Anesthetic complications in plastic surgery are generally rare, but potentially catastrophic. Thus, maintaining patient safety in the operating room is a major concern of anesthesiologists, surgeons, hospitals, and surgical facilities. Circumventing preventable complications is essential and pressure to avoid these complications in plastic surgery is increasing (1). Although all surgeries carry risk, there are often additional factors pertaining to plastic surgeries that may aggravate existing comorbid conditions. Patients undergoing plastic surgeries often present complex and difficult scenarios that anesthesiologists must take into account. These case scenarios can be classified as 1) those inherent to the age of the patients in which these conditions appear, 2) those with medical comorbidities involved, and 3) conditions that pose difficulties in airway management (1).
Pediatric patients often have congenital defects, such as cleft lip and palate, that present difficulties for anesthesiologists. These include issues with ventilation and intubation, for example. In a review of perioperative airway complications following pharyngeal flap palatoplasty, Peña et al. reported a ten percent incidence of airway complications in the 88 patients studied (2). For these patients, intravenous access may need to be established before the induction of anesthesia. Using straight laryngoscope blades, external laryngeal manipulation and a piece of rolled gauze packed in the cleft palate defect may help. Fiber-optic bronchoscopes, Bullard laryngoscopes and laryngeal masks are also other alternatives for securing the airway. Elderly patients are also at greater risk for perioperative complications. This is due to the combined effects of reduced organ function and the prevalence of age related concomitant diseases. The risks associated with plastic surgery and anesthesia in this age group can be minimized by understanding the physiological changes associated with aging (1). Elderly patients are more prone to heat loss and shivering, for example, due to a reduced basal metabolic rate and impaired thermoregulation. Drug metabolism is also slower in elderly patients, as they generally have reduced renal and liver function, leading to increased susceptibility to drug-related toxicity. Additionally, the incidence of postoperative delirium in the elderly population is almost 10%. Causes may include patients’ age, baseline low cognitive function, dementia and depression.(3). Delirium is also associated with increased duration of hospital stay and poorer functional recovery.
Case scenarios with medical comorbidities involved, such as surgeries for obese patients, diabetics, and burns patients also add complexity to the role of the anesthesiologist. The most common surgery that obese patients choose to undergo is liposuction, and the complications associated with this procedure can vary from mild to severe, including death (1). Generally, liposuction requires the use of wetting solution (containing epinephrine and lidocaine) to minimize blood loss. Excess wetting solution may lead to lidocaine toxicity. However, if the patient receives general anesthesia, the lidocaine component of the wetting solution can be further reduced or eliminated without an increase in postoperative pain (1). Patients with conditions like diabetes and hypertension often undergo surgeries such as debridement and flap cover. Both of those procedures are associated with significant blood loss, hypothermia, cognitive dysfunction and other complications associated with being in the prone position. The most common complications associated with the prone position are injuries to the central nervous system, injuries to peripheral nerves (ulnar neuropathy), direct pressure injuries (to ears, breasts, genitalia and other dependent areas) and peripheral vessel compression and occlusion. It is advisable to maintain a neutral neck position to minimize the risk of occluding the carotid or vertebral arteries and internal jugular veins (4). As for patients with acute burns, anesthesiologists should be careful to avoid succinylcholine for muscle relaxation in major burns (more than 10% of total body surface area), if more than 24 hours old. Succinylcholine can cause hyperkalemia and possibly cardiac arrest. Non-depolarizing muscle relaxants (e.g., pancuronium, vecuronium, etc.) may be used, although higher doses may be required (1).
Last but not least, conditions that pose difficulty in airway management can also add complications to anesthesia delivery. One of the most common conditions where difficulty in airway management can be expected is maxillofacial trauma (1). The difficulties associated with this condition can be avoided by carefully timing the surgery, so that tissue edema subsides but malunion of the facial bones does not occur. Maxillofacial reconstruction is often required to correct the effects of trauma (e.g., Le Fort fractures) and developmental malformations. Preoperative airway evaluation must be detailed and thorough, as the presence of active hemorrhaging, for example, may pose difficulty in fiberoptic laryngoscopy. If there are any anticipated signs of problems with mask ventilation or tracheal intubation, the airway should be secured prior to induction. This may involve fiberoptic nasal intubation, fiberoptic oral intubation or tracheostomy (1).
References
1. Nath, S. S., Roy, D., Ansari, F., & Pawar, S. T. (2013). Anaesthetic complications in plastic surgery. Indian Journal of Plastic Surgery: Official Publication of the Association of Plastic Surgeons of India, 46(2), 445–452. doi:10.4103/0970-0358.118626
2. Peña, M., Boyajian, M., Choi, S., & Zalzal, G. (2000). Perioperative Airway Complications following Pharyngeal Flap Palatoplasty. Annals of Otology, Rhinology & Laryngology, 109(9), 808–811. https://doi.org/10.1177/000348940010900904
3. Dasgupta, M. and Dumbrell, A. C. (2006). Preoperative Risk Assessment for Delirium After Noncardiac Surgery: A Systematic Review. Journal of the American Geriatrics Society, 54: 1578-1589. doi:10.1111/j.1532-5415.2006.00893
4. Edgcombe, H., Carter, K., Yarrow, S. (2008). Anaesthesia in the prone position. British Journal of Anaesthesia, 102(2), 165-183. doi: 10.1093/bja/aem380
