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38 Part II&Anesthesia
LIPOSUCTION
5. What is a commonly accepted threshold for liposuction that indicates when liposuction should be performed
in an acute care hospital, or a facility with the capability for overnight obser vation?
A. 2 liters total aspirate.
B. 4 liters total aspirate.
C. 5 liters total aspirate.
D. 6 liters total aspirate.
E. 8 liters total aspirate.
LIPOSUCTION
6. What is the suggested fluid management protocol for liposuction with total aspirate >5 liters?
A. Maintenance fluids alone.
B. Maintenance fluids + 1 L Lactated Ringer's.
C. Maintenance fluids + 10 mL/kg of albumin.
D. Maintenance + replacement of 0.25 mL of IV crystalloid per mL of aspirate >5 liters.
E. Twice the maintenance rate.
LIPOSUCTION
7. In tumescent infiltration, what is the American Society of Plastic Surgery (ASPS) recommended maximum
dose of lidocaine?
A. 7.0 mg/kg.
B. 15.0 mg/kg.
C. 35.0 mg/kg.
D. 55.0 mg/kg.
E. 60.0 mg/kg.
LIPOSUCTION
8. How long after tumescent infiltration do plasma concentrations of lidocaine peak?
A. 30 minutes.
B. 90 minutes.
C. 5 hours.
D. 12 hours.
E. 30 hours.
LIPOSUCTION
9. A 32-year-old female undergoes 5 liters of liposuction with 9 liters of tumescent. The circulating nurse acci-
dently infused each tumescent bag with double the normal amount of lidocaine. What would be one of the
first clinical signs the patient develops postoperatively in PACU that would denote lidocaine toxicity?
A. Seizure.
B. A-V block.
C. Hypotension.
D. Metallic taste in mouth.
E. Generalized ulcerative rash.
TREATMENT
10. What is a helpful adjunct to resuscitation (in addition to standard BLS and ACLS protocols) specifically in
patients with lidocaine toxicity?
A. IV fluid bolus.
B. Lipid emulsion therapy.
C. Giving epinephrine subcutaneously to tissues to prevent excess lidocaine migrating intravenously.
D. Correcting acidosis.
E. Dantrolene.
Chapter 7&Procedure-Specific Anesthesia Guidelines for the Aesthetic Surgery Patient 39
Answers
RHYTIDECTOMY
1. A 52-year-old female with no past medical history undergoes an uncomplicated rhytidectomy. As the patient is
being extubated, she experiences a rise in her systolic pressure to 180 mmHg that is sustained for a few minutes. What complication is she most at risk for?
B. Hematoma.
Specifically, when a patient undergoes a facelift, optimal hemodynamic control is critical. Perioperative
systolic BP control is important, with BP > 150 mmHg serving as a major risk factor for a postoperative
hematoma. An increase in blood pressure would not cause a seroma, PONV, or uncontrollable pain. An
increase in intraoperative blood pressure could lead to an increased risk of stroke; however, it would not
be the most common complication.
REFERENCE
1. RamanadhamSR,MapulaS, Costa C, NarasimhanK, Coleman JE, RohrichRJ. Evolution of hypertensionmanagement
in face lifting in 1089 patients: optimizing safety and outcomes. Plast Reconstr Surg 2015;135(4):1037–1043
RHYTIDECTOMY
2. A 43-year-old male with a past medical history of moderate asthma and class I obesity is undergoing a rhyti-
dectomy under total intravenous sedation (TIVA). Which of the following is the biggest risk factor for him to
potentially develop hematoma postoperatively?
A. Male gender.
Male gender is the biggest risk factor for hematoma formation after preoperative high blood pressure.
History of asthma, obesity, and IV fluids are notable risk factors for hematoma formation. Performing the
case under TIVA may confer some advantages such as improved blood pressure control and may possibly
be protective against hematoma formation.
1
1,2,3
REFERENCES
1. Desai M. General inhalation anesthesia for cosmetic surgery. In: Friedberg BL, ed. Anesthesia in Cosmetic
Surgery. New York: Cambridge University Press; 2007
2. Ramanadham SR, Mapula S, Costa C, Narasimhan K, Coleman JE, Rohrich RJ. Evolution of hypertension manage-
ment in facelifting in 1089 patients:optimizing safety and outcomes. Plast ReconstrSurg 2015;135(4):1037–1043
3. Lau WC, Eagle KA. Managing cardiovascular risk and hypertension. In: Young VL, Botney R, eds. Patient Safety in
Plastic Surgery. New York: Thieme Publishers; 2009
FIRE SAFETY
3. A 21-year-old female is about to undergo full-face CO2laser resurfacing. A timeout was performed.
Intraoperatively, there is a combustion in the operating room near the patient's face; however, she is not
harmed. What would have been the best solution to minimize the combustion risk?
C. Decreasing FiO
Decreasing FiO2to the lowest level that supports adequate oxygenation is the best solution that would
minimize combustion risk. Open-circuit oxygen delivery and use of supplemental oxygen both would
increase the risk of combustion. Supplemental narcotic use and a CHG bath the night before would not
have any effect on combustion risk intraoperatively. In addition, CHG is typically not used on the face/
around the eyes.
to the lowest level that supports adequate oxygenation.
2
1,2
REFERENCES
1. Blakely KR, Klein KW, White PF, et al. A total intravenous anesthetic technique for outpatient facial laser
resurfacing. Anesth Analg 1998;87:827
2. Friedberg BL. The dissociative effect and preemptive analgesia. In: Friedberg BL, ed. Anesthesia in Cosmetic
Surgery. New York: Cambridge University Press; 2007
40 Part II&Anesthesia
SURGICAL DURATION
4. A 56-year-old female patient who has had massive weight loss plans to undergo liposuction of flanks, back,
hips as well as bilateral mastopexy and abdominoplasty. She calls the office 2 weeks before the surgery asking if she can have a blepharoplasty as well. The surgeon is trying to calculate the surgical duration to see
whether staged procedures should be recommended. After how many hours of surgery it is recommended to
stage the procedures?
B. 6 hours.
In general, in massive weight loss body contouring patients, if surgery will take more than 6 hours
staging the operations should be considered. The other time frames are incorrect.
1
REFERENCE
1. Whizar-Lugo VM, Cisneros-Corral R, Reyes-Alveleyra MA, et al. Anesthesia for plastic surgery procedures in previously morbidly obese patients. Anestesia en México 2009;21:186
LIPOSUCTION
5. What is a commonly accepted threshold for liposuction that indicates when liposuction should be performed
in an acute care hospital, or a facility with the capability for overnight obser vation?
C. 5 liters total aspirate.
Liposuction of over 5 liter total aspirate is considered large volume and should be performed in a hospital or
other facility with the capability for overnight observation. This level of liposuction has an increased risk for
fluid shifts and electrolyte imbalance, and attention to volume status is necessary.
1,2
REFERENCES
1. Berry MG, Davies D. Liposuction: a review of principles and techniques. J Plast Reconstr Aesthet Surg
2011;64:985
2. American Society of Plastic Surgeons. Practice advisory on liposuct ion: executive summary. Available at www.
plasticsurgery.org.
LIPOSUCTION
6. What is the suggested fluid management protocol for liposuction with total aspirate >5 liters?
D. Maintenance + replacement of 0.25 mL of IV crystalloid per mL of aspirate >5 liters.
For patients undergoing large-volume liposuction, the suggested fluid management is to give a maintenance
rate of fluid plus 0.25 mL of crystalloid per mL of aspirate over 5 liters.
1,2
REFERENCES
1. Berry MG, Davies D. Liposuction: a review of principles and techniques. J Plast Reconstr Aesthet Surg
2011;64:985
2. American Society of Plastic Surgeons. Practice advisory on liposuct ion: executive summary. Available at www.
plasticsurgery.org
LIPOSUCTION
7. In tumescent infiltration, what is the American Society of Plastic Surgery (ASPS) recommended maximum
dose of lidocaine?
C. 35.0 mg/kg.
In tumescent infiltration, the ASPS has recommended a maximum dose of lidocaine of 35.0 mg/kg.
1,2
REFERENCES
1. Klein JA. The tumescent technique for liposuction surgery. AM J Cosmetic Surg 1987;4:1124
2. Neal JL, Bernards CL, Butterworth JF IV, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg
Anesth Pain Med 2010;35:152
Chapter 7&Procedure-Specific Anesthesia Guidelines for the Aesthetic Surgery Patient 41
LIPOSUCTION
8. How long after tumescent infiltration do plasma concentrations of lidocaine peak?
D. 12 hours.
Plasma levels of lidocaine typically peak from 12 hours following tumescent infiltration.
1,2
REFERENCES
1. Klein JA. The tumescent technique for liposuction surgery. AM J Cosmetic Surg 1987;4:1124
2. Neal JL, Bernards CL, Butterworth JF IV, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg
Anesth Pain Med 2010;35:152
LIPOSUCTION
9. A 32-year-old female undergoes 5 liters of liposuction with 9 liters of tumescent. The circulating nurse acci-
dently infused each tumescent bag with double the normal amount of lidocaine. What would be one of the
first clinical signs the patient develops postoperatively in PACU that would denote lidocaine toxicity?
D. Metallic taste in mouth.
The first signs of lidocaine toxicity occur at plasma levels of 5 to 10 μg/mL and include central nervous
system symptoms such as perioral numbness, confusion, lethargy, restlessness, metallic taste, vertigo,
slurred speech, and tinnitus. The other answer choices all occur at plasma levels >10 μg/mL. Seizures,
coma, and delirium occur between 10 and 20 μg/mL. A-V block, hypotension, and other cardiac
manifestations occur >20 μg/mL of lidocaine.
1,2
REFERENCES
1. Klein JA. The tumescent technique for liposuction surgery. AM J Cosmetic Surg 1987;4:1124
2. Neal JL, Bernards CL, Butterworth JF IV, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg
Anesth Pain Med 2010;35:152
TREATMENT
10. What is a helpful adjunct to resuscitation (in addition to standard BLS and ACLS protocols) specifically in
patients with lidocaine toxicity?
B. Lipid emulsion therapy.
Lipid emulsion therapy specifically is helpful in patients with lidocaine toxicity. Dantrolene is used in
the treatment of malignant hyperthermia. Giving epinephrine to the local tissue would not prevent
worsening intravenous lidocaine toxicity. The remaining options are all used commonly in resuscitation
of patients in general.
1,2
REFERENCES
1. Klein JA. The tumescent technique for liposuction surgery. AM J Cosmetic Surg 1987;4:1124
2. Neal JL, Bernards CL, Butterworth JF IV, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg
Anesth Pain Med 2010;35:152
8. Multimodal Analgesia for the Aesthetic Surgery Patient
Anmol Chattha, Sammy Sinno, Aaron M. Kearney
See Essentials of Aesthetic Surgery, pp. 107–115
COMPLICATIONS
1. A 45-year-old opioid-naïve female patient is undergoing an abdominoplasty. She experiences intense, uncon-
trolled postoperative pain over the following week. Which of the following will have an increased incidence?
A. Nausea.
B. Hernia formation.
C. Psychiatric illness.
D. Delayed wound healing.
E. Deep vein thrombosis.
NERVE BLOCKS
2. Which of the following technical factors of nerve block administration has the greatest impact on block
efficiency?
A. Use of a large-bore needle.
B. Timing of the nerve block (preincision vs. postincision).
C. Volume of dose.
D. Concentration of dose.
E. Total dose.
MEDICATION SIDE EFFECTS
3. What is one potential disadvantage of using gabapentin in multimodal analgesia?
A. Sedation.
B. Hypoglycemia.
C. Urinary retention.
D. Bradycardia.
E. Nausea.
MEDICATION SIDE EFFECTS
4. What is one potential side effect of ketamine?
A. Nausea and vomiting.
B. Tachycardia.
C. Hypertension.
D. Hallucinations and nightmares.
E. Decreases time to first analgesic.
CHRONIC OPIOID USE
5. What percentage of elective hand surgery patients continue to take opioids 90 days after surgery?
A. 1%.
B. 10%.
C. 20%.
D. 40%.
E. 80%.
Chapter 8&Multimodal Analgesia for the Aesthetic Surgery Patient 43
CHRONIC OPIOID USE
6. A 45-year-old opioid naïve female is undergoing a routine abdominoplasty with rectus plication. Which of the
following risk factors would most likely be a risk factor for opioid abuse in this patient?
A. High socioeconomic background.
B. Female sex.
C. Family history of substance abuse.
D. Psychiatric illness.
E. Opioid naïve status.
44 Part II&Anesthesia
Answers
COMPLICATIONS
1. A 45-year-old opioid-naïve female patient is undergoing an abdominoplasty. She experiences intense, uncon-
trolled postoperative pain over the following week. Which of the following will have an increased incidence?
D. Delayed wound healing.
Postsurgical pain intensity was associated with delayed wound healing. Postsurgical pain decreases surgical
outcomes, increases cost of care, decreases patient satisfaction, and has no change on the possibility of a
patient developing a deep vein thrombosis. Postoperative pain was not associated with hernia formation
or psychiatric illness.
REFERENCE
1. Joshi GP, Beck DE, Emerson RH, et al. Defining new directions for more effective management of surgical pain in
the United States: highlights of the inaugural Surgical Pain Congress. Am Surg 2014;80:219
NERVE BLOCKS
2. Which of the following technical factors of nerve block administration has the greatest impact on block efficiency?
E. Total dose.
Total dose of anesthetic affects the efficiency of the block. However, the volume and concentration do not
seem to be key contributors. Use of a large- or small-bore needle does not impact the efficiency either, and
the timing of the nerve block does not seem to make a difference in the efficiency of action of the block.
1
1,2,3
REFERENCES
1. Lovich-Sapola J, Smith CE, Brandt CP. Postoperative pain control. Surg Clin North Am 2015;95:301
2. Golembiewski J, Dasta J. Evolving role of local anesthetics in managing postsurgical analgesia. Clin Ther
2015;37:1354
3. Joshi GP, Janis JE, Haas EM, et al. Surgical site infilt ration for abdominal surgery: a novel neuro-anatomical-based
approach. Plast Recon Surg Glob Open 2016;4:e1181
MEDICATION SIDE EFFECTS
3. What is one potential disadvantage of using gabapentin in multimodal analgesia?
A. Sedation.
Sedation and dizziness are occasional side effects of gabapentin that may affect discharge from the
surgical facility. The other answer choices are not side effects of using gabapentin.
1,2
REFERENCES
1. Adam F, Menigaux C, Sessler DI, et al. A single preoperative dose of gabapentin (800 milligrams) does not aug-
ment postoperative analgesia in patients given interscalene brachial plexus blocks for arthroscopic shoulder
surgery. Anesth Analg 2006;103:1278
2. Paech MJ, Goy R, Chua S et al. A randomized, placebo-controlled trial of preoperative oral pregabalin for post-
operative pain relief after minor gynecological surgery. Anesth Analg 2007;105:1449
MEDICATION SIDE EFFECTS
4. What is one potential side effect of ketamine?
D. Hallucinations and nightmares.
Hallucinations and nightmares can occur, particularly when ketamine provides effective analgesia. The
other answer choices are not side effects of ketamine. Ketamine actually reduces nausea and vomiting,
increases time to first analgesic, and reduces pain scores when VAS >4.
1
Chapter 8&Multimodal Analgesia for the Aesthetic Surgery Patient 45
REFERENCE
1. Lovich-Sapola J, Smith CE, Brandt CP. Postoperative pain control. Surg Clin North Am 2015;95:301
CHRONIC OPIOID USE
5. What percentage of elective hand surgery patients continue to take opioids 90 days after surgery?
B. 10%.
Two studies of elective hand surgery patients showed that 3.1 to 13% of patients were still taking opioids 90
days after surgery. Older patients (>66 years old) following low-risk surgery have a 44% increased likelihood
of chronic use at 1 year compared with controls. There is a risk of persistent opioid use following exposure to
opioid medications in the perioperative period, even in opioid naïve patients.
1,2
REFERENCES
1. Johnson SP, Chung KC, Zhong L, et al. Risk of prolonged opioid use among opioid-naïve patients following com-
mon hand surgery procedures. J Hand Surg 2016;41:947
2. Clarke H, Soneji N, Ko DT, et al. Rates and risk factors for prolonged opioid use after major surgery: population-
based cohort study. BMJ 2014;348:g1251
CHRONIC OPIOID USE
6. A 45-year-old opioid naïve female is undergoing a routine abdominoplasty with rectus plication. Which of the
following risk factors would most likely be a risk factor for opioid abuse in this patient?
D. Psychiatric illness.
Psychiatric illness along with male sex, history of prior substance abuse, and low socioeconomic
background is a risk factor for opioid abuse. Having a family history of substance abuse can put one at a
higher risk, but it is not most likely to be a risk factor in this case. Opioid naïve status has no bearing on
being a risk factor for opioid abuse.
1,2,3
REFERENCES
1. Johnson SP, Chung KC, Zhong L, et al. Risk of prolonged opioid use among opioid-naïve patients following com-
mon hand surgery procedures. J Hand Surg 2016;41:947
2. Clarke H, Soneji N, Ko DT, et al. Rates and risk factors for prolonged opioid use after major surgery: population-
based cohort study. BMJ 2014;348:g1251
3. Sun EC, Darnall BD, Baker LC, et al. Incidence of and risk factors for chronic opioid use among opioid-naive
patients in the postoperative period. JAMA Intern Med 2016;176:1286
PART III
Safety