General anesthesia in an office-based plastic surgical facility: a report on more than 23,000 consecutive office-based procedures under general anesthesia with no significant anesthetic complications

The popularity of elective office-based plastic surgery has increased significantly over the past two decades. The continuing demand for improved aesthetic results has stimulated the development of ever more complex plastic surgical techniques. These techniques may require extended periods of operative time spent under anesthesia. Patients have come to expect an almost perfect anesthetic and surgical experience, with safety and comfort being their foremost concerns. Because of increasingly complex and lengthy operations, the authors believe that intravenous sedation, used for many years in their plastic surgery practice, is now suboptimal for most longer and complex surgical procedures. In their experience, under most circumstances, general anesthesia provides the optimal anesthetic experience for the patient, anesthesiologist, and surgeon. The authors present a consecutive 18-year study of general anesthesia in more than 23,000 procedures in an accredited, office-based plastic surgical facility that offers a very safe and uniformly pleasant anesthesia experience for patients. There were no intraoperative or postoperative deaths and no significant complications. The authors' experience differs from the common perception that general anesthesia is too risky for aesthetic surgery procedures.     

The integral role of the plastic surgeon at a level I trauma center

The role of plastic surgery in urban level I trauma centers in the United States has been largely undefined, despite the undeniable historical involvement of plastic surgery in reconstruction of posttraumatic defects. To explore and define this role, case data were prospectively collected during a 29-month period following initiation of a full-time plastic surgery position at an established urban level I trauma center. Referring and/or interacting surgical service, anatomical area of interest, and procedure data were tabulated. A total of 1009 operative reports comprising 1104 procedures were recorded. The most common interacting surgical services were orthopedics and general/trauma surgery; however, interaction occurred with a total of 10 surgical specialties. The upper extremity was the most common anatomical area operated on followed by head and neck, lower extremity, trunk, urogenital, and breast. A wide variety of procedures were performed in each anatomical area, demonstrating the broad scope of reconstructive surgery practiced in a trauma setting. Three hundred and twenty-four procedures involved expertise in microsurgery, flaps, and burn or frostbite care. Additional procedures commonly performed demonstrated considerable overlap with other fields of surgical specialization. This overlap in skills proved advantageous in distribution of facial trauma call and hand surgery coverage. Data presented in this study reinforce the idea that plastic surgery is a specialty defined by concept rather than anatomical area, and also demonstrate a significant role for plastic surgeons in a level I trauma center.     

Malignant hyperthermia in plastic surgery

Malignant hyperthermia is a seemingly rare genetic myopathy. Hypermetabolic crisis accompanied by a rise in body temperature to as high as 44 degrees C is its hallmark. Malignant hyperthermia is usually triggered by potent inhalated anesthetics and/or depolarizing muscle relaxants. Because of the extraordinary risk of death in patients who are at risk, plastic surgeons may be reluctant to operate on these patients. Five such patients were referred to the Plastic Surgery Service and the UCLA Malignant Hyperthermia Center for anesthetic and surgical management following plastic surgical procedures aborted for first episodes of malignant hyperthermia. They were anesthetized with nitrous oxide, barbiturates, opiates, tranquilizers, and nondepolarizing muscle relaxants. The patients were not treated prophylactically with dantrolene. Cardiac monitoring, end-tidal pCO2, and rectal temperatures were followed. After completion of their plastic surgical procedures, all five patients had a vastus lateralis muscle biopsy performed and subsequent caffeine/halothane contracture studies completed. The contracture study was positive in all patients studied. No anesthetic or surgical complications were encountered. This study demonstrates that patients at risk of developing malignant hyperthermia crisis can have plastic surgical procedures performed safely while undergoing appropriately selected general anesthesia.     

A SIMPLIFIED METHOD of COLONY HYBRIDIZATION USING RADIOLABELED PROBES IN SEALED PETRI DISHES

A simplified colony hybridization procedure was developed using sealed disposable plastic petri dishes in place of sealed plastic bags. Prior to hybridization, the dishes were sealed with successive layers of parafilm, plastic wrap and aluminum foil to prevent evaporation of the solution. This self-contained procedure eliminates some of the technical problems such as spilling of radioactive materials, leakage of solution, sealing of plastic bags and the formation of air bubbles. Therefore, this method allows for safer and easier handling of radioactive materials during hybridization procedures.     

Options to avoid the second surgical site: a review of literature

As esthetics gain importance, periodontal plastic surgical procedures involving soft tissue grafts are becoming commoner both around natural teeth as well as around implants. Periodontal soft tissue grafts are primarily used for the purpose of root coverage and in pre-prosthetic surgery to thicken a gingival site or to improve the crestal volume. Soft tissue grafts are usually harvested from the palate. Periodontal plastic surgical procedures involving soft tissue grafts harvested from the palate have two surgical sites; a recipient site and another donor site. Many patients are apprehensive about the soft tissue graft procedures, especially the creation of the second/donor surgical site in the palate. In the past decade, newer techniques and products have emerged which provide an option for the periodontist/patient to avoid the second surgical site. MucoMatrixX, Alloderm^®, Platelet rich fibrin, Puros^® Dermis and Mucograft^® are the various options available to the practicing periodontist to avoid the second surgical site. Use of these soft tissue allografts in an apprehensive patient would decrease patient morbidity and increase patient’s acceptance towards periodontal plastic surgical procedures.     

Safety and efficacy in an accredited outpatient plastic surgery facility: a review of 5316 consecutive cases

Advances in medicine have improved the delivery of health care, making it more technologically superior than ever and, at the same time, more complex. Nowhere is this more evident than in the surgical arena. Plastic surgeons are able to perform procedures safely in office-based facilities that were once reserved only for hospital operating rooms or ambulatory surgery centers. Performing procedures in the office is a convenience to both the surgeon and the patient. Some groups have challenged that performing plastic surgery procedures in an office-based facility compromises patient safety. Our study was done to determine whether outcomes are adversely affected by performing plastic surgery procedures in an accredited outpatient surgical center. A retrospective review was performed on 5316 consecutive cases completed between 1995 and 2000 at Dallas Day Surgical Center, Dallas, Texas, an outpatient surgical facility. Most cases were cosmetic procedures. All cases were analyzed for any potential morbidity or mortality. Complications requiring a return to the operating room were determined, as were infection rates. Events leading to inpatient hospitalization were also included. During this 6-year period, 35 complications (0.7 percent) and no deaths were reported. Most complications were secondary to hematoma formation (77 percent). The postoperative infection rate for patients requiring a return to the operating room was 0.11 percent. Seven patients required inpatient hospitalization following their procedure secondary to arrhythmias, angina, and pulmonary emboli. Patient safety must take precedence over cost and convenience. Any monetary savings or time gained is quickly lost if safety is compromised and complications are incurred. The safety profile of the outpatient facility must meet and even exceed that of the traditional hospital-based or ambulatory care facility. After reviewing our experience over the last 6 years that indicated few complications and no deaths, we continue to support the judicious use of accredited outpatient surgical facilities by board-certified plastic surgeons in the management of plastic surgery patients.     

Vascular delay revisited

The technique of vascular delay has been used by plastic surgeons for nearly 500 years and has proven useful for reliably transferring tissue and allowing for a greater volume of tissue to be reliably harvested. Delay procedures are an essential plastic surgical tool for a variety of aesthetic and reconstructive procedures. Despite the widespread use of vascular delay procedures, the mechanism by which this phenomenon occurs remains unclear. A number of groups have exhaustively examined microvascular changes that occur during vascular delay. Theories have been proposed ranging from the dilation of choke vessels to changes in metabolism and new blood vessel formation. Inherent in these theories is the concept that ischemia is able to act as the primary stimulus for vascular changes. The purpose of this review is to revisit the theories proposed to underlie the delay phenomenon in light of recent advances in vascular biology. In particular, the participation of bone marrow-derived endothelial progenitor cells in the delay phenomenon is explored. Greater understanding of the role these cells play in new blood vessel formation will be of considerable clinical benefit to high-risk patients in future applications of delay procedures.     

The role of the plastic surgeon in the management of surgical infection.

At our Medical Center, our reconstructive service has actively sought referrals of acute and chronic infections by declaring an interest in undertaking the integrated management and reconstruction of these cases. The practices of the two senior surgeons were reviewed for three academic years (1992 to 1995). Cases of surgical infection were analyzed as to site, ablative procedures, and reconstructive procedures. In total, 139 patients with 147 infections were identified. Sites of infection included head and neck (9.5 percent), trunk and pelvis (39.5 percent), upper extremity (22 percent), and lower extremity (29 percent). One-hundred thirty-one ablative procedures were done on this group, as were 126 reconstructive procedures, including 17 fasciocutaneous flaps, 26 pedicled muscle flaps, and 28 microsurgical flaps. With a mean follow-up of 14 months, 92 percent of these patients had resolution of infection. The 8 percent failure group included recurrences, amputation, and death. This series demonstrates that a plastic surgery service can attract a diverse population of surgical infections and manage them successfully with ablation and a wide variety of reconstructive procedures. The coordination of ablation and reconstruction may be optimally performed by the plastic surgeon.     

Biomechanical properties of the human ankle in relation to passive stretch

Viscous/plastic properties were investigated in the passive tissue opposing dorsiflexion of the human ankle. The foot was rotated (dorsiflexed) and fixed. Due to viscous/plastic properties, the passive torque declined with time. After 300 s, torque, relative to the initial torque at 0 s, had fallen by 22.7% +/- 2.6% (mean +/- 1S.D.), as an expression of the relative importance of the viscous/plastic tissue properties for the passive torque. By a peel-off technique the number of different tissue elements with viscous/plastic properties was found to be at least three. After 100 s, all but one of these elements had yielded completely. Viscous/plastic properties were unchanged by stretching when measured 90 min after a single stretching program and when measured 24 h after stretching procedures had been performed twice a day for three weeks.     

Endoscopic brow lift: a retrospective review of 628 consecutive cases over 5 years

Since its introduction in 1992, endoscopic brow lift has gained tremendous recognition because it has been promoted as a novel technique to correct brow ptosis as well as glabella rhytids in a minimally invasive manner with fewer complications than the classic coronal brow lift method. In this retrospective study, 628 endoscopic brow lift procedures performed over a 5-year period (1997-2001) at Manhattan Eye Ear and Throat Hospital were reviewed. The number of endoscopic brow lift procedures performed at this institution has declined 70 percent. The purpose of this study was to elucidate the causes of this striking trend by soliciting the opinions of 21 New York plastic surgeons on their current brow ptosis management. The response rate was 84 percent (21 of 25 surgeons contacted). Currently, 25 percent of the interviewed plastic surgeons perform endoscopic brow lift regularly, 50 percent of the plastic surgeons perform endoscopic brow lift occasionally, and 25 percent of the participants no longer perform endoscopic brow lift. While most patients (70 percent) were satisfied with their results, only 50 percent of the plastic surgeons were pleased with the long-term results (after more than 2 years of follow-up). Observed postsurgical complications of endoscopic brow lift included alopecia, hairline changes, infected hardware, brow asymmetry requiring surgical revision, prolonged forehead/brow paresthesia, frontal branch nerve paralysis, and scalp dysesthesia. These complications were similar to those resulting from open brow lifts. Seventy-one percent of the surveyed New York plastic surgeons routinely administered botulinum toxin type A (Botox) within 6 months of the endoscopic brow lift procedure. Possible explanations for the decline in the overall number of endoscopic brow lift procedures include the following: (1) the selection criteria for the ideal endoscopic brow lift patients are currently more limited; (2) other techniques equal or surpass endoscopic brow lift in effectiveness and predictability; and (3) endoscopic brow lift is ineffective in the majority of patients. There is no single superior surgical procedure for brow ptosis management available at this time.     

Hot Melt “Corner Point Method” for Attaching Large Plastic Sections to Glass Slides

We describe a fast method for firm attachment of large plastic sections to glass slides with EVA-copolymers, commonly known as hot melt sticks. Solid hot melt sticks dissolve slowly in xylene to form an adhesive gel within 6 hours. Small drops of hot melt gel are applied to the corners of the sections and surrounding slide surface at ambient or elevated temperatures. The gel sticks to both the plastic and the glass slides. The hot melt “corner point method” prevented detachment of sections in staining procedures. As an additional technique, we suggest the use of hot melt adhesive for attaching plastic specimen blocks to wooden blocks or metallic specimen holders.     

DNA probe attachment on plastic surfaces and microfluidic hybridization array channel devices with sample oscillation

DNA probe immobilization on plastic surfaces and device assembly are both critical to the fabrication of microfluidic hybridization array channel (MHAC) devices. Three oligonucleotide (oligo) probe immobilization procedures were investigated for attaching oligo probes on four different types of plastic surfaces (polystyrene, polycarbonate, poly(methylmethacrylate), and polypropylene). These procedures are the Surmodics procedure, the cetyltrimethylammonium bromide (CTAB) procedure, and the Reacti-Bind procedure. To determine the optimal plastic substrate and attachment chemistry for array fabrication, we investigated plastic hydrophobicity, intrinsic fluorescence, and oligo attachment efficiency. The Reacti-Bind procedure is least effective for attaching oligo probes in the microarray format. The CTAB procedure performs well enough to use in array fabrication, and the concentration of CTAB has a significant effect on oligo immobilization efficiency. We also found that use of amine-modified oligo probes resulted in better immobilization efficiency than use of unmodified oligos with the CTAB procedure. The oligo probe immobilization on plastic surfaces by the Surmodics procedure is the most effective with regard to probe spot quality and hybridization sensitivity. A DNA hybridization assay on such a device results in a limit of detection of 12pM. Utilizing a CO(2) IR laser machining and adhesive layer approach, we have developed an improved procedure for realizing a DNA microarray inside a microfluidic channel. This device fabrication procedure allows for more feasible spot placement in the channel and reduced sample adsorption by adhesive tapes used in the fabrication procedure. We also demonstrated improved hybridization kinetics and increased detection sensitivity in MHAC devices by implementing sample oscillation inside the channel. A limit of detection of 5pM has been achieved in MHAC devices with sample oscillation.     

Patient-reported outcome measures in plastic surgery: use and interpretation in evidence-based medicine

Understanding patients' perceptions of surgical results and their impacts on quality of life is of primary importance in plastic surgery, as procedures are largely performed to improve either appearance or function. Patient-reported outcome measures are questionnaires specifically designed to quantify aspects of health-related quality of life from the patient's perspective. This article presents an overview of patient-reported outcome measures. It also aims to provide plastic surgeons with the necessary critical appraisal skills to interpret and apply evidence from patient-reported outcomes research in their own clinical practice.     

A new resorbable tack fixation technique for endoscopic brow lifts

The endoscopic brow lift is now widely accepted in aesthetic plastic surgery, and various fixation techniques have been described in the literature. New developments and technology have expanded the use of resorbable devices in different surgical specialties, including plastic surgery. The authors present a technique that offers simple, fast, and reliable forehead fixation for endoscopic brow lifts using resorbable tacks. Successful facial rejuvenation was obtained in the majority of the patients without complications, need for follow-up visits to tighten the flap fixation system, or secondary procedures to extract the fixation system.     

Safety and efficacy of office-based surgery with monitored anesthesia care/sedation in 4778 consecutive plastic surgery procedures

Office-based surgery has several potential benefits over hospital-based surgery, including cost containment, ease of scheduling, and convenience to both patients and surgeons. Scrutiny of office-based surgery by regulators and state-licensing agencies has increased and must be addressed by improved documentation of safety and efficacy. To evaluate the safety and efficacy of the authors' office-based plastic surgery, a review was undertaken of 3615 consecutive patients undergoing 4778 outpatient plastic surgery procedures under monitored anesthesia care/sedation in a single office. The charts of 3615 consecutive patients who had undergone office-based surgery with monitored anesthesia care/sedation between May of 1995 and May of 2000 were reviewed. In all cases, the anesthesia protocol used included sedation with midazolam, propofol, and a narcotic administered by a board-certified registered nurse anesthetist with local anesthesia provided by the surgeon. Charts were reviewed for patient profile, types of procedures, multiple procedures, duration of anesthesia, American Society of Anesthesiologists class, and complications related to anesthesia. Outcomes measured included death, airway compromise, dyspnea, hypotension, venous thrombosis, pulmonary emboli, protracted nausea and vomiting lasting more than 24 hours, and unplanned hospital admissions. Statistical analyses were performed using the Microsoft Excel program and the SAS package. Results were as follows: 92.3 percent of the patients were female and 7.7 percent were male, with a mean age of 42.7 years (range, 3 to 83 years). Patients underwent aesthetic (95.6 percent) and reconstructive (4.4 percent) plastic surgery procedures. Same-session multiple procedures occurred in 24.8 percent of patients. The vast majority of patients were healthy: 84.3 percent of patients were American Society of Anesthesiologists class I, 15.6 percent were class II, and 0.1 percent were class III. The operations required a mean of 111 minutes. There were no deaths, ventilator requirements, deep venous thromboses, or pulmonary emboli. Complications were as follows: 0.05 percent (n = 2) of patients had dyspnea that resolved, 0.2 percent (n = 6) of patients had protracted nausea and vomiting, and 0.05 percent (n = 2) of patients had unplanned hospital admissions (<24 hours). One patient had an emergent intubation. No prolonged adverse effects were noted. There was a 30-day follow-up minimum. Outpatient surgery is an important aspect of plastic surgery. It was shown that office-based surgery with intravenous sedation, performed by board-certified plastic surgeons and nurse anesthetists, is safe. Appropriate accreditation, safe anesthesia protocols, and proper patient selection constitute the basis for safe and efficacious office-based outpatient plastic surgery.     

Breast reduction

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the preoperative considerations that must be weighed to appropriately assess operative risk of breast reduction. 2. Have a full understanding of the basic techniques that are available to treat the patient with macromastia. 3. Identify which patients are best suited to a particular technique. 4. Identify common complications associated with breast reduction and understand how to treat them. SUMMARY: Breast reduction remains a basic plastic surgery procedure designed to alleviate upper torso complaints resulting from macromastia. Historically, the inverted-T inferior pedicle procedure was the dominant technique for the treatment of macromastia for 40 years. The past two decades have seen a reexamination of breast reduction technique in an attempt to improve on the results and minimize complications. As a result, a new genre of procedures based on different pedicles and short-scar skin management techniques has been introduced. With these new procedures, the plastic surgeon now has a variety of different techniques that can be offered for reducing the hypertrophic breast. Strategically applying the concepts inherent in these procedures to the correct patient can provide outstanding results with few complications. In this article, the concepts and results of these various procedures are discussed to give the reader a basic understanding of the options available for breast reduction.     

DRGs, costs, and outcome for plastic surgical patients

The purpose of this study was to analyze hospital cost, resource utilization, and outcome by age for a large group of hospitalized plastic surgical patients using the DRG format. Hospital cost per patient for all plastic surgical admissions (both inpatient and potentially ambulatory patients) treated (N = 1632) at an academic medical center increased with age and peaked for plastic surgical patients 75 to 80 years of age ($11,585 per patient). Although DRG payment would have produced an aggregate profit of $2,404,854, older plastic surgical patients (65 years of age and above) generally produced losses. Older plastic surgical patients demonstrated a longer hospital length of stay, a greater severity of illness, a higher percent of outliers, and a greater mortality than younger plastic surgical patients. In addition, older plastic surgical patients had higher clinical resource utilization based on a number of clinical parameters such as emergency admission, SICU utilization, need for blood transfusions, and need for plasma product infusions. This study suggests that the current DRG reimbursement methodology may be inequitable vis-à-vis the older plastic surgical patient. As additional pressures encourage the performance of more ambulatory procedures (previously performed as inpatients), our profit margins may decline and possibly affect our ability to provide quality plastic surgical care.     

Patient safety in plastic surgery

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Recognize risk factors for venous thromboembolism and identify patients who would benefit from prophylactic anticoagulation; 2. Describe the effects of hypothermia in the perioperative period. 3. Understand the importance of blood pressure control in the plastic surgery patient. SUMMARY: This article provides a summary of important factors that contribute to improved patient safety in plastic surgery. The identification of patients and procedures that have an increased risk of complications enables the physician to carry out prophylactic measures to reduce the rate of these complications. Venous thromboembolism, hypothermia, bleeding diathesis, and perioperative hypertension are identifiable risks of plastic surgery, which can lead to significant morbidity and mortality. An evidence-based system and individual practice measures can help to decrease these risks. Thorough preoperative patient evaluation, detailed informed consent, and perioperative care delivered in a safe environment can contribute to improved safety in plastic surgery.     

Cosmetic medicine: facial resurfacing and injectables

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the most common options available for minimally invasive facial rejuvenation. 2. Identify key elements essential to each treatment option. 3. Know how to avoid and manage complications for these procedures. SUMMARY: Minimally invasive cosmetic procedures continue to increase in popularity. This article is intended to provide a broad and practical overview of common minimally invasive cosmetic techniques available to the plastic surgeon.     

Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery

The use of tobacco is a significant contributor to preventable morbidity and mortality in the United States. A significant proportion of cardiovascular diseases, various oral and pulmonary neoplasms, nonmalignant respiratory diseases, and peripheral vascular disorders can be attributed to the use of cigarettes. Surgical outcomes can also be adversely affected as a result of cigarette smoking with intraoperative and postoperative pulmonary, cardiovascular, and cerebrovascular complications as well as increased wound healing complications. These are found across the entire spectrum of surgical specialties. Tissue ischemia and wound-healing impairment secondary to the influence of tobacco is particularly problematic for the plastic surgeon, especially during elective facial aesthetic procedures, cosmetic and reconstructive breast operations, abdominoplasty, free-tissue transfer, and replantation procedures. By educating and providing guidelines to those patients who smoke and by refusing to operate on individuals who fail to abstain, tobacco-associated surgical morbidity in the plastic and reconstructive surgery patient can be eliminated.