation may be more achievable in an ICU/HDU. The site for immediate postoperative care is principally dictated by the general condition of the patient.

Patients are usually fit—aged 20–40yr. Many surgeons exclude patients with a body mass index >30 due to a higher incidence of wound breakdown, infection, and haematoma formation.

A mastopexy is a surgical procedure for correcting breast ptosis when breast volume is adequate. Anaesthetic implications are similar. Blood loss is less.

FBC and group and save. Crossmatching is generally unnecessary except for larger reductions.

Timing in relation to the menstrual cycle is unimportant.

All patients should receive DVT prophylaxis (TED stockings, daily low molecular weight heparin).

Place ECG electrodes on the patient's back. Lie the patient on ‘incontinence pads’ to absorb blood loss.

Take care to position the patient carefully on the operating table. The anaesthetic machine is usually at the head end. Ensure that the chest and arms are symmetrical. Confirm that cannulae are firmly positioned and their plastic caps covered with cotton wool/‘Gamgee’ if the hands are to be positioned behind the buttocks. Local pressure damage to skin may otherwise ensue. Drip extension sets are needed; ensure that the drip runs freely.

Blood loss depends on surgical technique. Use of cutting diathermy causes less bleeding than a scalpel. Infiltration with dilute adrenaline-containing LA helps reduce blood loss. All surgeons have their own recipe. Check the dosage being used; in practice this is seldom a concern (see liposuction p. 528).

Fewer than 5% of patients require transfusion. Mild falls in haemoglobin are well tolerated in this young patient group.

Moderate reductions may involve removal of 500g of tissue per breast.

Haematoma formation is an early complication. Occasionally nipple perfusion may be compromised and requires decompression of the pedicle. Return to theatre may be indicated. Later complications include wound infection, dehiscence, and fat necrosis.

Patients are usually fit and well. Check FBC.

Conventional augmentation involves creation of an SC pocket for a silicone implant via an inframammary incision.

Modern techniques involve pocket formation by the insertion of an inflatable capsule mounted on an introducer via a small incision in the anterior axillary line. This is then removed and the implant inserted.

Haematoma formation may require early return to theatre. Later complications include infection, capsule formation, and rupture.

Soybean-oil-filled implants have been withdrawn from use in the UK. There are insufficient data concerning the long-term consequences of soybean oil breakdown. Saline implants are not perceived as sufficiently realistic and are unpopular with many women.

Breast reconstruction following mastectomy is common. Options include insertion of a breast implant, reconstruction with a pedicled myocutaneous flap (e.g. latissimus dorsi or transverse rectus abdominis muscle ‘TRAM’), and a free flap repair (usually TRAM).

Surgery is offered as the child grows older and is aware of prominent ears. Often precipitated by teasing at school. Child may be self-conscious and anxious.

Obtain consent for suppositories.

Anaesthetic machine usually at the foot end.

PONV is common. Propofol maintenance is well tolerated.

Avoid morphine. Use shorter-acting opioids (fentanyl or alfentanil) and NSAIDs.

Surgeons use extensive LA/adrenaline infiltration to aid surgery. This provides good analgesia.

20ml/kg crystalloid IV may improve the quality of early recovery.

Dressings should be firm without being excessively tight. Scalp discomfort and itching can be a source of irritation.

Excessive pain may be due to haematoma formation and requires a return to theatre for drainage.

NSAIDs should be discontinued for at least 2wk prior to surgery.

Incisions are placed in concealed areas (e.g. preauricular, extending up to the temporal region within the hair). The skin is mobilised by SC undermining and wrinkles/skin folds are improved by traction. Redundant skin is excised. Surgery is adapted to suit the needs of the patient and may include forehead lift, upper and lower blepharoplasty, and removal of submental/submandibular fat. It is occasionally combined with septorhinoplasty.

Discuss the choice of airway device with the surgeon (e.g. oral tube or nasal north-facing). Consider using a throat pack if there is nasal surgery.

The anaesthetic machine is usually at the patient's foot end. Long breathing system tubing and drip extension sets are required.

A moderate hypotensive technique (70–80 systolic) and 30° head-up tilt will help minimise blood loss and improve surgical conditions. Remifentanil is ideal.

Use routine antiemetics.

LA infiltration and specific nerve blocks provide good postoperative pain relief.

Use a warming blanket.

There is a requirement for morphine in the immediate recovery period and to facilitate a smooth emergence, but pain is not a prominent feature of facelift. Discomfort is attributed to platysma tightening. Regular postoperative NSAIDs and simple analgesics are required. Marked pain should raise the suspicion of haematoma formation.

Recent advances have involved more extensive procedures with deeper tissue undermining. These are all performed under GA. The composite facelift mobilises platysma, cheek fat, and orbicularis oculi muscle. This flap is then repositioned en bloc with the overlying skin. Complications are more frequent.

The aim of anaesthesia is to produce a hyperdynamic circulation with high cardiac output, adequate vasodilation, and wide pulse pressure. Patients with lower limb trauma are often young and fit. Patients with head and neck cancer are often smokers with ischaemic heart disease. The elderly or patients with limited cardiorespiratory reserve may not be suitable for surgery.

Isoflurane is the inhalational agent of choice due to its beneficial effects on systemic vascular resistance (SVR). Propofol maintenance is also ideal since it lowers SVR, is rapidly metabolised, is antiemetic, and may avoid postoperative shivering (there is also some in vitro evidence that propofol may be more favourable for microvascular flow by avoiding the effect of volatiles on red cell membrane stiffness). Remifentanil is used by many.

A regional block is helpful to supplement anaesthesia. The sympathetic block and dense analgesia produce excellent conditions for graft survival. Lower limb flaps are especially suitable. Surgery on multiple sites may not all be covered by the block. Skin grafts are often taken from the leg to cover a muscle flap.

Anaesthetic management requires a good practical knowledge of circulatory physiology. Blood flow through the microvasculature must be optimal to help ensure flap survival. Blood flow is primarily influenced by changes in perfusion pressure, calibre of vessel, and blood viscosity (Hagen–Poiseuille formula). We only have a superficial understanding of the physiology of the microcirculation. Much of our anaesthetic management is based on perceived wisdom, rather than on the results of randomised controlled trials.

Monitor core (e.g. rectal, oesophageal) and peripheral temperature. Insulate the skin probe from any overlying warming blanket. Aim for a normal or even supranormal core temperature and a core-peripheral difference of <2°C. This must be achieved by the time that microvascular anastomosis is commenced. A widening of the core—peripheral temperature difference may herald vasoconstriction. Local vascular spasm may jeopardise the surgery.

Correct any preoperative fluid deficit and commence volume loading. Continue maintenance crystalloid, and add 10ml/kg colloid bolus (e.g. Gelofusine^® or Voluven^®) as required to expand the intravascular volume. Aim for CVP 12mmHg (or 2–4mmHg above baseline), urine output 2ml/kg/hr, widened pulse pressure, and low SVR. Colloid will expand the intravascular volume more effectively than crystalloid. Transplanted tissue lacks intact lymphatics and excess crystalloid may contribute to flap oedema. Take care to avoid excessive volume loading in the elderly, who are more prone to develop pulmonary oedema.

Moderate hypotension and haemodilution during the early phase of dissection may help limit blood loss. Thereafter, maintain systolic arterial pressure (SAP) at >100mmHg or higher depending on preoperative blood pressure recordings.

Viscosity is closely related to haematocrit (Hct). Viscosity rises dramatically when Hct >40%. Aim for 30%, which in theory gives the best balance between blood viscosity, arterial oxygen content, and tissue oxygen delivery.

Dextran reduces platelet adhesiveness and factor VIII concentration. It may help maintain graft patency. Depending on surgical preference, give 500ml Dextran 40 during the procedure, and include 500ml in the daily IV fluid for 2–3d.

Potent vasodilators (e.g. sodium nitroprusside, hydralazine, and phenoxybenzamine) are unnecessary. Sufficient vasodilation can be produced by the anaesthetic agent provided that the patient is warm, volume loaded, pain free, and normocarbic. Nifedipine 10mg given with the premedication and continued three times a day for 5d in high-risk patients such as smokers, diabetics, and arteriopaths may improve flap survival. Chlorpromazine 1–2mg IV (dilute a 50mg ampoule to give a 1mg/ml solution for injection) is useful to narrow a widened core—peripheral temperature difference when all other factors have been corrected. The surgeon may use papaverine directly on the vessels to prevent local spasm.

Prophylactic antibiotics are given at induction and may be repeated during the procedure.

Continue meticulous care well into the postoperative period. Flap observation is a specialised nursing skill and care is often best provided on the plastic surgical ward. The need for HDU/ITU may be dictated by patient factors.

Vasoconstriction from cold, pain, low circulating volume, hypotension, and hypocarbia will put the flap at risk and needs prompt correction.

Treat shivering with pethidine 25mg IV. Continue with warming blanket in recovery.

The health of the flap is monitored clinically. Hourly observations include a ‘flap chart’ where temperature, colour, and arterial pulses (using a Doppler probe if possible) are monitored. A pale, pulseless flap with sluggish capillary filling may indicate problems with the arterial supply. A swollen, dusky flap, which blanches easily with a brisk capillary return, indicates a venous outflow problem. An early surgical decision needs to be made concerning re-exploration.

Analgesia by continuous epidural is ideal for lower limb flaps. An axillary brachial plexus catheter (e.g. continuous infusion of 0.25% bupivacaine 5ml/h for 2–3d) is useful for procedures on the forearm and hand.

Careful consideration should be given as to whether more invasive analgesic techniques are justified for procedures on the upper torso (e.g. thoracic epidural or intrapleural analgesia). Potential risks may outweigh the benefits. These patients often do very well with IV PCA. For head and neck procedures IV PCA is best.

Attitudes vary concerning perioperative NSAIDs. They are valuable analgesics and reduce platelet adhesiveness. They may produce increased oozing following lengthy and extensive surgery. Administration postoperatively when clot is more established may be preferable.

A ‘pedicle flap’ is constructed when arteriovenous connections remain intact but the raised flap is rotated to fill a neighbouring defect. Examples include rotation of rectus abdominus muscle to fill a sternal wound, rotation of pectoral muscle to reconstruct a defect in the side of the neck following tumour excision, and pedicled latissimus dorsi breast reconstruction. Whilst the procedure may be technically simpler than free tissue transfer, anaesthesia requires similar attention to detail.

Overall free flap survival is >95%. Flap failure will result in further reconstructive procedures. Patients in poor general condition with coexisting disease have the highest risk of flap failure.

Patients presenting for aesthetic surgery are often fit and well.

Fat is infiltrated with dilute local anaesthetic with adrenaline. Back and forth movement of the cannula disrupts fatty tissue which is then aspirated by either suction apparatus or syringe.

Injection of fluid helps fat breakdown and aids aspiration. There are several recipes for SC infiltration solutions: 1000ml warmed Hartmann's solution containing 50ml 1% lidocaine and 1ml 1:1000 adrenaline is popular; 1ml infiltrate per 1ml aspirate is commonly used (superwet technique).

The tumescent technique refers to a large volume of LA/adrenaline infiltrate to produce tissue turgor. Developed as an outpatient technique and performed without additional anaesthesia or sedation. 3ml infiltrate per 1ml aspirate is often used. There is little evidence that this technique is superior to the superwet technique, and it may produce more complications. It may provide unsatisfactory anaesthesia when used alone. Additional sedation or general anaesthesia may be necessary.

Blood loss depends on the volume of LA/adrenaline infiltrate used and the extent of liposuction required. Loss is approximately 1% of the volume of the aspirate for the tumescent technique. This may increase to 40% without SC infiltration.

Extensive liposuction physiologically resembles a burn injury and large fluid shifts result. Replace aspirate 1:1 with IV crystalloid.

Encourage oral fluids and monitor urine output.

Check Hct following extensive liposuction (>2500ml aspirate).

Bruising can be considerable.

Use NSAIDs and simple analgesics for pain relief.

Complications are associated with excessive liposuction. In the UK aspiration is restricted to approximately 2 litres of fat. Considerably higher-volume procedures have been reported especially in the USA (in excess of 10 litres). Deaths have occurred from pulmonary oedema and lidocaine toxicity. Morbidity is related to high aspiration volume and high lidocaine dosage.

Elderly patients for excision/grafting of skin lesions or pretibial lacerations may be in poor general health. A local or regional technique may be preferable to a GA.

Patients with extensive burns for debridement and grafting require careful assessment—see below.

Split skin graft (SSG). Consists of epidermis and variable portion of dermis. Much wider usage than FTSG. Usually harvested with a skin graft knife or power-driven dermatome. Donor sites will heal spontaneously within 2wk. Donor sites are chosen according to the amount of skin required, colour and texture match, and local convenience. Meshing is used to expand the extent of the area that the graft is required to cover. Common donor sites are the thigh, flexor aspect of forearm, upper arm, and abdomen. SSG can be harvested using LA cream. It should be applied at least 2hr in advance and covered with an occlusive dressing. Anaesthesia does not extend into the deeper dermis so the technique is unsuitable for FTSG. Lateral cutaneous nerve of thigh (LCNT) or femoral 3 in 1 block provides useful analgesia of a thigh donor site. Excess harvested skin can be stored at 4°C for 2–3wk.

Two anaesthetists may be required. Two surgical teams will considerably speed up the procedure and help minimise complications.

Blood loss. Ensure 6–8U are crossmatched. Debrided tissue bleeds freely. Losses can be difficult to estimate, particularly in small children. Regularly check Hct and maintain at approximately 30%.

Temperature control. A large exposed body surface area will lose heat rapidly by radiation and evaporation. Measure core temperature. Use all methods available for heat conservation. Little body surface area may be available for warming blankets. Maintain the operating theatre at 25°C.

Monitoring. Placement of non-invasive monitoring devices may be difficult. An arterial line facilitates measurement of blood pressure and blood sampling. A central venous line is valuable to provide reliable venous access for this and future procedures, and helps in the management of intravascular volume. Maintain strict asepsis during line insertion. Cannulae may need to be stitched. Try to place through intact skin. A urinary catheter is essential.

Suxamethonium is contraindicated except in the first 24hr following burn. Massive K⁺ release may cause cardiac arrest.

Postoperative care. Return to the burns unit. Large body surface area burns (e.g. >40%) or those with additional injury (e.g. smoke inhalation) may need continued ventilation on ICU until warm and stable.

Analgesia is best provided by IV opioids either as PCA or continuous infusion. Suggest early intervention of the acute pain team. Dressing changes may be helped by Entonox or ketamine/midazolam sedation.

Antibiotics and early nutrition are important to increase survival.