Optimizing Patient Outcomes and Safety With Liposuction.

Since its advent in the early 1980s, liposuction has made tremendous advancements, making it the most popular aesthetic surgery performed today. The goal of this Continuing Medical Education (CME) article is to provide a foundation of knowledge of the relevant anatomy, preoperative evaluation, intraoperative technique, and postoperative management for surgeons performing liposuction. Finally, the prevention and management of potential complications will be reviewed along with measures to optimize patient safety and outcomes.

Perioperative versus postoperative celecoxib on patient outcomes after major plastic surgery procedures.

BACKGROUND: Controversy continues to surround the use of cyclooxygenase (COX)-2 inhibitors in the perioperative period. We designed this randomized, double-blind, placebo-controlled study to examine the hypothesis that administration of celecoxib preoperatively or postoperatively and for 3 days after major plastic surgery would improve pain control and clinically important patient outcomes. Another objective of the study was to determine whether perioperative administration of celecoxib offered any advantages over postoperative administration alone. METHODS: One hundred and twenty healthy consenting patients undergoing major plastic surgery (e.g., breast augmentation, abdominoplasty procedures) using a standardized general anesthetic technique were randomized to one of three treatment groups: 1) control group (n = 40) received two placebos orally before and after surgery, as well as one placebo BID for 3 days after surgery; 2) postoperative group (n = 40) received two placebos before surgery and 2 celecoxib 200 mg p.o. after surgery, followed by one celecoxib 200 mg p.o. BID on postoperative day #1, #2 and #3; and 3) perioperative group (n = 40) received 2 celecoxib 200 mg p.o. 30-90 min before surgery, and two placebos after surgery, followed by one celecoxib 200 mg p.o. BID on postoperative day #1, #2, and #3. Pain scores, the need for rescue analgesics, and side effects were recorded at specific time intervals in the postoperative period. Follow-up evaluations were performed at 24, 48, 72 h, and 7 days after surgery to assess postdischarge pain, analgesic requirements, return of bowel function, resumption of normal daily activities, quality of recovery, as well as patient satisfaction with pain management. RESULTS: Compared with the control group, the two celecoxib groups had similar significant reductions in postoperative pain and need for opioid analgesics during the first three postoperative days (P < 0.01). Patients recovered bowel function 1 day earlier and resumed normal activities 2 days earlier in the celecoxib groups. In addition, patient satisfaction with pain management and quality of recovery were significantly improved in the celecoxib (versus control) groups (P < 0.05). CONCLUSION: Celecoxib (400 mg p.o.) administered on the day of surgery and for 3 days postoperatively is effective in improving postoperative pain management, as well as the speed and quality of recovery after major plastic surgery. However, perioperative administration offers no advantages over simply giving the drug after surgery.

Transdermal scopolamine: an alternative to ondansetron and droperidol for the prevention of postoperative and postdischarge emetic symptoms.

BACKGROUND: Given the controversy regarding the use of droperidol and the high cost of the 5-HT3 antagonists, a cost-effective alternative for routine use as a prophylactic antiemetic would be desirable. We designed two parallel, randomized, double-blind sham and placebo-controlled studies to compare the early and late antiemetic efficacy and adverse event profile of transdermal scopolamine (TDS) 1.5 mg, to ondansetron 4 mg IV, and droperidol 1.25 mg IV for antiemetic prophylaxis as part of a multimodal regimen in "at risk" surgical populations. METHODS: A total of 150 patients undergoing major laparoscopic (n = 80) or plastic (n = 70) surgery procedures received either an active TDS patch (containing scopolamine 1.5 mg) or a similar appearing sham patch 60 min before entering the operating room. All patients received a standardized general anesthetic technique. A second study medication was administered in a 2-mL numbered syringe containing either saline (for the two active TDS groups), droperidol, 1.25 mg, or ondansetron, 4 mg (for the sham patch groups), and was administered IV near the end of the procedure. The occurrence of postoperative nausea and vomiting/retching, need for rescue antiemetics, and the complete response rates (i.e., absence of protracted nausea or repeated episodes of emesis requiring antiemetic rescue medication) was reported. In addition, complaints of visual disturbances, dry mouth, drowsiness, and restlessness were noted up to 72 h after surgery. RESULTS: There were no significant differences in any of the emetic outcomes or need for rescue antiemetics among the TDS, droperidol, and ondansetron groups in the first 72 h after surgery. The complete response rates varied from 41% to 51%, and did not significantly differ among the treatment groups. The overall incidence of dry mouth was significantly more frequent in the TDS groups than in the droperidol and ondansetron groups (21% vs 3%). CONCLUSIONS: Premedication with TDS was as effective as droperidol (1.25 mg) or ondansetron (4 mg) in preventing nausea and vomiting in the early and late postoperative periods. However, the use of a TDS patch is more likely to produce a dry mouth.

Perioperative Corneal Abrasion: Updated Guidelines for Prevention and Management.

Corneal abrasion is the most common ocular complication in surgery. Treatment requires pain control, antimicrobial prophylaxis, and close monitoring. Pain improves significantly after 24 hours and should be resolved by 48 hours. Persistent, worsening, or new symptoms warrant immediate specialist consultation. The authors review the pathophysiology of perioperative corneal abrasion, and propose updated evidence-based guidelines for improved patient care.

Refining the anesthesia management of the face-lift patient: lessons learned from 1089 consecutive face lifts.

BACKGROUND: The importance of anesthetic technique is often underappreciated in face-lift procedures and is sparsely written about in the literature. Appropriate control of blood pressure, anxiety, pain, and nausea is essential for reducing the complications of face lift, primarily, hematoma risk. This study discusses the standard anesthetic protocol provided at the authors' institution and describes the preoperative, intraoperative, and postoperative management of face-lift patients resulting in low hematoma and complication rates. METHODS: One thousand eighty-nine patients who underwent face-lift procedures performed by a single surgeon (R.J.R) were included in a retrospective chart review following institutional review board approval. Patient demographics, operative data including additional ancillary procedures, and the anesthesia regimen were recorded. In addition, postoperative complications and reoperation rates were documented. RESULTS: Between 1990 and 2013, 1089 face-lift procedures were performed. Of these, 10 patients developed postoperative hematomas. Benzodiazepines were commonly administered preoperatively to reduce anxiety level. Intraoperatively, a specific regimen and combination of inhalation agents, neuromuscular blockers, antiemetics, antihypertensives, and narcotics was given to control the ease of induction and emergence from anesthesia. Postoperatively, nausea, vomiting, anxiety, pain, and hypertension were treated as needed. CONCLUSIONS: The described protocol is safe and has been instituted at the authors' facility for approximately 20 years. The benefit of this regimen is related to the synergy of combination therapy. It is successful in reducing patient anxiety and pain, controlling blood pressure and postoperative emesis, and subsequently results in a reduced risk of hematoma. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Role of the Superwet Technique in Face Lift: An Analysis of 1089 Patients over 23 Years.

BACKGROUND: The use of superwet technique of infiltration and autologous tissue sealants during rhytidectomy has benefits of decreasing bleeding and edema, improving visualization, and easing dissection. The purpose of this study was to analyze whether these intraoperative strategies resulted in more consistent and reproducible outcomes and significantly decreased hematoma rates. METHODS: A retrospective review was performed on 1089 consecutive face lifts performed by a single surgeon. Fisher's exact test was used to determine significant differences in hematomas between those patients who received platelet-rich plasma and superwet technique and those who did not. Multivariate logistic regression was used to evaluate demographic variables and intraoperative interventions for risk of complication. RESULTS: Five hundred eighty-seven of 1089 face lifts received platelet-rich plasma and 926 of 1089 underwent a superwet technique. Ten hematomas were recorded, six in the group that did not receive platelet-rich plasma compared to four who did (p = 0.527). One hematoma was observed before implementation of the superwet technique and nine were in the group after (p = 1.00). Multivariate analysis showed male sex to be a significant factor for hematoma (p < 0.001). CONCLUSIONS: This analysis showed excellent outcomes with a hematoma rate of 0.9 percent. Although no significant differences were noted, the authors attribute their consistent and reproducible results to the use of the superwet technique and platelet-rich plasma. The superwet technique allows for improved safety and visualization with improved hemostasis. Platelet-rich plasma potentially decreases ecchymosis and edema. Prospective studies are needed to determine significant differences between these intraoperative interventions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evolution of hypertension management in face lifting in 1089 patients: optimizing safety and outcomes.

BACKGROUND: Hematoma continues to be the most common complication after rhytidectomy. Perioperative hypertension is a known risk factor, and meticulous control of this has been shown to significantly reduce the incidence of postoperative hematoma development, thus improving outcomes and decreasing patient morbidity. Despite this, there are few well-described hypertension management regimens in the literature today. METHODS: A retrospective chart review of 1089 patients undergoing rhytidectomy performed by a single surgeon was conducted. A predetermined antihypertensive protocol was used in all patients that included the routine use of transdermal clonidine. A target systolic blood pressure of 140 mmHg or less was the goal of therapy, and close hemodynamic monitoring was used throughout the entire perioperative phase. The incidence of postoperative hematoma was then assessed. RESULTS: The overall incidence of postoperative hematoma was 0.9 percent (10 patients). Of these patients, five were female (0.05 percent) and five were male (5.2 percent). Preoperatively, 170 patients were noted to be hypertensive, with a systolic blood pressure greater than 140 mmHg. Postoperatively, 355 patients were found to be hypertensive (p < 0.001). Of the patients who developed a postoperative hematoma, eight patients (80 percent) had documented hypertension (systolic blood pressure >140 mmHg) in the postanesthesia care unit (p = 0.045). Male sex was found to be a significant risk factor for the development of hematoma (p < 0.001). CONCLUSIONS: Meticulous perioperative blood pressure control significantly reduces the rate of postoperative hematoma formation. The use of a specific protocol developed by our senior author and primary anesthesia provider contributed to our very low hematoma rates.

A note on anesthesia for mohs nasal defects.

Patients needing surgical repair after nasal Mohs surgery require immediate prescreening by an anesthesiology provider to determine if the patient is a candidate for the appropriate anesthetic or is to be delayed for more medical evaluation. These patients may need anesthesia anywhere on the spectrum from local anesthesia only to general endotracheal anesthesia, and this may affect where and when the plastic surgeon can proceed.

Avoidance and management of complications in soft tissue facial reconstruction.

Complications in nasal soft tissue reconstruction are inevitable, and all reconstructive surgeons should be comfortable with their management. Patient and surgical complications can be minimized with appropriate preoperative planning and coordination with the anesthesiologist. When managing undesirable results, it is important to realize that most results will improve over time with appropriate wound care and dermabrasion. Patience and attentiveness to the patient are the most-effective strategies for dealing with poor results.

Use of herbal supplements and vitamins in plastic surgery: a practical review.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Explain what governmental regulations control the labeling and distribution of herbal supplements. 2. List the more commonly used supplements and their reported benefits. 3. List the possible postoperative complications from consumption of the more commonly used herbal supplements. 4. Explain the preoperative management of patients using herbal supplements. 5. Know additional resources to consult when unanswered questions arise. BACKGROUND: The American public spends over $5 billion per year on herbal supplements, and approximately 20 percent of all Americans use prescription medications concurrently with herbal supplements. As the number of people who take alternative medicines rises, there is growing awareness among health care providers of the need to become educated and to educate their patients on the effects that such supplementation may have on their health. As plastic surgeons, we have an added responsibility to become informed because of potential adverse interactions with other medications and anesthesia in the elective surgical patient. METHODS: Literature regarding commonly encountered herbal supplements and vitamins was reviewed and summarized to include reported indications for use and potential adverse effects and interactions specific to the perioperative patient. RESULTS: Abundant literature exists regarding herbal supplementation, but very little scientific evidence exists to advocate the use of the majority of supplements available on the market. In addition, little is known about the positive and negative interactions that these supplements are capable of producing, and those interactions that are known are based on case reports. CONCLUSIONS: With the lack of quality scientific studies to support the efficacy of most herbal products available and the limited regulation of these products by the government, health care providers are faced with a significant public health dilemma. This article provides a brief overview of information published on commonly encountered herbal supplements and vitamins taken by plastic surgery patients.

Simplifying circumferential body contouring: the central body lift evolution.

BACKGROUND: Optimal central body contouring may be achieved with a combination of circumferential liposuction and excisional techniques for patients with diffuse lipodystrophy or generalized skin laxity or after massive weight loss. The central body lift has evolved to improve the contour of the trunk and proximal lower extremity in patients with skin redundancy and lipodystrophy. Liposuction is used as an adjunct to improve the results of excisional body contouring. The authors' goal is to review the literature and describe the evolution of their technique for the central body lift, which optimizes safety and contouring of the abdomen, thighs, and buttocks using a circumferential abdominoplasty and discontinuous circumferential liposuction. METHODS: The authors present a retrospective chart review of their series of 151 patients over a 12-year period that underwent the central body lift procedure. Patient selection, safety factors, key operative elements, and postoperative care are reviewed and discussed. RESULTS: There were three major complications (2.0 percent) (two deep vein thromboses and one pulmonary embolus) and 32 minor complications (21.1 percent). Surgical revision was required in eight patients (5.3 percent). Overall patient and physician satisfaction was high. CONCLUSIONS: The central body lift is an effective and safe body contouring technique for patients with diffuse lipodystrophy or generalized skin laxity or after massive weight loss. Adherence to safety guidelines is critical.

Fluid resuscitation in liposuction: a retrospective review of 89 consecutive patients.

BACKGROUND: In 1998, the senior author presented the intraoperative fluid ratio, defined as the volume of super-wet solution and intraoperative intravenous fluid divided by the aspiration volume, to guide resuscitation fluid volumes in super-wet liposuction. The senior author demonstrated that intraoperative fluid ratios of 2.1 for small-volume and 1.4 for large-volume liposuction were safe and did not cause volume overload sequelae. A high urine output was common and reflected a mild overresuscitation, which could have adverse consequences in patients with undiagnosed cardiopulmonary disease. The purpose of this study was to compare overresuscitation sequelae in a cohort of consecutive super-wet liposuction patients using a new fluid management formula in which replacement fluid was given after 5000 cc of lipoaspirate instead of 4000 cc, as initially described. METHODS: The charts of 89 consecutive patients undergoing super-wet liposuction were retrospectively reviewed. RESULTS: The intraoperative fluid ratio was 1.8 for the small-volume reductions (< 5000 cc, n = 68) and 1.2 (> 5001 cc, n = 21) for the large-volume reductions. There were no episodes of pulmonary edema, congestive heart failure exacerbation, or other major complications. The average urine output in the operating room, the recovery room, and while on the floor was 1.5, 1.6, and 2.9 cc/kg/hour for the small-volume group and 1.7, 1.8, and 2.5 cc/kg/hour for the large-volume group. CONCLUSIONS: The super-wet subcutaneous infiltration liposuction technique for both small- and large-volume reductions is safe and can be performed without adverse cardiopulmonary sequelae. Given the high urine outputs, the intraoperative fluid ratio can be further improved by possibly eliminating the replacement fluid altogether.

Optimal timing of acustimulation for antiemetic prophylaxis as an adjunct to ondansetron in patients undergoing plastic surgery.

We designed this study to evaluate the antiemetic efficacy of transcutaneous electrical acupoint stimulation in combination with ondansetron when applied before, after, or both before and after plastic surgery. A randomized, double-blind, sham-controlled study design was used to compare three prophylactic acustimulation treatment schedules: preoperative--an active device was applied for 30 min before and a sham device for 72 h after surgery; postoperative--a sham device was applied for 30 min before and an active device for 72 h after surgery; and perioperative--an active device was applied for 30 min before and 72 h after surgery (n = 35 per group). All patients received a standardized general anesthetic, and ondansetron 4 mg IV was administered at the end of surgery. The incidence of vomiting/retching and the need for rescue antiemetics were determined at specific time intervals for up to 72 h after surgery. Nausea scores were recorded with an 11-point verbal rating scale. Other outcome variables assessed included discharge times (for outpatients), resumption of normal activities of daily living, complete antiemetic response rate, and patient satisfaction with antiemetic therapy and quality of recovery. Perioperative use of the ReliefBand significantly increased complete responses (68%) compared with use of the device before surgery only (43%). Median postoperative nausea scores were significantly reduced in the peri- and postoperative (versus preoperative) treatment groups. Finally, patient satisfaction with the quality of recovery (83 +/- 16 and 85 +/- 13 vs 72 +/- 18) and antiemetic management (96 +/- 9 and 94 +/- 10 vs 86 +/- 13) on an arbitrary scale from 0 = worst to 100 = best was significantly higher in the groups receiving peri- or postoperative (versus preoperative) acustimulation therapy. For patients discharged on the day of surgery, the time to home readiness was significantly reduced (114 +/- 41 min versus 164 +/- 50 min; P < 0.05) when acustimulation was administered perioperatively (versus preoperatively). In conclusion, acustimulation with the ReliefBand was most effective in reducing postoperative nausea and vomiting and improving patients' satisfaction with their antiemetic therapy when it was administered after surgery.

Comparative efficacy of acustimulation (ReliefBand) versus ondansetron (Zofran) in combination with droperidol for preventing nausea and vomiting.

BACKGROUND: Antiemetic drugs are costly, are associated with variable efficacy, and can produce unwanted side effects when used for prophylaxis against postoperative nausea and vomiting. This clinical study was designed to compare the efficacy of transcutaneous electrical acupoint stimulation using a ReliefBand to ondansetron (Zofran) when utilized alone or in combination for preventing postoperative nausea and vomiting after plastic surgery. METHODS: A single-center, randomized, double-blind, placebo- and sham-controlled study design was conducted to compare three prophylactic antiemetic treatment regimens in 120 outpatients undergoing plastic surgery procedures with routine low-dose droperidol prophylaxis: (1) ondansetron (n = 40), 4 mg intravenous ondansetron and a sham ReliefBand; (2) acustimulation (n = 40), 2 ml intravenous saline and an active ReliefBand; and (3) combination (n = 40), 4 mg intravenous ondansetron and an active ReliefBand. The incidences of postoperative nausea and vomiting, as well as the need for "rescue" antiemetics, were determined at specific time intervals for up to 72 h after surgery. The outcome variables assessed included recovery times, quality of recovery score, time to resumption of normal diet, and patient satisfaction with the prophylactic antiemetic therapy. RESULTS: Use of the ReliefBand in combination with ondansetron significantly reduced nausea (20 vs. 50%), vomiting (0 vs. 20%), and the need for rescue antiemetics (10 vs. 37%) compared with ondansetron alone at 24 h after surgery. Furthermore, the ability to resume a normal diet (74 vs. 35%) within 24 h after surgery was significantly improved when the ReliefBand was used to supplement ondansetron (vs. ondansetron alone). Finally, the quality of recovery (90 +/- 10 vs.70 +/- 20) and patient satisfaction (94 +/- 10 vs. 75 +/- 22) scores were significantly higher in the combination group the ondansetron group. There were no significant differences between the ReliefBand and ondansetron when administered as adjuvants to droperidol for antiemetic prophylaxis. CONCLUSIONS: The ReliefBand compared favorably to ondansetron (4 mg intravenously) when used for prophylaxis against postoperative nausea and vomiting. Furthermore, the acustimulation device enhanced the antiemetic efficacy of ondansetron after plastic surgery.