Sabtu, 30 Agustus 2008
Breast Augmentation Using Stem Cells? Not Yet...
An interesting article claims that plastic surgeons in Europe and Japan are using stem cells for breast augmentation. It also states that some surgeons in the United States are also performing stem cell breast augmentation.
The closest thing to stem cell breast augmentation that I have experience with is fat grafting to the breast. Fat actually does contain a large amount of stem cells, and the procedure does work. However, due to significant controversy regarding its possible effects on mammography and breast cancer detection, I don't recommend it except in those situations where breast implants are not able to be used. The standard of care for breast augmentation is still the breast implant, and I expect that this will not change for a long time.
I know of no plastic surgeons in the U.S. who actually experiment with stem cells for breast augmentation.
Story credit: upi.com
Photo credit: The Soap Box
Thanks for reading.
Michigan-based Plastic Surgeon
Anthony Youn, M.D.:
Jumat, 29 Agustus 2008
September Skin Spa Specials!
Selasa, 26 Agustus 2008
Pam Anderson - No to Botox but Yes to Juvederm?
Here is a photograph of Pam Anderson during a recent press tour in Australia to promote her new reality show on E!. As you can see, there is no sign of any Botox in her forehead, but her lips look pretty plump, possibly due to Juvederm injections. The cupid's bow of her upper lip looks obliterated, which can happen when a good amount of injectable filler is placed there. This is one of the few photos that I've seen where Pam looks all of her 41 years. Maybe the jet lag hasn't been kind. I always look (and feel) like hell after a long plane flight.
Juvederm lasts around 6-12 months, and I find it works very well in the lips when injected conservatively.
Photo credit: dlisted.com
Thanks for reading.
Michigan-based Plastic Surgeon
Anthony Youn, M.D.:
Minggu, 24 Agustus 2008
Has Jennifer Aniston Had Her Lips Plumped?
Photos of Jennifer Aniston have recently surfaced, showing a possible lip augmentation. If she's had it done, it is a subtle job, possibly with Restylane. Some may argue that her lips look the same, but if you compare the 'then' to the 'now,' you can see that the lip proportions have changed. In the 'then' photo, her upper lip is slightly smaller than her lower lip. In the 'now' photo, the upper lip is actually larger than the lower lip.
I have stated many times on this blog that the natural lip proportions (with some exceptions) have the lower lip 1.5 times the size of the upper lip. Quite often plastic surgeons become overzealous in augmenting the upper lip, making it appear larger than the lower lip. This creates the all-too-common 'trout pout.' Whether Jennifer Aniston has had her lips done or not, I'm sure John Mayer would agree that her "Body is a Wonderland."
Photo credit: Daily Mail
Thanks for reading.
Michigan-based Plastic Surgeon
Anthony Youn, M.D.:
Jumat, 22 Agustus 2008
The Top 10 Worst Female Celeb Body Parts?
10. Jennifer Love Hewitt's Hips
9. Jennifer Garner's Toes
8. Paris Hilton's Wonky Eye
7. Jennifer Lopez's Buttocks
6. Tori Spelling's Breasts
5. Sarah Jessica Parker's Hands
4. Mischa Barton's Thighs
3. Jenna Jameson's Lips
2. Tara Reid's Stomach
1. Amy Winehouse's...Pick Something
I would definitely disagree with a number of their choices, especially Jennifer Love Hewitt and Jennifer Lopez. I wonder what a list of the Top 10 Worst Male Celeb Body Parts would include? Maybe Kenny Rogers' eyelids, Fred Thompson's neck, Mickey Rourke's cheeks, and Brad Pitt's face? ;)
To see photos of the 'offending' body parts from Celeb Slam, click here for their post.
Thanks for reading.
Michigan-based Plastic Surgeon
Anthony Youn, M.D.:
Rabu, 20 Agustus 2008
Christina Applegate Breast Cancer and Reconstruction
As you may know by now, Christina Applegate has undergone a double mastectomy for possible breast cancer. She has the BRCA1 gene, which is a marker for high breast cancer risk. Ms. Applegate elected to undergo a prophylactic mastectomy, essentially removing all her breast tissue in order to prevent a potentially deadly cancer from appearing. In an interview, she stated that the next eight months would be spent undergoing breast reconstruction surgery.
What reconstructive surgery may she be having? It sounds to me that she is probably going to undergo breast reconstruction using breast implants. This process can take several surgeries. Most commonly, temporary breast implant expanders are placed at the time of the mastectomy. These implants are gradually filled over several months to expand the remaining skin and muscle. When they are the desired size, then another surgery is performed where the expander implants are replaced with permanent breast implants. Usually a few months later the nipples are recreated during a third surgery. The final step is often tattooing of the nipples and areola, in order to get the darker color of the real thing.
I wish her the best in her recovery and future treatments. I thought she was great in Married with Children.
Photo credit: prphotos.com
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Michigan-based Plastic Surgeon
Anthony Youn, M.D.:
Senin, 18 Agustus 2008
California Senate Approves "Donda West Law"
The California Senate has approved, by a margin of 37-1 the Donda West law, named after Kanye West's late mother. This law makes it mandatory for anyone undergoing a cosmetic surgery to have a history and physical performed prior to surgery.
Ho hum. Most plastic surgeons already do this. Instead of enacting unnecessary laws, why not limit plastic surgery to those who are actually trained at it? The California legislature has recently approved a bill allowing oral surgeons (DDS dentists) to perform all sorts of facial plastic surgery. How ridiculous! You wouldn't want me performing your root canal, so why have an oral surgeon do your facelift?
Photo credit: prphotos.com
Thanks for reading.
Michigan-based Plastic Surgeon
Anthony Youn, M.D.:
Minggu, 17 Agustus 2008
What is the Most Nipped and Tucked City?
Do you think this may have to do with Senator Nancy Pelosi's influence? She does look mighty good for her age.
Here is the remainder of the top 10:
2: Honolulu
3: Sacramento
4: Miami
5: Tucson
6: San Diego
7: Richmond, VA
8: Washington, DC
9: Rochester, NY (not Rochester, MI)
10: Seattle
Other notables:
34: Grand Rapids, MI
48: Los Angeles, CA
Which are the least nipped and tucked?
Lincoln, NE
Fort Wayne, IN
Montgomery, AL
Toledo, OH
Madison, WI
I actually get quite a few patients who come from Toledo to have plastic surgery here in Metro Detroit...
For the full list from Men's Health, click here.
Thanks for reading.
Michigan-based Plastic Surgeon
Anthony Youn, M.D.:
Sabtu, 16 Agustus 2008
Principles of Reconstructive Surgery
Introduction
Plastic and reconstructive surgery is a field that relies upon basic principles to restore form and function to the human body. Whether it is a gunshot wound to the face, a congenital hand deformity, or a malformed breast, plastic surgeons must be adept at adapting a fundamental knowledge of human anatomy and physiology to create ingenious solutions to ever-changing challenges. Unlike techniques which must be modified with each new advance in medical technology, the use of principles makes it possible for the plastic surgeon to address problems as varied as the infinite diversity of the human species. Rote memorization of operative steps and mathematical formulas are insufficient. The reconstruction of the human body depends upon the ability to devise creative solutions based on core principles. Over the years, numerous efforts have been made to categorize these principles. Despite changes in technique, the fundamental principles of plastic and reconstructive surgery have withstood the test of time.
Ambrose Paré
The earliest principles of reconstructive surgery may be attributed to the French surgeon, Ambrose Paré, who in 1564 published five basic principles of plastic surgery. The first principle was “to take away what is superfluous.” Whether applied to the excision of redundant tissue or the complete amputation of a surplus structure such as a digit or a supernumerary nipple, this first principle emphasized the need to eliminate that which served no purpose. The second principle was “to restore to their places things which are displaced.” Whether applied to a congenital deformity, such as a cleft lip, or an acquired deformity, as in trauma, this principle required recognition of normal parts and diagnosis of the abnormal position. Likewise, the third and fourth principles, “to separate tissues which are joined together,” and “to join those tissues which are separate,” also required the ability to conceptualize a hypothetical norm. Indeed, a given defect could often be determined accurately only after distorted tissue was returned to its normal shape. This was true whether applied to a congenital defect, such as syndactyly, or an acquired defect, such as a burn contracture. Finally, the fifth principle, “to supply the defects of nature,” also required the ability to visualize restoration to a normal state.
Modern Plastic Surgery: Gillies and Millard
Building upon these early ideas, Sir Harold Gillies and D. Ralph Millard took the principles of Paré to the next level. Recognizing that the remodeling of human tissue was different from clay, Gillies and Millard took as their founding principle
Table 10.1. Gillies’ ten commandments of plastic surgery
- Thou shalt make a plan.
- Thou shalt have a style.
- Honor that which is normal and return it to normal position.
- Thou shalt not throw away a living thing.
- Thou shalt not bear false witness against thy defect.
- Thou shalt treat thy primary defect before worrying about the secondary one.
- Thou shalt provide thyself with a lifeboat.
- Thou shalt not do today what thou canst put off until tomorrow.
- Thou shalt not have a routine.
- Thou shalt not covet thy neighbor’s plastic unit, handmaidens, forehead flaps, Thiersch grafts, cartilage nor anything that is thy neighbor’s.
that “plastic surgery is a constant battle between blood supply and beauty.” That is to say, the reshaping of human structures demanded that its vitality as living tissue be respected. Drawing upon the wisdom of his mentor, Sir Harold Gillies, Millard produced one of the most widely recognized efforts to outline the principles of reconstructive surgery. In 1950, Millard codified rules learned from Gillies and published them as the “ten commandments” of plastic surgery (Table 10.1). Shortly thereafter, the pair expanded these ideas to 16 principles that would apply not only to plastic surgery problems but also to a philosophy of life in general. Millard went on to develop the concept of principles still further in his classic tome, Principalization of Plastic Surgery. Divided into four broad sections, this work offered 33 commonsense rules to help plastic surgeons fashion answers to a variety of surgical problems.
Preparational Principles
Millard’s first 12 principles fell under the framework of “Preparational Principles”-that is, principles to keep in mind before making the opening incision. The first principle was to “correct the order of priorities.” Applied broadly, this could mean emphasizing integrity and ethics; it could mean prioritizing function over form; and it could also mean performing a blepharoplasty before a facelift since the latter could affect the former but not vice versa. The bottom line was that whether in life or in a specific procedure, each part needed to be considered in the context of the whole.
The second principle was that “aptitude should determine specialization,” meaning that the plastic surgeon should play to strengths when deciding whether to focus on reconstructive surgery, cosmetic surgery, microvascular surgery, craniofacial surgery, head and neck oncology, hand surgery, burn physiology or laboratory research. Millard emphasized that a person who initially appeared inept in one area could later progress to excel above all others in the same area. Using himself as an example, Millard revealed that he took an aptitude test early in his career that determined that he would be well-suited to writing and possibly medicine, but completely unsuited for surgery due to a perceived inability to visualize objects in three dimensions. Despite this, he went on to become one of the most accomplished plastic surgeons in history, known especially for the three-dimensional rotation-advancement flap that is the standard of care for cleft lip repair today.
The third principle was to “mobilize auxiliary capabilities.” That is to say, the plastic surgeon should incorporate individual talents to develop a “personal style with individual flair.” Advised to develop one primary capability and several secondary talents such as sculpture, music, writing or painting, the ideal plastic surgeon would be multi-talented for maximal depth and versatility in the operating room. The fourth principle was to “acknowledge your limitations so as to do no harm,” a self-evident principle that spoke to the temptation to persevere on a case with endless complications. Instead, the successful surgeon should know when to stop. The flip side of this was the fifth principle, which was to “extend your abilities to do the most good.” This spoke to the moral obligation to use plastic surgical training to alleviate human suffering, that is, to reconstruct mutilated or severely deformed patients instead of limiting one’s practice to purely aesthetic procedures. The sixth principle was to “seek insight into the patient’s true desires.” Delving into the psyche, this principle directed the plastic surgeon to decipher a patient’s actual problems instead of merely taking the stated problem at face value to preempt patient disappointment, improve public relations and prevent postoperative legal complications.
The seventh principle was to “have a goal and a dream.” In plastic surgery, this principle shifted depending on whether a procedure was primarily cosmetic, in which the goal would be to surpass normal, or primarily reconstructive, in which the goal would be to attain normal. Either way, the plastic surgeon should have a target in mind before beginning an operation. The eighth principle was to “know the ideal beautiful normal.” While this ideal beautiful normal could vary among different ethnic backgrounds, it was important for the plastic surgeon to be able to define it in order to attain pleasing aesthetic proportions and visual harmony.
The ninth principle was to “be familiar with the literature.” Knowing what had already been described assisted a surgeon in discriminating between procedures that would and would not be successful; it also gave the surgeon access to a collective bank of experience that allowed extension beyond what one person could accrue in a lifetime. The tenth principle, to “keep an accurate record,” was like the sixth principle in that its underlying purpose was both to further patient care and provide legal protection for the surgeon. In addition, since memory was inherently unreliable, accurate written and photographic records provided baseline references that allowed the plastic surgeon to coordinate multi-staged procedures to achieve a successful final result.
The eleventh principle was to “attend to physical condition and comfort of position.” Often overlooked by single-minded surgeons, the basis of this principle was the belief that the optimal surgical performance depended upon good physical condition and a comfortable working position for the surgeon. Finally, the twelfth principle, “do not underestimate the enemy,” acknowledged that peril lay behind every procedure. Thus, whether the enemy was hypertrophic scar formation or inadequate vascular supply, it was never possible to be overly vigilant in preventing surgical complications.
Executional Principles
The second category of principles addressed the wielding of the blade. The thirteenth principle, “diagnose before treating,” emphasized that observation was the basis of surgical diagnosis. The plastic surgeon must use all senses—particularly visual and tactile cues—to accurately determine a problem before proceeding with an operation. The fourteenth principle was reminiscent of Paré, in that it advised the plastic surgeon to “return what is normal to normal position and retain it there.” As previously mentioned, displacement of structures could be due to failure in normal embryonic development or as a direct result of trauma, ablation, scar contraction, or even the aging process, but correction required the ability to recognize the norm in order to restore displaced parts to their correct place.
The fifteenth principle stated that “tissue losses should be replaced in kind.” More specifically, when attempting reconstruction of lost body parts, bone should be replaced with bone, muscle with muscle and glabrous skin with glabrous skin. If exact replacement was impossible, then a similar substitute should be made, such as a beard with scalp, thin skin for an eyelid, thick skin for the sole of a foot, and a prosthesis for an eye. The idea was that replacing like with like would give the most natural outcome. The sixteenth principle advised the plastic surgeon to “reconstruct by units.” By basing reconstruction on unit borders demarcated by creases, margins, angles and hairlines, surgical scars could often be concealed by the meeting of light and shadow.
The seventeenth principle was to “make a plan, a pattern and a second plan (lifeboat).” By visualizing an entire operation from beginning to end, the plastic surgeon could anticipate possible difficulties and then proceed to devise a secondary plan for use should the primary plan fail. The eighteenth principle was to “invoke a Scot’s economy.” This involved thrift in surgery, in which no tissue was ever discarded until it was certain that it was no longer needed. A corollary of this was to discard the useless, as once a piece of tissue was determined to have no further value it should be removed—but refrigerated storage was advised even then in case the tissue could be used later.
The nineteenth principle was to “use Robin Hood’s tissue apportionment.” That is, Robin Hood would steal from the rich to give to the poor. Likewise, this principle advised using excess tissue to make up for areas with tissue deficits by rotating, transposing, or transplanting expendable tissue flaps to areas in need. The corollary to this was the twentieth principle, to “consider the secondary donor site.” That is, while reconstructing deficient areas with tissue taken from areas that were more ample, the resulting secondary defect must also be considered to make sure that its sacrifice was not too deforming. The twenty-first principle was to “learn to control tension.” In opening, tension usually facilitated a clean cut with the scalpel; in closure, tension could lead to tissue necrosis or excess scarring; in flap design, skin tension lines could be identified and used to camouflage scars. The twenty-second principle was to “perfect your craftsmanship.” For the plastic surgeon, “good” suggested mediocrity, and nothing short of perfection was acceptable. The twenty-third and final executional principle was “when in doubt, don’t!” Doubt should function as a deterrent, and if a solution to a problem left seeds of doubt, it was better to develop a better idea.
Innovational Principles
The third category of principles governed the generation of new concepts in plastic surgery. The twenty-fourth principle was to “follow up with a critical eye.” That is, it was important to follow patients postoperatively over time to critically evaluate results, as regular review of one’s handiwork was the best way to spur advancement and improvement of surgical procedures. Likewise, the twenty-fifth principle, to “avoid the rut of routine,” exhorted surgeons to shun mindless and tenacious clinging to unthinking rituals. Again, by thinking outside the box, the plastic surgeon could make the advance to the next level of innovation and development. The twenty-sixth principle, “imagination sparks innovation,” was the “breakthrough” or problem-solving principle that encouraged free-spirited thinking and creativity.
The twenty-seventh principle, “think while down and turn a setback into a victory,” was labeled the “prince of principles” by Millard. It admonished the surgeon not to panic or despair, or compound error when faced with possible defeat. Instead, the surgeon should keep cool while determining the cause of loss, expend no energy in worrying about a compromised position, and make certain not to repeat the same mistake while thinking one’s way to recovery. Finally, the twenty-eighth principle was to “research basic truths by laboratory experimentation.” By testing even minor theories in the laboratory, the surgeon could discover answers to plastic surgical questions in a controlled setting.
Contributional Principles
The fourth set of principles governed ways to contribute to the field of plastic surgery. The twenty-ninth principle was to “gain access to other specialties’ problems.” By consulting with physicians or surgeons from other specialties, it could be possible to learn management of common complications that would both benefit patients as well as broaden the base of plastic surgery. The thirtieth principle was that “teaching our specialty is its best legacy.” The implication was that the best way to extend plastic surgery was to transmit knowledge via lectures, books, symposiums and personal experiences to ensuing generations. The thirty-first principle was to “participate in reconstructive missions.” Moreover, the ideal method to conduct such missions was to lend specialists not just to operate, but to teach people in underdeveloped countries how to perform the operations and manage all the postoperative care themselves.
Inspirational Principles
The final set of principles attempted to prod the plastic surgeon to strive for perfection. Toward this end, the thirty-second principle was to “go for broke!” That is, the plastic surgeon should use every means possible to overcome obstacles, strive for the very best, and seek perfection. The thirty-third and last principle was to “think principles until they become instinctively automatic in your modus operandi.” By incorporating principles constantly and consistently into plastic surgical practice, it would become second nature to avoid rote memorization of techniques and instead stimulate the imagination to engage in innovative problem solving.
The Reconstructive Ladder
The traditional approach to the reconstruction of a variety of defects is based on the concept of the reconstructive ladder (Fig. 10.1). The basic notion is that one should use the simplest approach to solving a reconstructive problem, before advancing up the ladder to a more complex technique. Consequently, if the procedure fails, one can climb to the next level of complexity. For example, a lower extremity venous stasis ulcer should be treated by dressing changes alone or by a split-thickness skin graft if these are applicable. A more complex reconstruction with a free flap should be reserved as a last resort if all simpler options have been ruled out or have failed. More recently, however, experienced reconstructive surgeons are beginning to realize that certain problems are not amenable to simple solutions. In select cases, bypassing the lower rungs of the reconstructive ladder and proceeding directly to microvascular free tissue transfer is the optimal approach. A good example of this is post-mastectomy breast reconstruction. For many surgeons, the free TRAM or DIEP flaps have become the standard of care.
Pearls and Pitfalls
Plastic surgery takes passion, determination and sacrifice. As plastic surgeons, we would like to create perfection. Yet techniques and procedures are always evolving, so the operative process must be based upon principles. Without a commitment to perfection, a concept of what beauty is, and what the end result will be ahead of time, the surgeon is lost. Poets can be our role models, because poets are creative and can help show us how to get going with the creative process. Ultimately, however, plastic surgery involves sacrifice, focus, determination and, above all, will power. When these qualities are combined, the plastic surgeon is able to elevate the work that is performed. A person who is able to go to work and create something close to perfection, striving for perfection, will lead a very satisfying life. By its very nature, then, plastic surgery gives us the opportunity to enjoy that ideal life.
Surgery under Conscious Sedation
Introduction
Conscious sedation is a technique that combines the use of local anesthesia and intravenous sedation. It is defined as a depressed level of consciousness to the point that the patient is in a state of relaxation, but maintains respiratory drive and the ability to protect the airway. The patient is also capable of purposefully responding to physical and verbal stimulation. This is in contrast to deep sedation, in which the patient is unable to respond to verbal stimuli, will only respond to painful stimulation with withdrawal and has potential compromise of airway protection and respiratory drive. As opposed to monitored anesthesia care (MAC), in which an anesthesiologist or nurse anesthetist are required, conscious sedation can be performed by a nurse under the supervision of the operating surgeon.
Conscious sedation is rapidly gaining acceptance and popularity among plastic surgeons. It has been utilized for many years by other specialties, and now with the growth in office-based procedures and surgicenters, there has been a corresponding increase in the role of conscious sedation. Currently, almost all aesthetic procedures can be performed using a local anesthetic combined with some form of intravenous sedation. These include breast augmentation, breast reduction, mastopexy, abdominoplasty, rhytidectomy, rhinoplasty, blepharoplasty and liposuction.
Benefits and Disadvantages of Conscious Sedation
There are a number of benefits to the use of conscious sedation instead of general anesthesia or deep sedation. First, the complications associated directly with the administration of a general anesthetic are avoided. These are not negligible, and include adverse cardiopulmonary effects, airway injury and positional nerve injuries. Such complications occur in roughly 1-2% of aesthetic procedures performed under general anesthesia. The incidence of postoperative nausea and vomiting, which account for most unintended admissions after outpatient surgery, is much less than that associated with general anesthesia. Secondly, the risk of developing deep vein thrombosis (DVT) as a result of blood pooling in the lower extremities during general anesthesia is greatly reduced due to the continued contraction of leg muscles and the spontaneous shifting of the patient during the procedure. Third, as a result of the relatively large dose of an amnestic medication that is used, most patients have no memory of the procedure, no recollection of experiencing pain, and many choose to undergo conscious sedation at subsequent procedures. Finally, because it can be performed safely without the presence of an anesthesiologist, there is a considerable saving in cost to the patient.
Conscious sedation is not suited to all patients. Furthermore, the use of conscious sedation requires a surgeon who can “multi-task,” focusing on the operation
as well as on the vital signs and level of arousal of the patient. The fact that the patient is conscious and can shift position or move freely, necessitates that the surgeon be prepared to stop working at any moment. Nevertheless, many patients are well-suited for conscious sedation.
Preoperative Considerations
Prior to using conscious sedation for the first time, the surgeon must familiarize herself with the medications she will be using, as well as their side effects and reversal agents. She must also be familiar with ACLS protocol, airway management and have readily available resuscitation equipment. Immediate access to an anesthesiologist in case of emergency is strongly recommended.
Proper patient selection is an important preoperative decision. Those with moderate to significant cardiopulmonary disease are poor candidates. Patients should meet the criteria of the American Society of Anesthesiologists status I or II. This means that candidates for conscious sedation should be healthy or have only a mild systemic disease that results in no functional limitation (e.g., obesity, diabetes, hypertension and extremes of age). All other patients should receive monitored anesthesia care by an anesthesiologist or general anesthesia. Furthermore, individuals with anxiety disorders and extreme fear of the operating room may not be suited for conscious sedation.
Prior to the procedure, patients may benefit from premedication with intravenous diazepam (Valium), administered in increments of 5-10 mg. The dose administered usually ranges from 10 to 50 mg, with the goal being adequate preoperative subjective relaxation of the patient with the desired endpoint being of slurred speech. Oral diazepam is also an option; however, it has to be given almost an hour prior to the procedure in order to be effective. A second medication that should be administered preoperatively is an antiemetic. Ondansetron (Zofran), given as a single 4 mg intravenous injection is used routinely at our institution. Recently, we have found that clonidine (0.1-0.3 mg PO) given 30 minutes prior to the procedure is not only effective in lowering blood pressure during surgery, it also contributes significantly to patient relaxation during the procedure. It does, however, cause post-procedure orthostatic hypotension.
Intraoperative Considerations
Tumescent Anesthesia
As stated previously, conscious sedation—as it pertains to plastic surgery, involves the administration of local anesthesia in addition to the intravenous sedation. In fact, it is the methodical use of tumescent anesthesia that ensures a smooth, relatively pain free procedure. Tumescence, or wetting solution as it is more appropriately termed, should be infiltrated into the surgical field. Two goals should be kept in mind: anesthesia of the sensory nerves and vasoconstriction of the blood vessels in the region. Achieving these goals requires at least 10 minutes for the wetting solution to exert its effects. Two solutions are commonly used at our institution:
Liposuction solution 1 liter bag of Lactated Ringer’s solution
50 ml of 1% plain lidocaine
1 ml of epinephrine (1:100,000)
Face/breast solution 250 ml bag of normal saline
100 ml of 1% lidocaine + epinephrine (1:100,000)
10 ml of sodium bicarbonate
Table 9.1. Simple medication regimen that can be used for conscious sedation
Medication Dosage Range Purpose Reversal Agent Preoperative
Diazepam 5-10 mg Preoperative Flumazenil (0.2 mg/min; (up to 50 mg) sedation up to 5 doses; reversal in 1-2 min)
Ondansetron 2-4 mg Prevention of None postop nausea and vomiting
Intraoperative
Midazolam 0.5-2 mg Anxiolytic, Flumazenil (0.2 mg/min; sedative up to 5 doses; reversal in 1-2 min)
Fentanyl 12.5-50 mcg Analgesia Naloxone (0.1-0.2 mg/ 2 minutes) reversal in 2-3 minutes
Intravenous Sedation Regimens
Although there are a number of intravenous sedation regimens available, an excellent choice is the combined use of midazolam (Versed) and fentanyl (see Table 9.1). The advantage of using this combination is that midazolam has both anxiolytic and amnestic effects, whereas fentanyl is a potent, short-acting analgesic. The combination of fentanyl and midazolam is superior to midazolam alone in decreasing patients’ subjective report of pain and anxiety. The main drawback of fentanyl is respiratory depression; however unlike other commonly used intravenous opiates such as morphine, it does have a very short half life. Midazolam, in contrast, has minimal effects on the respiratory system except in the elderly, in which lower doses should be utilized. Both of these medications have antagonists. Flumazenil (Mazicon) and naloxone (Narcan), the antagonists of midazolam and fentanyl respectively, should be readily available in the operating room.
Another method of intravenous sedation involves the use of propofol in combination with an opiate and benzodiazepine. The fact that a deeper level of sedation can be maintained makes this technique preferable for selected patients who are very anxious. Nevertheless, the disadvantage of this combination is the higher risk of respiratory depression, and the lack of a reversal agent for propofol. This technique necessitates a higher degree of experience and training in anesthetic technique including the ability to intubate the patient if needed. The use of propofol is not discussed in this chapter.
In the operating room, one nurse should be responsible for continuously monitoring patient status using pulse oximetry, blood pressure and cardiac monitoring. This should be performed by a nurse with appropriate experience and background in continuous patient monitoring; however specialized anesthesia training is usually not needed. It is important to emphasize that this nurse should have no other duties to perform during the procedure. The patient’s oxygen saturation, blood pressure, heart rate, level of arousal and respiratory status should be monitored every 5 minutes. Changes in vital signs, level of arousal and the oxygen saturation are communicated to the surgeon. In addition, the surgeon should make his own assessment of arousal based on response to verbal stimulation, as well as the patient’s degree of discomfort.
Based on the patient’s condition, 0.5 to 2 mg of midazolam should be administered at the 5 minute intervals. In addition, fentanyl should be given in increments of 12.5 to 50 mcg. After local anesthetic is infiltrated, fentanyl administration is infrequently required, except in preparation for subsequent local anesthetic administration to a new surgical site. The total dose of fentanyl should rarely exceeded 200 mcg over the course of the procedure. Toward the end of the case, the amount of sedation should be decreased to allow the patient to slowly return to a normal state of arousal and awareness.
During conscious sedation, supplemental oxygen is usually not necessary. The ability of the patient to maintain an oxygen saturation over 95% without supplemental oxygen is a useful guideline to avoid oversedation (crossing from conscious to deep sedation). Occasional periods of deep sedation may occur, usually lasting for a few minutes at most. Brief stimulation and rarely jaw thrust may be required to maintain adequate ventilation. The use of small incremental doses of midazolam, limited use of narcotics and effective local anesthesia help to limit episodes of deep sedation. Nevertheless, as a safety measure, the capability to convert to general anesthesia or immediate assistance from an anesthesiologist should always be available. Foley catheters and sequential compression devices are generally not required due to the relatively short length of procedures utilizing conscious sedation, and the fact that venous stasis is minimal due to spontaneous patient movement and leg muscle contractions. For cases involving large volume liposuction or those that are longer than a few hours, a Foley catheter should be used to monitor fluid status and to allow greater flexibility in intraoperative fluid resuscitation.
Postoperative Considerations
Following the procedure, many hospitals will allow patients to bypass the recovery room and proceed directly to the outpatient day surgery area. This saves the patient the extra costs of recovery room care. Patients are monitored postoperatively in a standard manner. Those who choose to go home the day of surgery must meet criteria for discharge (ability to ambulate to a chair and the bathroom, bladder control, tolerate oral intake without emesis). Patients who received preoperative clonidine must be monitored for orthostatic hypotension.
Inpatient stay in an observation unit is appropriate for longer cases that involve multiple procedures, as well as for older patients who live alone. Postoperative nausea and vomiting is the major factor contributing to unintentional hospital admission after outpatient surgery. It begins shortly after arrival in the recovery room and usually lasts no longer than 12-24 hours postoperatively. A number of studies support the administration of a preoperative antiemetic (see preoperative considerations).
Pearls and Pitfalls
One of the risks of conscious sedation is crossing over into deep sedation. The responsible surgeon and monitoring nurse should be able to identify and handle patients who briefly slip into deep sedation. In very rare instances, a patient may require jaw thrust, mask ventilation or narcotic reversal. It is critical that the surgeon be comfortable performing these steps if necessary. A common pitfall leading to over sedation is to administer excessive amounts of fentanyl, instead of maximizing the use of the local anesthetic. Towards the end of the procedure, there is nothing wrong with cutting back on the amount of sedation, and allowing the patient to become more awake. In addition, excessive administration of versed can result in the opposite effect: an overly anxious, and occasionally claustrophobic patient. When this occurs, it is best to withhold sedation, reassure the patient and allow her to reorient herself.
Suggested Reading
- American Society of Anesthesiologists task force on sedation and analgesia by nonanesthesiologists. Practice guidelines for sedation and analgesia by nonanesthesiologists. Anesthesiology 1996; 84:459.
- Byun MY, Fine NA, Lee JY et al. The clinical outcome of abdominoplasty peformed under conscious sedation: Increased use of fentanyl correlated with longer stay in outpatient unit. Plast Reconstr Surg 1999; 103:1260.
- Dionne RA, Yagiela JA, Moore PA et al. Comparing efficacy and safety of four intravenous sedation regimens in dental outpatients. J Am Dent Assoc 2001; 132:740.
- Iverson RE. Sedation and analgesia in ambulatory settings. American society of plastic and reconstructive surgeons. Task force on sedation and analgesia in ambulatory settings. Plast Reconstr Surg 1999; 104:1559.
- Finder RL, Moore PA. Benzodiazepines for intravenous conscious sedation: Agonists and antagonists. Compendium 1993; 14:972.
- Kallar S. Conscious sedation in ambulatory surgery. Anesth Rev 1991; 18:9.
- Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 1990; 16(3):248.
- Marcus JR, Few JW, Chao JD et al. The prevention of emesis in plastic surgery: A randomized, prospective study. Plast Reconst Surg 2002; 109:2487.
- Marcus JR, Tyrone JW, Few JW et al. Optimization of conscious sedation in plastic surgery. Plast Reconst Surg 1999; 104:1338.
Basic Anesthetic Blocks
Introduction
Regional anesthetic blocks can be a valuable supplement or even replacement to the more common field block used in plastic surgery. The principle behind a regional nerve block is to anesthetize a sensory nerve that supplies innervation to the area of injury at a single more proximal site. The advantages of this technique over a field block are that it is usually much faster, it requires a smaller volume of local anesthetic, and it avoids distortion of the surgical site, as well the bleeding that often ensues after multiple needle sticks. It does, however, require a thorough knowledge of the anatomy of the nerve, and it does not always provide complete anesthesia to the desired site secondary to collateral innervation.
This chapter will focus on regional nerve blocks in two key anatomic regions: the face and hands.
Choice of Anesthetic Agent
The previous chapter discussed the various anesthetic agents in detail. Briefly, most blocks can be achieved using 1% lidocaine with epinephrine (1:100,000). The addition of epinephrine prolongs the duration of action of the anesthetic, as well as providing vasoconstriction of the site. Epinephrine can be used anywhere in the face; however it should not be used in the fingers or penis. The addition of bupivicaine to the lidocaine solution can prolong the duration of anesthesia for several hours, providing additional post-procedure pain relief. Furthermore, sodium bicarbonate can be added to the lidocaine solution to cut back on the burning sensation from the injection.
Choice of Syringe and Needle
A 5 ml syringe is usually sufficient for most blocks since rarely is more than this amount required. The smaller syringe is also easier to maneuver. The needle should be a 25 or 27 gauge. The length of the needle must be sufficient to reach the target. For example, the infraorbital foramen is usually reached through the oral cavity, requiring at least a 1 inch needle.
Regional Block of the Scalp
Indication
Anesthesia of the scalp down to the periosteum.
Technique
The scalp is innervated by branches of the trigeminal and cervical nerves. These nerves can be anesthetized as they penetrate the scalp. They become subfascial along
a line that encircles the head (like a skull-cap). This line passes just above the tragus and through the glabella and occiput. A wheal should be raised in the subdermal plane along this line. About 10 ml of lidocaine is required every few centimeters.
Supraorbital Nerve Block
Indication
Anesthesia of the upper eyelid and medial forehead.
Technique
Palpate the supraorbital notch/foramen at the junction of the medial and middle thirds of the orbital ridge (about 2.5 cm off the midline of the face). Raise a wheal using a 25 gauge 1 inch needle. Advance the needle until the tip meets the foramen, and inject 1-2 ml while withdrawing.
Infraorbital Nerve Block
Indication
Anesthesia of the lower eyelid, medial cheek region or upper lip.
Extraoral Technique
Place the index finger in the canine fossa pointing caudal towards the infraorbital foramen. Raise a wheal using a 25 gauge 1 inch needle about 1 cm lateral to the ala of the nose. Advance the needle towards the tip of the finger until the tip meets the foramen on the maxilla. Inject 1-2 ml into the foramen and while withdrawing. The infraorbital canal runs in a superolateral direction.
Intraoral Technique
Retract the cheek with the thumb and introduce the needle into the upper gingival sulcus above the second bicuspid. Rest the syringe on the lower lip of the patient. Aim slightly laterally away from the midline along the maxilla until the infraorbital foramen is encountered. Inject 1-2 ml into the foramen and inject while withdrawing. The infraorbital canal runs in a superolateral direction.
Mental Nerve Block
Indications
Anesthesia of the lower lip, anterior portion of the lower jaw (including the anterior lower teeth).
Extraoral Technique
The mental foramen is located directly below the root of the second lower bicuspid at the midpoint between the lower and upper margins of the mandible. The needle is inserted into the skin and a wheal is raised. It is aimed inferolaterally towards the mental foramen, and anesthetic is injected while the needle advances until bone is met. After instilling 1 ml of anesthetic, the needle is used to palpate the mental foramen after which an additional 1 ml is injected into the foramen.
Intraoral Technique
With the mouth closed, the cheek is retracted and needle inserted into the gingivobuccal sulcus below the bicuspids. A wheal is raised, and the needle is aimed towards the root of the second bicuspid and advanced at 45˚ until bone is reached. After instilling 1 ml of anesthetic, the needle is used to palpate the mental foramen after which an additional 1 ml is injected into the foramen.
Regional Block of the External Nose
Indications
Anesthesia of the skin of the nose.
Technique
The two sides of the nose should be anesthetized separately. The needle is introduced into the skin about 1 cm lateral to the alar base. A wheal is raised, and the needle is advanced towards the radix; 2-3 ml is injected along this line. The needle is withdrawn almost completely and then directed downward towards the oral commissure. An additional 1-2 ml is injected along this course. The entire procedure is repeated for the other side of the nose.
Regional Block of the External Ear
Indication
Anesthesia of the ear.
Technique
The anterior ear is supplied by the auriculotemporal nerve and the posterior ear by the greater auricular nerve and occipital nerve (including its mastoid branch). These nerves all reach the ear from the superior, posterior and inferior directions only. A needle is inserted 2 cm above the helix and advanced anteroinferiorily and posteroinferiorily. The needle is removed and inserted 3 cm posterior to the ear and advanced anterosuperiorily and anteroinferiorily. The needle is removed and inserted 1 cm below the ear, advancing it posterosuperiorily and anterosuperiorly. When these three injections are completed, a continuous infiltration around the entire ear (excluding the anterior portion) has been achieved.
Radial Nerve Block
Indication
Anesthesia of the radial dorsum of the hand and proximal thumb, index and middle finger. The ring finger should also be blocked with an ulnar nerve block.
Technique
- Identify extensor pollicus longus (dorsal tendon of the anatomical snuffbox).
- Insert the needle over the tendon at the base of the first metacarpal.
- Inject superficial to the tendon (about 2 ml) and over the snuffbox (1 ml).
Median Nerve Block
Indication
Anesthesia of the palmar side of the thumb index finger and middle finger, and radial side of the ring finger. Also, the nailbeds of the above fingers can be blocked with this technique. The thenar region (palmar cutaneous branch of the median nerve) can also be blocked.
Technique
- Identify flexor carpi radialis and palmaris longus by having the patient make a clenched fist and slight wrist flexion.
- Insert the needle 2 cm proximal to the proximal wrist crease.
- As the needle passes through the flexor retinaculum, 3 ml of anesthetic is injected.
- Injection of an additional 1 ml above the retinaculum will anesthetize the palmar cutaneous branch supplying the thenar eminence.
Ulnar Nerve Block
Indications
Anesthesia of the little finger and ulnar side of the ring finger.
Technique
- Identify flexor carpi ulnaris by having the patient forcefully ulnar deviate the wrist slightly with the fingers fully extended.
- The ulnar nerve lies radial to the flexor carpi ulnaris tendon.
- Insert the needle 2 cm proximal to the wrist on the radial side of the tendon directed towards the midline.
- After parasthesias are felt, inject 4 ml of anesthetic in a fanwise fashion along the course of the nerve.
Digital Nerve (Ring) Block
Indications
Anesthesia of the digit.
Technique
- With the dorsum of the hand facing upward, insert the needle into the dorsal skin at the midpoint between the digits (the apex of the “V” of the web space) and raise a wheal.
- Advance the needle towards the palm perpendicular to the skin and infiltrate along this course about 2 ml of anesthetic.
- Withdraw the needle almost completely and then begin advancing the needle towards the middle of the digit, infiltrating the skin on the dorsum of the finger base.
- The digital nerves on either side of the finger should be anesthetized in this manner.
Pearls and Pitfalls
- The supraorbital, infraorbital and mental foramena all lay along a vertical line that also includes the pupil in the midgaze position. Therefore, if any two of the foramena have been located, the third can be easily found.
- Epinephrine requires about 10 minutes until full effect, and the same is true for lidocaine used in a regional block. Therefore, one should administer the block in advance.
- Several studies reviewing thousands of cases of digital anesthesia have found that using epinephrine in the digits is entirely safe, with almost no cases of digital ischemia secondary to the epinephrine. However, until a prospective trial demonstrates the absolute safety of this practice, epinephrine should not be used in the digits.
- An adequate block is not always 100% successful at eliminating pain from the site of injury. Often a supplemental field block is required after the initial regional block has taken effect.
Suggested Reading
- Stromberg BV. Anesthesia. In: McCarthy JG, ed. Plastic Surgery. 1st ed. Philadelphia: WB Saunders Company, 1990.
- Wedel DJ. Anesthesia in hand and upper extremity surgery. In: Berger RA, Weiss AC, eds. Hand Surgery. Philadelphia: Lippincott Williams and Wilkins, 2004.
- Zide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg 1998; 101(3):840-51.
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