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Postoperative pain can be managed with NSAIDs such as parecoxib, ibuprofen, ketoprofen, ketorolac, or diclofenac combined with low doses of opioids. Tramadol is recommended because of its dual mechanism of analgesic action. Methocarbamol can be associated with the previous scheme. Some investigators have found adequate analgesia with the continuous or intermittent administration of local anesthetics through catheters implanted during surgery [ 46 , 47 ].
PRACTICE ADVISORY FOR PREANESTHESIA EVALUATION
It has not been defined if paravertebral blocks decrease the incidence of chronic postoperative pain in breast surgery [ 48 ]. The evaluation of candidates for abdominal contour surgery allows patients to be classified according to the possibilities of surgery taking in consideration the skin, fat, and muscles. Liposuction is the second most common procedure in plastic surgery, and it is perhaps the one with the highest morbidity and mortality [ 49 ]. Liposuction consists in removing fat from unwanted areas to build and improve contour. It can be performed in most subcutaneous fat deposits, being more frequent in the abdomen, hips, waist, torso, neck, and extremities.
In men, it is usually done also in the pectoral region. The selection of patients is a determining factor since there are people who want to sculpt their silhouette because they have failed in weight loss and are looking for massive liposuction as a fast track to their false expectations of a suitable silhouette without taking into consideration that this procedure is not an alternative for the management of obesity.
The pre-anesthetic assessment should be meticulous and must reject patients with moderate or severe cardiomyopathies or pneumopathies and those with thrombophilia or a history of pulmonary embolism. It is advisable not to associate liposuction with non-plastic procedures such as gynecological surgery.
Patient's knowledge and perception of preanesthesia check-up in rural India
Surgeon and anesthesiologist must make a comprehensive management plan to meet the goals of patients, when possible. Figure 3 is a plasticine model developed by one of our patients to inform the surgeon of her esthetic goals with liposuction and fat gluteal grafting. Plasticine model made by the patient to accurately show us the shape and size that she wants for her buttocks. There are two types of liposuction: the dry technique and the tumescent one. The latter is defined as the removal of subcutaneous fat under anesthesia infiltrated with large volumes of saline solution added with epinephrine and a local anesthetic, usually lidocaine.
The original definition excludes the use of another type of anesthesia, whether it is neuraxial or general, as well as the fact that it is done without the presence of an anesthesiologist.
These high doses make it obligatory to perform these procedures in surgery rooms that have all the facilities for monitoring, cardiac resuscitation, ventilatory support, and, always, recovery area under the care of an anesthesiologist. One of the limitations during cosmetic surgery, especially during tumescent liposuction, is the total dose of the local anesthetic.
For this reason, it is advisable not to combine liposuction with other procedures that require the injection of local anesthetics as the maximum dose of these drugs can be exceeded. PPX local anesthetics should never be used in tumescent liposuction. There is no agreement on the best anesthetic technique for liposuction, whether it is the modality under local anesthesia with the Klein solution or with general anesthesia or neuraxial block. With both procedures deaths have been reported [ 49 , 56 , 57 ], and the reports are not completely reliable.
Higher volumes increase the risk of complications, especially hypovolemia due to bleeding and acute hydro-electrolytic alterations. Another topic of interest in the management of these patients is the replacement of fluids during the trans-anesthetic period; Trott et al. These authors emphasize that this fluid replacement guide does not replace a good clinical criterion and communication between the surgeon and the anesthesiologist is always fundamental.
It is a procedure that combines liposuction of the entire truncal midsection to accomplish a complete curvier contour figure from every angle. It can be combined with dermolipectomy, with plication of the rectus abdominis muscle, and with or without umbilicoplasty or gluteal fat grafting [ 61 , 62 ]. Surgery of the abdominal wall usually involves resection of skin excess and can be done with or without liposuction lipoabdominoplasty and with or without plication of the rectus abdominis muscle [ 63 ].
The most common patients include those that have had multiple pregnancies or patients that have lost a lot of weight either by dieting and exercise or after bariatric procedures. Mommy makeover.
The combination of two or more simultaneous cosmetic surgeries has become fashionable, particularly breast surgery and tummy tuck [ 64 ]. In our plastic surgery group, the most usual combination is breast-abdominoplasty, liposuction, and gluteal lipoinjection. For abdominal body contour surgeries liposuction, abdominoplasty, and mommy makeover , we prefer spinal anesthesia with lumbar approach, taking the block up to T4. Due to the length of the procedure, it is prudent to use some adjuvant that prolongs the anesthetic time up to 4—5 hours. Bupivacaine 0. Ropivacaine or L-bupivacaine can also be used.
The combination of two or more surgeries of the body contour is now safe, having overcome the complications of the individual procedures. It is vital to establish measures to prevent DVT, PE, infections, and postoperative pain, to name a few [ 64 ]. Cosmetic facial surgery involves several procedures, some of which are performed under local anesthesia injected by the plastic surgeon [ 65 ].
Surgeries in which the intervention of the anesthesiologist is required involve generally prolonged interventions, in healthy patients or with added pathologies, in which plastic surgeons request the support of an anesthesiologist to guarantee suitable transoperative care.
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Local anesthesia subcutaneous and nerve blocks combined with conscious sedation is the technique most used in our clinic [ 6 ]. Pre-anesthetic medication is the key to have a patient in optimal conditions: sedation, anxiolysis, and preventive analgesia. To prevent nausea and vomiting, it is recommended to add dehydrobenzoperidol 1. For maintenance, one or more drugs may be used in infusion: ketamine-midazolam, ketamine-propofol, and dexmedetomidine with or without low doses of opioid [ 6 , 25 , 66 ].
These drugs should be infused and diluted, in separate i.
Nasal oxygen should be administered throughout the procedure to maintain normal O 2 saturation. The patient must be monitored, as well as corneal protection to avoid abrasive injuries. It is mandatory that the surgical group looks out frequently the total dose of local anesthetic administered to avoid exceeding the recommended top doses. In the first hour of surgery, the previous fast fluid deficit should be replaced and then administer adequate volume to obtain diuresis of 0. In our opinion, general anesthesia should be avoided and reserved for very select, complex cases or for patients who cannot tolerate or cooperate with conscious sedation [ 6 ].
The selection is indistinct and must be based on the physical conditions of the patient. In Lotus Med Group, we use isoflurane, sevoflurane, or desflurane and avoid or minimize the use of muscle relaxants. When the patient is extubated, special attention should be paid to avoid coughing and bowing that may facilitate bleeding in the surgical site. Autologous fat grafting. Autologous fat grafting refers to the transfer of fat from one or more areas to other areas to improve body contouring.
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It is in vogue among plastic surgeons and their patients. It is a natural filler, available, and easy to obtain, which is usually reintegrated in the receptor sites, although it has an unpredictable percentage of resorption. The most frequent areas where fat is transferred include the hips, buttocks, breast, face, and hands. A typical grafting procedure is done in three phases: harvesting of adipose tissue from the donor area; processing of the lipoaspirate to eliminate cellular debris, acellular oil, and excess of infiltrated solution; and reinjection of the adipose tissue at the receptor site [ 67 , 68 , 69 ].
We have observed that spinal anesthesia decreases bleeding at the donor site when compared to general anesthesia and facilitates rapid recovery, with less postoperative pain and home discharge on the same day without complications. Acute postoperative pain is an unresolved issue, including plastic surgery patients. The multiple neural ending injuries in liposuction and tummy tuck, even muscle elongations during breast implants, are just some examples that make it necessary to plan a rational analgesic scheme.
The ideal analgesia should start from the pre-anesthetic phase using preemptive and preventing drugs. The combined use of opioids with NSAIDs is the cornerstone in the prevention and management of pain after plastic surgery. The controversy not clarified about the utility versus the negative effects of cyclooxygenase inhibitors has favored multiple investigations whose results allow the safe use of these drugs.