Anesthesia in aesthetic (plastic) surgery

Operations in aesthetic surgery are classified as both simple and complex. The duration of operations can vary significantly: from several minutes to several (7-8) hours. Operations are performed both inpatient and outpatient, with the share of outpatient operations being, according to the Center for Plastic and Reconstructive Surgery, about 3-5%.

Most patients undergoing aesthetic surgery are in physical condition class I-II, and the risk of anesthesia and surgery is usually in the IA-PI (ASA I-II) range. Preoperative evaluation is performed according to generally accepted standards and necessarily includes routine laboratory tests, electrocardiography, and examination by an anesthesiologist.

It is important to assess the patient's psychological status, as this, among other things, influences the choice of anesthesia method, although in most cases patients in the aesthetic surgery clinic prefer to be in a state of drug-induced sleep even during minor outpatient surgeries.

Mutual understanding and trust between the anesthesiologist and the patient are of great importance for the choice of the method of anesthesia and the patient's assessment of the quality of the anesthesia performed.

As is known, the choice of one or another method of anesthesia is influenced by many factors:

• traumatic nature of the operation;
• the area of the body where the intervention is performed;
• duration of the operation;
• patient's position on the operating table;
• the degree of influence of the operation and anesthesia on the patient’s circulation, respiration and other vital systems;
• performing operations on an outpatient or inpatient basis.

Local infiltration anesthesia

Local infiltration anesthesia is the simplest and safest method of pain relief; it has less effect on the patient's vital functions than other types of anesthesia.

In addition, local anesthesia reduces afferent impulses and prevents the development of pathological reactions associated with pain and tissue trauma during surgery.

Tissue infiltration with a local anesthetic solution can be used in various ways: independently, with intravenous administration of sedatives, and also as an analgesic component of general anesthesia.

The introduction of the first portions of local anesthetic causes pain or discomfort. Therefore, narcotic analgesics or sedatives are used for premedication or intravenous sedation during the anesthesia period.

The most commonly used local anesthetic is lidocaine solutions at a concentration of 0.25-0.5% (maximum dose 2000 mg of 0.25% solution and 400 mg of 0.5% solution).

The use of 0.25% bupivacaine solution for long-term postoperative pain relief is possible, but limited due to its high toxicity (maximum dose is 175 mg, with the addition of adrenaline in a dilution of 1:200,000 - 225 mg).

The addition of adrenaline to local anesthetic solutions significantly increases the duration of local anesthesia, slows the entry of the drug into the circulating blood and, therefore, reduces the effects of resorptive action.

Even when the recommended doses of administered local anesthetics are exceeded, manifestations of their toxicity are rare. Thus, according to C. Gumicio et al., when administering lidocaine at a dose of 8.5 mg/kg (on average for an adult - 600 mg) with adrenaline, the concentration of lidocaine in the blood plasma did not exceed 1 mg/ml.

It is known that toxic effects are observed at concentrations of 5 mcg/ml and higher. It should be borne in mind that the usual doses used for adults may be toxic for children.

Local anesthesia with or without intravenous sedatives can be used for aesthetic surgeries on the face, minor corrective surgeries on the mammary glands and limbs, and small-volume liposuction.

As an analgesic component of general anesthesia, the introduction of local anesthetics is advisable to use in complex aesthetic operations on the head and rhinoplasty, volumetric mammoplasty, operations on the anterior abdominal wall. The amount of the administered drug should not exceed the maximum permissible doses.

Intravenous administration of nutritive agents

In plastic surgery, intravenous sedation combined with local anesthesia is not a simple procedure. This method is most suitable for calm and balanced patients without serious concomitant diseases.

Intravenous sedation allows for the patient to remain still and calm during surgery under local anesthesia, and reduces the discomfort associated with being in the operating room and the administration of local anesthetic.

Benzodiazepines are most often used in the operating room. Midazolam has some advantages. It is twice as active as diazepam in terms of sedative-hypnotic effect, starts to act faster and causes more pronounced amnesia, provides early and complete awakening and a shorter sedative effect after surgery. In addition, diazepam causes pain and irritation of the vein when injected.

The benzodiazepine antagonist flumazenil reverses all the effects of benzodiazepines, which is especially important for outpatients. However, the high price of flumazenil will likely limit its use in clinical practice for a long time to come.

The combined use of benzodiazepines with narcotic analgesics significantly increases patient comfort during local anesthesia. Midazolam (2-5 mg intravenously) followed by fentanyl (25-50 mcg intravenously) is widely used. However, this combination can cause significant respiratory depression and a high probability of hypopnea and apnea. The use of the agonist-antagonist butorphanol (stadol, moradol) at a dose of 0.03-0.06 mg/kg instead of fentanyl causes respiratory depression to a much lesser extent. When a more pronounced sedative effect is required, barbiturates can be used.

The combination of benzodiazepines with ketamine is another good combination for providing a short period of deep analgesia during infiltration of the surgical area with local anesthetic.

The advantage of ketamine is that it causes less muscle relaxation, which prevents the tongue from falling back and ensures the patency of the upper respiratory tract. This property of ketamine allows for high-level safety in operations on the patient's head and neck with the additional use of local anesthesia.

The administration of ketamine can cause complications in some patients, so contraindications for its use may include angina pectoris, heart failure, hypertension, cerebrovascular accident, convulsive syndromes, mental disorders, thyroid disease with its hyperfunction, and increased intraocular pressure.

Midazolam significantly neutralizes the cardiovascular and psychosomatic reactions to the administration of ketamine. For induction, the dose of midazolam is 0.03-0.075 mg/kg and ketamine - 0.5-1 mg/kg. If necessary, ketamine can be administered by continuous infusion - 10-20 mg/(kg - min). Atropine should be used to prevent salivation and other adverse reactions.

It is advisable to warn patients about possible dreams after surgery. If the use of ketamine is highly undesirable, then analgesia can be performed with narcotic analgesics.

Propofol (Diprivan - Zeneca) is increasingly becoming the drug of choice as a hypnotic. Its main advantages are: rapid and complete awakening even after long operations, good health and good mood of patients, lower incidence of nausea and vomiting than after using other drugs. The disadvantages of propofol are pain during administration and decreased blood pressure. Pain during administration of the hypnotic is reduced after preliminary intravenous administration of lidocaine or a narcotic analgesic. The decrease in blood pressure can be prevented by varying the effect of action.

In long operations, the advantages of the very expensive propofol sometimes "compete" with the costs of the entire anesthesia. Therefore, in such situations it is advisable to use midazolam as a basic anesthesia, and maintain it with nitrous oxide and continuous propofol administration in small doses.

Despite the high costs, it is important to consider that propofol reduces the duration of postoperative observation and the number of medical personnel required for this. Its use allows for rapid discharge and, most importantly, leaves a good impression of the anesthesia for the patient.

Other sedatives used in plastic surgery include droperidol, benzodiazepines, antihistamines, and phenothiazines.

The main negative property of all these drugs is the long duration of action, which allows them to be used only for long operations and in patients in hospital conditions. Therefore, successful intravenous sedation requires the correct choice of drug and variation of the effect of action in accordance with the patient's reaction.

The method of intravenous sedation in combination with local anesthesia can be used in most aesthetic surgeries, except in cases where it is not possible to ensure adequate spontaneous ventilation of the lungs, as well as in operations with significant blood loss and in patients with serious concomitant diseases.

General anesthesia

Torso and facial surgeries can be performed with or without tracheal intubation. Induction of anesthesia and tracheal intubation are performed in a standard manner using barbiturates.

Anesthesia can be maintained by various methods. Since cosmetic surgeries often involve infiltration of the surgical area with local anesthetic solutions containing adrenaline, the need for narcotic analgesics may be limited to the induction period and the time of infiltration of the surgical area with local anesthetic. Narcotic analgesics are administered repeatedly before infiltration of the next surgical area or continuously in small doses to relieve the patient's reaction to the intubation tube.

The use of local anesthesia allows to significantly reduce the consumption of analgesics both during the operation and after its completion. At the same time, the frequency of nausea and vomiting in the postoperative period is significantly reduced.

Propofol in combination with narcotic analgesics can be used both for induction and maintenance of anesthesia. These drugs can be combined with nitrous oxide, midazolam or low concentrations of inhalation anesthetics. Propofol with nitrous oxide (compared to barbiturates) provides faster awakening and the ability of the patient to self-care. Intravenous drip administration of drugs allows for a reduction in the required dose and provides a faster recovery from anesthesia.

General anesthesia with artificial ventilation is indicated for plastic surgery on the anterior abdominal wall, extensive mammoplasties, large-volume liposuctions, rhinoplasty, and in elderly patients with concomitant diseases.

Use of adrenaline-containing solutions

Extensive cosmetic surgeries and large-volume liposuctions may be accompanied by significant blood loss, which requires restoration of fluid balance during surgery and in the postoperative period. The use of the technique of infiltration of the surgical area with solutions containing adrenaline (1:200,000) allows a significant reduction in blood loss. This is desirable for many cosmetic surgeries and is becoming a mandatory condition for liposuction.

The use of freshly prepared solutions with adrenaline, careful infiltration, and waiting until the adrenaline begins to act (10-15 minutes) are important rules for surgeons.

In plastic surgery, infiltration of subcutaneous fat with a large amount of local anesthetic with adrenaline is often used, so control over the total dose of local anesthetic administered is mandatory.

Since adrenaline-containing solutions are administered subcutaneously, after the initial period of absorption, a local vasoconstrictive effect is observed, which limits further entry of the drug into the circulating blood. However, transient tachycardia, sometimes with hypertension and arrhythmia, is often observed. Attempts to treat tachycardia, hypertension and arrhythmia with appropriate drugs can lead to a prolonged effect of the latter, which persists after the action of adrenaline has ended, causing, in turn, bradycardia and hypotension. If the patient has risk factors such as arrhythmia, coronary circulation disorders, cerebrovascular diseases, then small doses of ultra-short-acting beta-blockers can be used to prevent tachycardia and hypertension. But in such situations, it is better to refuse the administration of adrenaline solutions, and perhaps even surgery.

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