Essentials of Aesthetic Surgery

22
Part I Basic Considerations
FOCAL LENGTHS AND DISTANCES
NOTE:



2 advocate the use of lens with a focal length equal to
at least to prevent unwanted distortion of the
image.

photography.

photographers

lengths to prevent distortion.
• The manufacturer will supply the size of the sensor in the manual.
Sensors and Recommended Focal Lengths





1/2.7 inch
5.270
3.960

5.270
10
½ inch
6.400
4.800
8.000
20

8.800
6.600
11.000
20
4 3 inch
18.000
13.500
22.500
50

36.000
24.000
43.300
50

views (Fig. 3-1).

4
Focal length distortion in facial features. A, Photograph taken using a 105 mm lens
1:10. B, Photograph taken with a 50 mm lens 1:10, which caused a lens distortion called a barrel
distortion.
A
B

23
Chapter 3 Photography for the Aesthetic Surgeon
A
photography. These have better-quality lenses and sensors than “point-and-shoot”
consumer cameras.



SENIOR AUTHOR TIP:
focal length is about 1.5×; therefore I recommend a 50-60 mm lens for facial photos
and a wider one for body photos.
VARIABLES TO CONSIDER IN FACE OR NECK SERIES
All of the facial series in this chapter are intended to be photographed in addition to the
standardized facelift and necklift series. There are, however, variables that exist in each
face series depending on the surgical procedure. These variables are noted in each section.
The following possible variations should be considered for standardized facelift and necklift
series:
Head positioning
Oblique variables
True lateral
HEAD POSITIONING
The is used as a reference line for correct head positioning in
radiographs.
• Some physicians have used it as a standard for head alignment when photographing
the face.
• Horizontal plane that traverses the top of the tragus (external auditory canal) across
the infraorbital rim
5
6
Head positioning. A, Patient shown in the Frankfort plane. Neck retraction can
overemphasize the degree of submental soft tissue. B, Patient shown in the natural horizontal
facial plane.
A
B

24
Part I Basic Considerations
Some physicians choose to use the for alignment.5
• Achieved when patients look straight ahead as if looking into a mirror at eye level7
• Preferred for photographing plastic surgery
• Used in patients with low-set ears7
OBLIQUE VARIABLES
Preferences vary for photographing oblique views.
• Some prefer the nasal tip to touch the opposite side of the cheek for the rhinoplasty
series.
• Some prefer the dorsum to visually touch the medial eye.
Both views are shown in Fig. 3-3, but one may be excluded once the preferred view is
chosen.
Options for oblique views. A, Tip of the nose touching the side of the far cheek for a
rhinoplasty series. B, Dorsum touching the medial eye.
A
B

25
Chapter 3 Photography for the Aesthetic Surgeon
TRUE LATERAL
Photographing an underrotated or overrotated head in lateral views is a common
mistake.
Error can be corrected by viewing 8
A, Underrotation. B, True lateral. C, Overrotation.
A
B
C
STANDARD FACE/NECK SERIES

at a 1 m distance with an 80 mm focal length.
Face is typically photographed with the patient in a seated position.
TIP: Place a target on the wall for the patient to view while in the lateral position to
help with standardizing the eye to radix alignment.
OBJECTIVES
Basis for all cosmetic procedures
Show anatomic relationship of whole face
Show anatomic bone/muscle/skin structure
Show skin laxity around mandible and neck
Show volume loss/depletion in malar area

26
Part I Basic Considerations
KEY POINTS
The contour of the neck can vary greatly according to the head and shoulder position.

submental fat/jowl line or, conversely, neck extension can improve the jowl line.
6
Make sure that the head is in the standard anatomic position and that the patient is
sitting straight and not slumping.
Have patients relax and not smile.
Have patients remove distracting jewelry and/or heavily applied makeup.
Fold down turtlenecks and turn collars away from the neck.
Have patients pull hair back with neutral-colored headband.
For oblique views, line the radix of the nose to touch the medial part of the opposite
eye (see Fig. 3-3, ).
Any slight tilting of the head can sometimes distort the view. Check the earlobe
symmetry from the anterior view to determine the straightness of the head before
photographing.
7
• Check true lateral through oral commissure alignment.
• Use natural horizontal facial plane for positioning.
Overview of standard face series and set distances. Some of the photographs can be
eliminated, depending on the particular procedure performed.

27
Chapter 3 Photography for the Aesthetic Surgeon
SUPPLEMENTAL FACE/NECK VIEWS

conditions.
• Platysmal banding (teeth gritting)
• Reading view (head down) which accentuates submental fat.
1
View to show platysmal banding (teeth gritting). B, A reading view accentuates
submental fat.
B
A
STANDARD BROW AND EYELID SERIES
This series taken in addition to the standard face series.

sensor at a 0.5 m distance with an 80 mm focal length.
OBJECTIVES
Show brow-eye anatomic relationship to face
Show skin laxity or excess of upper and lower eyelids
Show ectropion/upper lid hooding
Show existing fat deposits
Show wrinkles of the forehead and glabellar area

28
Part I Basic Considerations
KEY POINTS
Photograph horizontally.
The closeup of brow should extend below the lower crease of the lower eyelids to
slightly above the hairline.
Have patients relax the brow while they gaze upward.
Make sure interpupillary line is horizontal in all views.
Have patients gaze downward to reveal any excess lower lid fat.
Photographs of the eyes and brow are taken in addition to the standard facelift/necklift
series. Image A was photographed at 0.8 m. Images B and C were photographed horizontally at
0.6 m with a 105 mm lens.
A
B
C
STANDARD LASER/CHEMICAL PEEL SERIES
This series taken in addition to the standard face series.

at a 0.5 m distance with an 80 mm focal length.
OBJECTIVES
Show depth of creases and folds
Show changes in skin coloration from area to area
Show subtleties of skin texture

29
Chapter 3 Photography for the Aesthetic Surgeon
KEY POINTS
Remove heavy makeup.
Photograph closeup oblique views of cheeks in the vertical position and at jawline to
slightly above eyebrow at 0.5 m.
Photograph lateral views at 1 m to show the tonal changes in the skin, if any, from the
cheek to the jaw to the neck.
For a chemical peel of the chest area, obtain an additional view at 1 m horizontally.

necklift series. Closeups are photographed at 0.6 m and 0.8 m with a 105 mm lens.
STANDARD LIP SERIES
Patient photographed using a vertically and horizontally positioned digital camera with

using an 80 mm focal length.
OBJECTIVES
Show proportional relationship to face
Show existing volume loss
Show projection and dimension
Show vermilion border irregularities/asymmetries
Show philtral dimension
Show loss of volume or excessive gum show from animated smiling view

30
Part I Basic Considerations
KEY POINTS
Have patients remove lipstick and liners.
Inferior philtral column and tip of Cupid’s bow should intersect opposite cheek in
oblique view
Have patients slightly part and relax the lips.
Complete standardized lip series. Closeups of the lips are photographed at 0.7 m with a
105 mm lens, whereas the full face is photographed at 1 m.
STANDARD RHINOPLASTY SERIES
This series taken in addition to the standard face series.

sensor at a 0.5 m distance with an 80 mm focal length.

31
Chapter 3 Photography for the Aesthetic Surgeon
Rhinoplasty series is the most specialized photographic series.
The nose is due to the angles in
the anatomy.
• Depending on the type of nose, it is often necessary to make small adjustments to
the series, as shown in the oblique view of Fig. 3-11.
• The oblique preference must be decided before photographing.
The series can also be used for facial fractures and Mohs reconstruction using forehead

OBJECTIVES
Show proportional relationship of nose to face
Show any existing deviation of the dorsal aesthetic lines in anterior view
Show existing asymmetries
Show projection of dorsal hump in lateral view
Show radix position in lateral view
KEY POINTS
Photograph closeup views horizontally.
Make sure that the camera is parallel to the subject, focused on the midpoint (nose),
and that a horizontal line is straight through the lower lateral eyes and perpendicular to
the dorsum.

be needed, especially if the patient has extremely low tip projection or large upper lip
that may block the alar area.
In the half-basal view (see Fig. 3-10, B), line the tip just below the eyes.
Have patients relax their face and not smile.
Have patients remove distracting jewelry.
Have patients pull their hair back with neutral-colored headband.
Standardized rhinoplasty
series. These photographs are taken
in addition to the standard face/
necklift series. Closeup views are
photographed with a 105 mm lens
at 0.8 and 0.6 m.
A
B
C

32
Part I Basic Considerations
SUPPLEMENTAL RHINOPLASTY VIEWS
If a patient is having a depressor septi release, additional lateral and anterior views of
the patient smiling are photographed.
Cephalic view (see Fig. 3-10, C) is also helpful to show nasal deviations.9
Additional anterior and lateral views are needed if the patient is having a depressor
septi release.
SENIOR AUTHOR TIP: I advocate always taking a lateral smiling photograph regardless
of depressor septi release.
STANDARD BODY SERIES

sensor at 5-foot distance with a 35 mm focal length.
Body series is photographed vertically with the patient in a standing position.
• Midpoint of the body should be centered in the frame
• Position of the lens axis should be parallel to the patient at all times.
• Photographing up or down should be avoided, because it can lead to distortion and


• The contour of the body and muscle structure can vary greatly with positioning of
the feet.
• For ease of positioning, place
cut-out feet or tape on the

patients, as shown in Fig. 3-12.
OBJECTIVES
Show proportional relationship of
body
Show volume and dimension
Show skin laxity and muscle tone
Show contour irregularities/
asymmetries
For ease of positioning, place cut-out feet

33
Chapter 3 Photography for the Aesthetic Surgeon
KEY POINTS
Feet are parallel to each other and separated a hip’s distance.
Weight is distributed evenly.
Knees are facing straight ahead.
Camera should be parallel with subject and positioned at midpoint of body (usually the
abdomen).
Have patients relax abdomen.
Have patients wear generic underwear, if any.
Standard body series.
SUPPLEMENTAL VIEWS FOR THE BODY CONTOURING SERIES
A “diver’s” view is sometimes photographed to evaluate skin laxity.10
• An oblique view with the patient bending forward while relaxing the abdomen.
If the back is to be suctioned, an additional view is photographed from above the
shoulders to below the hips.

34
Part I Basic Considerations
Supplemental views for body contouring. A and B, A diver’s view is an oblique view with
the patient bending over while relaxing the abdomen. C, Back view.
A
B
C
SENIOR AUTHOR TIP: I prefer to have a lateral diver’s view as well as an oblique view.
STANDARD ARM SERIES
KEY POINTS
Arms are photographed horizontally with elbows bent to 90 degrees with hands
forward.
Have patients remove watches and/or jewelry.
Standard arm series.
STANDARD MALE BODY SERIES

sensor at a 5-foot distance with a 35 mm focal length.
OBJECTIVES
Show proportional relationship of body
Show volume and dimension
Show skin laxity and muscle tone
Show contour irregularities/asymmetries

35
Chapter 3 Photography for the Aesthetic Surgeon
KEY POINTS
Photograph vertically.
Photograph above shoulders to just above groin area.
Position the camera parallel with subject and at midpoint of body.
Have patients relax shoulders.
Have patients position arms behind body in all views except the anterior and posterior.
In posterior oblique views, have patients hold arms in front and away from body.
Use a generic material/towel to cover undergarments.
The male body series.


sensor at a 5-foot distance with a 35 mm focal length.
OBJECTIVES
Show proportional relationship of body
Show volume and dimension
Show skin laxity and muscle tone
Show contour irregularities/asymmetries
Show skin irritations and/or worn grooves
KEY POINTS
Feet are parallel to each other and separated a hip’s distance. (If thighs touch, have
patients separate feet slightly wider.)
Weight is distributed evenly.

36
Part I Basic Considerations
Knees face straight ahead.
Position the camera parallel with subject and at midpoint of body.
Have patients fold hands across breast area but no higher. (If breasts are large, have
patient lift them to show abdomen.)
Have patient raise abdomen in anterior and lateral views to show the condition of skin.
Standard body contouring after weight-loss series, including view to document
intertriginous areas.

37
Chapter 3 Photography for the Aesthetic Surgeon

CHEST EXCISION SERIES
KEY POINTS
Horizontally with elbows bent at 90 degrees and hands forward
Arms straight out with palms facing down
For lateral chest wall excision, photograph the patient’s back as well as oblique views
with the arms raised and bent to 90 degrees.
Photograph below the breast area in oblique views.
Standard views for brachioplasty and/or lateral chest excision after massive weight loss.

38
Part I Basic Considerations
STANDARD BREAST AUGMENTATION SERIES

sensor at a 5-foot distance using a 35 mm focal length.
OBJECTIVES
Show proportional relationship of breasts to chest
Show breast laxity/skin tone
Show any asymmetries
Show nipple and areolar proportion and their relationship to breast
KEY POINTS
Photograph horizontally.
Photograph above shoulders and below navel for reference and proportion.
Position the camera parallel with subject and at midpoint of body.
Have patients relax shoulders.
Have patients remove jewelry, including wrist watch.
Standard breast augmentation series.
SUPPLEMENTAL BREAST AUGMENTATION VIEWS
If a patient has a capsular contracture, photograph with arms up.
• It is helpful to photograph the incisions after surgery, along with the standard series.

39
Chapter 3 Photography for the Aesthetic Surgeon
STANDARD BREAST REDUCTION/MASTOPEXY SERIES
KEY POINTS
Photograph horizontally.
Photograph above shoulders and below navel for reference and proportion.
Arms are behind patient in oblique and lateral views.
Position the camera parallel with subject and at midpoint of body.
Have patients relax shoulders.
Have patients remove all jewelry, including wrist watch.
Standard breast reduction series.
SUPPLEMENTAL BREAST REDUCTION/MASTOPEXY VIEWS
Photograph the incisions after surgery, along with the standard series.

40
Part I Basic Considerations
LIGHTING IN A CLINICAL SETTING
Patients should be photographed using a or
are preferred.

texture of skin.
• Additional lights can be used that are pointed toward the backdrop (away from the
patient), which helps to eliminate shadow casts and separate the background from
the patient.
• To preserve a natural appearance, shadows should be cast downward.
PATIENT PREPARATION
Have patients remove distracting items.
Heavy makeup, glasses, and large jewelry can detract from patient results.
Purchase disposable medical garments to ensure a “generic” patient appearance in
photographs, as well as consistent standardization.
FACIAL EXPRESSION
Slight animation can “pull” at facial anatomy, which can distort results.
Patients should relax their face, with their eyes focused straight ahead.
BACKGROUND
behind the patient is used to eliminate any unnecessary
items that may detract from the scene.
• Helps to produce a contour of the patient
• Medium blue often used, because it contrasts with a variety of skin tones
INFORMED CONSENT
The following are the basic guidelines for photographing patients and obtaining
photographic consents that are the standards used for HIPAA (Health Insurance Portability

additional requirements.
PHOTOGRAPHING FOR TREATMENT PURPOSES
Health care providers may photograph and/or create audio or video recordings of
patients for treatment purposes, without obtaining patients’ written authorization.
PHOTOGRAPHING FOR NONTREATMENT PURPOSES
If a patient agrees to be photographed or recorded for nontreatment purposes, the

examples of “nontreatment” purposes that require patient authorization are:
• Educational lectures and presentations for health care professionals (e.g., CME)

41
Chapter 3 Photography for the Aesthetic Surgeon


• Patient education materials
• Use in broadcast, print, or Internet media for educational or public interest purposes
According to HIPAA, authorizations are not required if the photograph or recording will


require authorization.



• Name
• Date of birth
• Address
• Telephone number
• Fax number
• E-mail address
• Social Security number
• Medical record number
• Account number
• Driver’s license number
• Credit card number
• Names of relatives
• Name of employer

• Vehicle or other device serial number

• Internet Protocol (IP) address numbers
• Finger or voice prints
• Date and time of treatment

• Recognition of the patient not only applies to the eyes but also to other
distinguishing features of the face.
1

consent form when using any part of the face for purposes other than treatment is
strongly recommended.
As standard practice, even if a patient has a “photographic consent for nontreatment

or on the Internet.
TIP: Tattoos, scars, and birthmarks are also identifying landmarks in body shots and
have been used successfully in lawsuits.

42
Part I Basic Considerations
TOP TAKEAWAYS

Uniformity and standardization are essential to producing accurate
photographic documentation.


images.

Special attention should be paid to obtaining photographic consent forms.

A standardized camera, lens, distance, and views will produce photos that can
be compared later.


to stand far enough from patients to prevent distortion (especially with facial
photos).

Digital photography requires good backup, with protection of HIPAA standards.

Photos are legal records! Every patient should sign a consent form; additional
consent should be obtained for publication or Internet use.
REFERENCES
1. Grom RM. Clinical and operating room photography. Biomed Photogr 20:251, 1992.
2. Roos O, Cederblom S. A standardized system for patient documentation. J Audiov Media Med
14:135, 1991.

Reconstr Surg 102:559, 1998.
4. Young S. Maintaining standard scales of reproduction in patient photography using digital
camera. J Audiov Media Med 24:162, 2001.
5. Williams AR. Positioning and lighting for patient photography. J Biol Photogr 53:131, 1985.
6. Sommer D. Pitfalls of nonstandardized photography in facial plastic surgery patients. Plast
Reconstr Surg 114:10, 2004.
7. Galdino GM, DaSilva D, Gunter JP. Digital photography for rhinoplasty. Plast Reconstr Surg
109:1421, 2002.
8. Davidson TM. Photography in facial plastic and reconstructive surgery. J Biol Photogr Assoc
47:59, 1979.

20:443, 1991.
10. Gherardini G. Standardization in photography for body contour surgery and suction-assisted
lipectomy. Plast Reconstr Surg 100:227, 1997.
11. Williams AR. Clinical and operating room photography. In Vetter JP, ed. Biomedical Photogra-
phy. Boston: Focal Press, 1992.

-
ber 28, 2000).

MD: Aspen Publishers, 1994.

43

every 2½ years1 (Fig. 4-1).
Prevent medical lawsuits with good patient selection, strong patient relationships, and
proper documentation.



Mark Gorney, Neal R. Reisman
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Aesthetic surgery
Gastroenterology
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Pulmonary medicine
Cardiology
Gynecology
Neurology
Internal medicine
Emergency medicine
Urology
All physicians
Anesthesiology
Diagnostic radiology
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Ophthalmology
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Other specialities
Pediatrics
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Frequency of malpractice claims by specialty.

44
Part I Basic Considerations
PATIENT SELECTION2
More than half of the malpractice claims against aesthetic surgeons are preventable;

EXPECTATIONS TOO GREAT
Patients with or those who expect major life
changes, are more likely to be disappointed with even a good surgery result.
• Disappointed patients are more likely to seek legal counsel.
Patients who associated with major surgical procedures
are more likely to be disappointed.
• Patients must understand the possible inherent complications associated with
surgery.
EXCESSIVELY DEMANDING PATIENTS

consultation should be managed with great caution. These patients demonstrate:



THE INDECISIVE PATIENT
SENIOR AUTHOR TIP: I have always had a concern about defending a decision to
perform completely elective surgery with, “The patient wanted this done.” I think a
patient cannot make a negligent decision. That is, the doctor has the responsibility to
NOT accept patients for completely elective surgery if the choice of procedure does

something does NOT mean it should be performed if inappropriate.
Question: “Doctor, do you think I ought to have this done?”
“I cannot make that decision for you; if you have any doubt whatsoever, I
strongly encourage you to reconsider.”
The decision to undergo surgery is motivated from within:

CAUTION:

THE IMMATURE PATIENT
Youthful and immature patients may have excessively romantic expectations.
and do not always correlate.
THE SECRETIVE PATIENT
Be cautious of patients desiring secret surgery or requesting elaborate precautions to
prevent knowledge of their surgery. This suggests guilt about the surgery.
patients are more likely to be
patients are more likely to

45
Chapter 4 Medicolegal Considerations in Aesthetic Surgery
FAMILY DISAPPROVAL
Family approval is not necessary, but

• Such reaction may deepen patient’s guilt and dissatisfaction.
PATIENTS PHYSICIANS DO NOT LIKE OR WHO DO NOT LIKE THEM



• Perception of bad outcome is more likely, even with a good result.
• Patients are much more likely to sue doctors they do not like.
THE “SURGIHOLIC
WARNING: Patients with multiple aesthetic surgeries are not good candidates because:
• Personality problems: Patients are probably compensating for poor self-image.

• Risk of unfavorable comparison with previous surgeons
SENIOR AUTHOR TIP: Performing surgery on surgiholics is not worth the risk.
BODY DYSMORPHIC DISORDER
Beware of patients who are occupied by physical traits that are hardly noticeable and
within normal limits. Patients with body dysmorphic disorder never carry a diagnosis
openly.




with a good surgical result.
PATIENT COMMUNICATION

perception of arrogance and disinterest, which leads to lawsuits.
Informed consent is a process and sometimes is never achieved, even after many visits.
TEN LISTENING BEHAVIORS TO AVOID4


• Surgeons must not become bored with the same complaints they have heard many
times before; patience is a virtue: refuse the urge to “move the conversation along.”


• More often than not, patients realize their doctor is merely “appearing engaged.”


• Patients’ explanations of their symptoms are often lengthy and unorganized.
• Physicians must actively listen to their patients’ explanations to appropriately
synthesize the information that allows proper care.
• A disorganized patient presentation is not a defense against a lawsuit.

46
Part I Basic Considerations


• Interruptions (phone, intercom, pager) should be avoided.


• Physicians should listen to patients, even those with distracting mannerisms or
physical characteristics.



data. Human patients, however, are not objective or quantitative; physicians must
comprehend the equally important patient emotional overtones and behavior.


• Surgeons should not become enamored with the patient’s speaking style or
mannerisms, because it may cause them to miss what the patient is saying.


• Angry or defensive reactions to patient comments should be avoided.
• “We” is used, instead of “you.”


• Note-taking is essential for documentation, but can be distracting.
• Surgeons should listen to and make eye contact with patients, then jot down the
key words needed to reconstruct the conversation shortly after the consultation.


• People can speak 150 words per minute but assimilate 500 spoken words per
minute; thinking about something other than what the speaker is saying requires
extra time and should not be done; active listening requires focus on the patient’s
words.
EMPLOYING GOOD LISTENING SKILLS



• Silence is golden; focus on what the patient is saying.


• Do not cross your arms (appearing defensive).
• Avoid sitting behind a desk (an ostensible barrier).
• Try to —a nonverbal communication that says, “I am interested.”
EMPLOYING GOOD SPEAKING HABITS



• Pause more often. Pausing during speaking gives the patient time to digest the

• Repeatedly invite questions; a good dialogue reinforces patients’ beliefs that they
are participating in their care.
• Ask patients to repeat instructions; repetition adds reinforcement.

• Use (e.g., “cutting out” instead of “excise”).
• A surgeon’s duty is not only to operate, but to ensure that their patients understand
the surgery process; if they do not understand it, the surgeon has breached his or
her duty.

47
Chapter 4 Medicolegal Considerations in Aesthetic Surgery

• The average patient retains only of what is said; repetition can increase patient


• After leaving the consultation, patients often remember questions they forgot to ask.
• Encourage patients to write down questions they have before consultations.
Answering their questions may avert a lawsuit.

• Start with a friendly handshake. Eye contact is critical and holds a patient’s
attention. A frown, raised eyebrow, sigh, or simple “hmmmm” can exacerbate

attitude, will help to develop a solid doctor-patient relationship, which is essential
for lawsuit avoidance.
DOCUMENTATION
TIP: Many lawsuits occur not because of bad doctoring, but because of bad charting!
Good doctors who chart poorly can still be sued—and lose.
Bad doctors can prevent lawsuits by charting well, and even if they are sued, they can win.
In today’s litigious environment, being a good physician means not only practicing good
medicine, but equally important, documenting the good medicine that is practiced.
TIP: Document defensively. The digital age poses many new problems. Interacting
with a laptop or notebook and not with the patient interferes with the doctor-patient
relationship. Developing a method by which the physician can create a healthy doctor-
patient relationship AND have proper documentation is critical. Be aware also of “smart
text” entries that default to a response. Check to make sure the entry is accurate.

• If it is not in the chart, it was not done.
• If the physician did not write it in the chart, then the physician did not consider it.
• If the physician writes it in the chart wrong, then the physician did not understand it.
• If the physician did not prescribe the right medications or treatment regimens, then
the physician did not know what he or she was doing.
SENIOR AUTHOR TIP:
MYTH: Doctors should document as little as possible; if you document too much, the
lawyer will just twist what you’ve written.
FACT:
surgeon’s reality: Scant documentation because of a busy lifestyle. If documentation

and rushed. Remember, a physician’s duty to patients includes not only good patient
care, but documentation of such care.

48
Part I Basic Considerations
KNOW THE LEGAL DEFENSES!
TIP: Knowledge of the available legal defenses helps to better buttress these defenses
with documentation. Below are three common legal defenses.



This means that perfection is not required:
• Doctors are human; they use judgment.
• Judgment is not perfect; mistakes happen.
• A mistake is not necessarily negligence.
Translation: Physicians can make a reasonable mistake and not be negligent.

SENIOR AUTHOR TIP: Judges and juries do not like finding medical negligence
against good, caring physicians. They know that hindsight is 20/20; they do not expect







practitioners.
• When physicians come to a fork in the medical road, they document why they go

to testify, with 20/20 hindsight, that left was the wrong choice, but physicians’


compassionate, trying to take good care of a patient.


at the time of the
event or shortly thereafter,

remember, and will so testify in court, conversations or events with their
physician that never actually occurred.

and events they have with their patients.

49
Chapter 4 Medicolegal Considerations in Aesthetic Surgery
TIP: A picture is worth a thousand words. A medicolegal document made at the time

IMPORTANCE OF LEGIBILITY
SENIOR AUTHOR TIP:
MYTH: Doctors should write illegibly; that way, the attorney won’t be able to read the
documentation, and thus won’t sue.
FACT: Physicians who write illegibly are more likely to be sued, and if they are sued, they
are more likely to lose, even if not negligent.






their way to the jury room.
Box “SLOPPY AT DOCUMENTATION IS SLOPPY AT PRACTICE”: HOW IT WORKS AT TRIAL
Much of this is moot as we have entered the electronic health record era. However,
“standard operative reports” may indicate a physician did everything the same and did
not properly care for the patient. Or, if dictated, incorrect entries like “had no carcinoma”
instead of “adenocarcinoma” may occur.
The duty is to read and correct everything entered before signing the document. The


will then scan this note and project it on the courtroom wall opposite the jury, call on
an unsuspecting nurse (or someone who commonly reads physician notes to care for
patients), and ask him or her to read the note; inevitably, the nurse will not be able to

is how that busy and rushed doctor” (pointing to the physician) “documents care of our
poor, injured patient” (gesturing sympathetically toward the attorney’s client). “If this
doctor didn’t have time to merely document patient care, she certainly didn’t have time to
properly care for our patient.”
They will then project these words superimposed on the physician’s notes:

The attorney will repeat this theme over and over, and hammer it home in the closing
statement.

50
Part I Basic Considerations
DOCUMENT DEFENSIVELY!
TIP: Documentation was originally required to protect the patient; in today’s legal
environment, however, documentation is to protect you! Protect yourself: document
defensively.


will allege that they did not know their patient well enough to provide patient care.
TIP: Physicians should not merely sign the bottom of each page, because the jury will
not think they read everything.
Question: Is template charting by a nurse or physician assistant acceptable, or do I have
to perform a full history and physical examination myself for every patient?
Template charting is acceptable, but physicians should circle, initial, and date


• If in doubt, GET ONE.

TIP:

are barely paid at all. When a consulted resident physician avoids a consult, the physician
must document the event properly; otherwise, he or she may be liable. The consult
physician’s name and the information relayed must be written down (e.g., “labs, path
report, and MRI results reported in full”). If physicians do not record that they reported
the information, at trial the consulted physicians will swear they did not: “She did not
tell me about that laboratory value! If she had, I would have been there in a heartbeat!”
Do NOT attack other physicians (especially in the medical record).
• Fight lawsuits as a team if possible.

Document troublesome patients!

patients; professionally document the patient’s troublesome nature, and good
attorneys will get the picture:


the patient’s circumstances.”

51
Chapter 4 Medicolegal Considerations in Aesthetic Surgery
Never alter a chart.
• Ink is like DNA: An expert can tell the year, make, and manufacturer of the ink on an
original document. If a chart is altered, the attorney will know.
Always document recommendations to see primary care!
• Patients think that all doctors are generalists, not specialists; it is important to
always tell patients to follow up with their primary care or OB-GYN physicians for all
medical problems outside your area of expertise.
INFORMED CONSENT2
SENIOR AUTHOR TIP:

procedure or surgery.
Without a consent, they risk legal liability for a complication, even if they are not
negligent; theoretically, they could even be charged with “battery,” the unlawful
touching of another (remember, if it is not in the chart, it did not happen).

intelligent decision. The judge will inform the jury no liability attaches if a reasonable
prudent person in the patient’s position, armed with the consent information, would
have accepted the treatment.
RIGHT OF REFUSAL
Document a patient’s refusal, and that the patient understood the consequences of
such refusal.
• Always time, date, and sign record entries.

• The diagnosis or suspected diagnosis

procedure

• The probability of success, based on a patient’s condition
• Possible consequences if advice is not followed.
TIP: Procedures that are cosmetic, experimental, or hazardous in nature, or which
could potentially alter the patient's sexual capacity, all require more thorough
documentation of foreseeable risks, possible untoward consequences, and potential

document thoroughly their consents.
NO FORM IS “FOOLPROOF
Some consents are too long (incomprehensible); others are too short!
Use a middle of the road consent form, and add to the form with handwritten notes.
THINK! Use judgment as to what is and is not important when adding to the consent.

52
Part I Basic Considerations
COMMON CLAIMS2
SCARRING IN GENERAL
Something every patient should know: Without a scar, there is no healing!
• Healing entails scar formation; without scarring, there is no healing.
• Healing qualities are individual (genetically programmed) and cannot be predicted;


BREAST REDUCTION
Unsatisfactory scar


BREAST AUGMENTATION
Generally, discuss autoimmune diseases and their corresponding lawsuits.
Encapsulation
Wrong size (too little, too much)
Infection
Repetitive surgeries and attendant costs
Nerve damage with sensory loss
FACELIFT AND BLEPHAROPLASTY
Excessive skin removal (the “starey look”)
Dry eyes; inability to close
Nerve damage, resulting in distorted expression
Skin slough, resulting in excessive scarring and additional surgeries
Blindness
TIP: A doctor’s company survey on blepharoplasties complicated by blindness found

each patient at home performed a physical maneuver that generated a sudden rise

shoes, etc.).
TIP: The outpatient surgical facility should not discharge any patient until at minimum

Physicians who undermine heavily vascularized tissues should strictly warn their patients
to AVOID any sudden blood pressure elevating maneuvers.
SEPTORHINOPLASTY
Unsatisfactory result: Improper performance allegations

Asymmetry

53
Chapter 4 Medicolegal Considerations in Aesthetic Surgery
TIP: Rhinoplasty has the highest degree of unpredictability. Avoid inappropriate use
of “brag books” containing only excellent results, or strictly counsel patients that these
results cannot always be obtained.
ABDOMINOPLASTY
Skin loss with poor scars (greater chance when preceded by suction-assisted
liposuction)
Nerve damage
Inappropriate operation
Infection with postoperative mismanagement
SKIN RESURFACING

Infection/postoperative mismanagement
Permanent discoloration postoperatively
SUCTION SSISTED LIPECTOMY


• Numbness
• Disappointment/dissatisfaction

• Unrecognized abdominal perforation, resulting in disabling secondary surgery or
death

• Pulmonary edema from overhydration
• Pulmonary embolism and death
CAUTION:

2

2

Lidocaine


TIP: 7

their surgery (and their surgeon). Inform patients that ultimately they, not you, control
their surgery satisfaction. Use the handout in Fig. 4-2.

54
Part I Basic Considerations
3× more
likely to have
WEIGHT GAIN
2× more
likely to have

4× more
likely to have
WEIGHT GAIN
1.5× more
likely to have

No
Yes
No
Yes
Eat a healthy diet
Exercise regularly

25% will have increased
productivity
96% will have decreased
clothing size
79% will have a high
self-appearance score
43% will have improved health
Results in better
SATISFACTION

(96% satisfaction rate)
WITH WEIGHT GAIN
83% will have decreased
or stagnant productivity
63% will have increased
or maintained clothing size
71% will have a low
self-appearance score
90% will have unimproved health
DISSATISFIED WITH


Road map for long-term successful results, based on survey responses of 209 patients,
given 6 months to more than 2 years postprocedure.
OTHER MISCELLANEOUS COMMON CLAIMS
Untoward reaction to medications or anesthesia
Improper use of preoperative or postoperative photos
Sexual misconduct (doctor or employee)

General dissatisfaction (The patient’s expectations were not met.)

55
Chapter 4 Medicolegal Considerations in Aesthetic Surgery
TOP TAKEAWAYS

This chapter provides a good, broad road map to limit liability in the care of
patients.

The digital age brings new issues that can complicate and increase liability.

The protection of patient privacy, especially with photographs must be
addressed. If a photograph shows a physician for any advertising purpose,

scrubbed of identifying metadata.

A patient communication consent that indicates how to interact with the
patient, such as cell phone, work phone, regular mail, texting, or social media is
recommended. This should be reviewed periodically and updated appropriately.

Electronic health records distract physicians from developing a good doctor-
patient relationship. Often, the physician is focused on a laptop and not listening
and interacting with the patient.

Because patients usually do not bring litigation against doctors they like, it is
wise to develop a behavior that involves interacting with the patient directly as
well as entering information appropriately.

An entry itself in an electronic health record may be problematic. Developing
smart text that speeds data entry is recommended. The default entry must

be voluminous, and the physician’s responsibility is to read, correct, and approve
before digitally signing the document.

Patient selection is a key aspect of a successful practice and avoiding additional
risks.

When possible, physicians should accept patients they like and in whom they
can achieve reasonable goals and expectations.

Doctors should know their limitations. Performing a procedure on a patient only
because they asked for it is unacceptable.

Physicians have the duty and responsibility to protect prospective patients and
ensure that choices of procedure and care are reasonable and appropriate. This
assumes that the physician has spent enough time listening to the patient and
that the physician understands the patient’s goals and expectations, answers

visit before surgery.

Informed consent is a process that may require multiple visits and multiple
discussions.

It has been said that doctors earn their living by the patients they care for but
develop their reputation based on those they do not.

56
Part I Basic Considerations
REFERENCES

Engl J Med 365:629, 2011.
2. Gorney M. Medical liability in plastic and reconstructive surgery. In Anderson RE, ed. Medical
Malpractice: A Physician’s Sourcebook. Totowa, NJ: Humana Press, 2005.
3. Gorney M. Communication and patient safety. In Anderson RE, ed. Medical Malpractice: A
Physician’s Sourcebook. Totowa, NJ: Humana Press, 2005.

5. Horton JB, Reece EM, Broughton G II, Janis JE, Thornton JF, Rohrich RJ. Patient safety in the


surgery setting. Plast Reconstr Surg 110:1337; discussion 1343, 2002.
7. Rohrich RJ, Broughton G II, Horton B, et al. The key to long-term success in liposuction: a guide
for plastic surgeons and patients. Plast Reconstr Surg 114:1945; discussion 1953, 2004.

PART II
Anesthesia

(Trang không có chữ)

59
GENERAL PRINCIPLES1,2
Anesthesia for patients undergoing purely elective aesthetic procedures presents

• Patient selection

• Choice of anesthetic technique(s)
• Personnel requirements
• Postoperative care and pain management
• Discharge criteria
• Patient satisfaction
Requires high level of understanding, communication, and cooperation between surgeon
and anesthesia provider to ensure optimal surgical outcome and patient experience
Regulatory agencies establish minimum standards of care in aesthetic surgery
environments.
• Accreditation Association for Ambulatory Health Care (AAAHC)
• The Joint Commission (TJC), formerly Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)
• American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
• Regulations may vary with regard to state and type of facility.
Professional societies provide consensus statements, guidelines, recommendations,
practice parameters, and advisories for evidence-based best practices for ambulatory

• American Society of Anesthesiologists (ASA)
• Society for Ambulatory Anesthesia (SAMBA)
• American Society of Regional Anesthesia and Pain Medicine (ASRA)
• American College of Cardiology and American Heart Association (ACC/AHA)
• American College of Surgeons (ACS)
• American Society of Plastic Surgeons (ASPS)
• American Society for Aesthetic Plastic Surgery (ASAPS)
ANESTHETIC GOALS
Anxiolysis
Amnesia
Analgesia
Sedation
Unconsciousness or hypnosis
Immobility, including muscle relaxation or paralysis
Quiet, nondistracting operating milieu, if patient awake
Attenuation of autonomic responses to noxious stimuli
Preservation of vital functions

60
Part II Anesthesia
OBJECTIVES OF ANESTHESIA IN THE AESTHETIC PATIENT2
Safe implementation of chosen technique
Fast-track characteristics with rapid onset and emergence
Predictable and reliable methodology


Patient satisfaction commensurate with entirely elective, often self-funded, procedures
TECHNIQUES

“Balanced” technique incorporates multiple classes of IV drugs (sedative-hypnotics,


Volatile agents
• Easier titration of depth, faster emergence, and early recovery

• Simple administration
• Typically less expensive maintenance agent

Component therapy involving sedative-hypnotic infusion (propofol, ketamine,
dexmedetomidine)
• Additional drugs such as midazolam, choice of narcotic, or muscle relaxant
supplemented either by IV bolus or infusion

Reduced incidence of postoperative nausea and vomiting (PONV)
High degree of patient satisfaction
More complex administration
Increased cost
Avoids gas delivery systems and therefore need for scavenging equipment
Avoids malignant hyperthermia (MH) triggers (see Malignant Hyperthermia section
later in the chapter)
Various well-described “recipes” for TIVA5,6,8 commonly include:
• Propofol: Sedation/hypnosis
• Midazolam: Anxiolysis and amnesia
• Ketamine: Dissociation and analgesia
• Opioids (fentanyl, alfentanil, remifentanil): Analgesia
• Rocuronium: Muscle relaxation
• Dexmedetomidine: Anxiolysis, sedation, analgesia, decreased adrenergic output
• Acetaminophen: Nonopioid analgesic
• Ketorolac: NSAID
Frequently accompanied by use of “depth of anesthesia” or “level of consciousness”
monitoring
Employs algorithm-driven surface EEG to calculate an “index” number that correlates
with hypnotic level
(BIS; Medtronic) commonly used in the United States
• Airway can be natural or controlled (endotracheal tube or supraglottic airway), with
either mechanical or spontaneous ventilation.

61
Chapter 5 Basics of Anesthesia for the Aesthetic Surgery Patient

Neuraxial (spinal or epidural)

transversus abdominal plane (TAP), truncal, or other
at multiple and varying levels

Selection determined by
• Type, extent, and duration of surgery
• Patient or surgeon preference
• Anesthesiologist experience
• Patient’s underlying medical status and/or any pertinent psychological aspects
Can be isolated anesthetic technique or involve combinations listed previously
IMPORTANT CONSIDERATIONS WITH ADMINISTRATION
OF ANESTHETICS
Standard of care for nonhospital locations should be equivalent to those of hospitals.
ASA Standards for Basic Anesthetic Monitoring10 (last amended 2011) must be met.
Emergency protocols must be established, documented, and rehearsed.
Transfer agreement with nearby/associated hospital for unplanned admission must be
established.
Preoperative risk assessment and evaluation are required, including laboratory tests
and specialty consultation as needed.11
Selection of anesthesia type with appropriate monitoring
Selection of appropriate model of provider(s)

nurse anesthetist (CRNA) or, in some states, an anesthesia assistant (AA)
• CRNA supervised by surgeon
• Surgeon supervising RN whose sole responsibility is administration of ordered
medication(s) and monitoring patient

patient care
Duration and complexity of procedure(s), especially if multiple procedures will be
performed simultaneously or concurrently
Preoperative medications and postoperative pain control plans
Discharge criteria and postoperative follow-up
PREOPERATIVE SCREENING, EVALUATION, AND PATIENT
SELECTION
GOALS
Identify and optimize comorbid conditions.

Align anesthetic needs and resources with proposed procedure and patient needs.
Minimize perioperative risk.
Reduce delays and cancellation.
Assess ability for safe and timely discharge.

62
Part II Anesthesia
TOOLS
Checklist-format patient questionnaire
Primary care physician/practitioner evaluation
Subspecialty consultations as needed
Old anesthesia records
In-person or phone interview with anesthesiologist or nurse
Video chat, Skype, or telemedicine
TIMING14
Process guided by
• Patient demographics
• Patients’ clinical conditions
• Invasiveness of procedure
• Nature of the health care system
Can be done day of surgery (DOS) if low severity of disease and procedure of low-
medium surgical invasiveness, otherwise in advance
THINGS ANESTHESIOLOGISTS LIKE TO KNOW OR REVIEW
Up-to-date history and physical examination
Pertinent active medical conditions
Current medications and therapies in place
Status of optimization of current problems
Pertinent subspecialty consultation
Pertinent diagnostic studies of record
Pertinent psychosocial conditions


History of PONV or postdischarge nausea and vomiting (PDNV) (discussed later in the
chapter)
History of other anesthetic complications like delayed emergence, unanticipated
admission, or prolonged postanesthesia care unit (PACU) stay
Personal or familial history suggestive of malignant hyperthermia


IDENTIFYING RISK FACTORS
2, 5,9,12
• Unstable angina
• Myocardial injury within 3-6 months
• Severe cardiomyopathy
• Uncompensated heart failure
• Aortic stenosis (moderate to severe) or symptomatic mitral stenosis
• Uncontrolled or poorly controlled hypertension
• High-grade arrhythmias

• Recent stroke within 3 months
• End-stage renal disease (ESRD)/dialysis

63
Chapter 5 Basics of Anesthesia for the Aesthetic Surgery Patient
• Severe liver disease
• Awaiting major organ transplant
• Sickle cell anemia
• Symptomatic or active multiple sclerosis
• Myasthenia gravis
• Severe chronic obstructive pulmonary disease (COPD)

• Severe obstructive sleep apnea (OSA)
• Morbid obesity
• Psychiatric status unstable, dementia
• Acute substance intoxication
• Poor functional status <4 metabolic equivalents (METs) (discussed later in the
chapter)
•
15 (2013) suggested associated with
increased 72-hour morbidity and mortality in ambulatory surgery:
1. Overweight BMI
2. Obese BMI
3. COPD
4. History of transient ischemic attack/stroke
5. Hypertension
6. Previous cardiac surgical intervention
7. Prolonged operative time
PREOPERATIVE TESTING
The culture shift is to NO routine testing.
Tests should be for indication only, as per current medical conditions or per procedure.

• Patient is healthy

• Blood loss expected to be minimal
• Procedure is designated low risk
Testing guidelines available from ASA, SAMBA, ACC/AHA
PREGNANCY H EST
Positive pregnancy tests have been reported in
which led to postponement, cancellation, or changes in
management of 100% of the cases.
14
Routine testing of all females within childbearing years .
Evidence-based medicine is inadequate or unsupportive with regards to anesthetic

stimulation of contractions, or premature birth.
ASA provides no consensus on routine testing versus based on clinical menstrual history.


practices and policies” according to ASA Choosing Wisely initiative
16
Many institutions perform routine point of care (POC) urine hCG on day of surgery.
Some institutions perform rapid qualitative serum hCG testing should urine results be
equivocal or contested by patient.

64
Part II Anesthesia
HEMOGLOBIN/HEMATOCRIT GB/HCT AND COMPLETE BLOOD CELL
COUNT

Patients with liver disease
Extremes of age
Preexisting anemia
Hematologic disorders

CHEMISTRIES
High-grade dysrhythmia, pacemaker, cardiac implantable electronic device (CIED), e.g.,

H/O heart failure
Diabetes

Hepatic disease
Poorly controlled hypertension
Malabsorption/malnutrition (note history of eating disorder or bariatric surgery)
BLOOD GLUCOSE
In diabetics, obtain by blood draw as preadmission testing (PAT) or by point of care
testing on day of surgery
HbA1C is helpful in perioperative glucose interpretation and management
COAGULATION STUDIES
Bleeding disorders


Chemotherapy
ELECTROCARDIOGRAM ox
Box WHEN TO OBTAIN A PREOPERATIVE ELECTROCARDIOGRAM
• Patient with known CAD or risk factors
•
• Patient with known arrhythmias (helpful to have a baseline)
• Patient with known peripheral or cerebral vascular disease
•
• Patient with signs or symptoms of active cardiac conditions, e.g., chest pain,
diaphoresis, shortness of breath (SOB), dyspnea on exertion (DOE)
• Patient with DM requiring insulin or end-organ damage
•
Based on cardiac risk
indicated for patients undergoing surgery,
(ACC/AHA 2014)

65
Chapter 5 Basics of Anesthesia for the Aesthetic Surgery Patient
cosmetic procedures (abdominoplasty, large-volume liposuction,
or body contouring after massive weight loss) with at least
supports obtaining baseline or current/updated ECG.
ECGs valid for if patient clinically stable
clinical risk factors:
• Coronary artery disease (CAD) with H/O myocardial infarction, coronary
artery bypass graft (CABG) bypass, percutaneous coronary intervention (PCI),
intracoronary stents
• Cerebral vascular disease, with H/O stroke or transient ischemic events
• Heart failure
• Diabetes, requiring insulin, poorly controlled, or with end-organ damage


• No risk factors: 0.4%
• One risk factor: 1.0%
• Two risk factors: 2.4%
• Three or more risk factors: 5.4%

Risk interpreted as:
• Patients with are and need no further testing.
• Patients with are a and should be evaluated for optimization or
further workup before elective surgery.
that should command attention and dissuade from elective
surgery in anything but a hospital setting, or not at all, are:
• Recent MI
• Unstable angina
• Uncompensated heart failure
• High-grade arrhythmias

Additional considerations used as risk factors
• Morbid obesity
• Poorly controlled hypertension


CHEST RADIOGRAPH
Not many indications in the elective aesthetic surgery patients
Active symptomatic pulmonary disease
ADVANCED CARDIOVASCULAR TESTING
Stress test, ECG, carotid duplex, vascular studies guided by subspecialty consultation

Used as a global descriptor of a patient’s clinical state based on history, physical
examination, and laboratory data
Most widely used and accepted method of describing preoperative health status
Gross predictor of overall risk; does not assess surgical risk per se9
Robust predictor of postoperative morbidity and mortality
Validated by and incorporated in current risk assessment models18

66
Part II Anesthesia
Other applications include allocation of resources and anesthesia reimbursement.19
18
Recently updated by ASA 2014

stable chronic severe diseases, e.g., ESRD with hemodialysis, moving from class IV to
class III



Class I
Normal, healthy patient
Class II
Mild systemic disease
Class III
Severe systemic disease
Class IV
Severe systemic disease that is a constant threat to life
Class V
Moribund patient not expected to survive without operation
Class VI
Patient declared brain dead for organ donation purposes
Emergency surgery (E) denotes any of the above patient classes requiring emergency operation (e.g., normal,
healthy patient for surgery is class IE).
Patients frequently present for aesthetic surgery with multiple medical problems that
represent an ASA III status.
ASA III patients are a widely disparate group with huge variations in pathophysiology.
NOTE: The presence of stable, optimized preexisting diseases consistent with an ASA III
status is NOT a contraindication for elective surgery.
NPO FASTING GUIDELINES AND PREVENTION OF PULMONARY
ASPIRATION 21
FASTING
ASA Guidelines for Fasting (in adults, updated 2011)


Clear liquids

2
Dairy, nonclear juices

6


6
Heavy meal (fried, fatty foods; meat)


Guidelines are limited to healthy patients undergoing elective procedures.




NOTE:

withdrawal headaches.

67
Chapter 5 Basics of Anesthesia for the Aesthetic Surgery Patient
ACID ASPIRATION PROPHYLAXIS AND CONSIDERATIONS
Aspiration of gastric contents occurring after the induction of
general anesthesia, during a procedure, or in the immediate period after surgery
ASA and SAMBA recommend NO ROUTINE administration of preoperative acid
aspiration prophylaxis medications.


• Obesity
• Pregnancy
• Diabetes

• Hiatal hernia
• After bariatric surgery (especially laparotomy band)
• Ileus or bowel obstruction
• Emergency surgery (e.g., return to OR for hematoma or wound dehiscence after PO
intake in PACU)

• Gastrointestinal stimulants (metoclopramide)
• Gastric acid blockers


• Antacid, nonparticulate (sodium citrate)
• Antiemetics (ondansetron, prochlorperazine) used alone or in combination

FUNCTIONAL STATUS OR FUNCTIONAL CAPACITY
Derived by estimating patient’s abilities to perform various tasks and activities of daily

Expressed in METs
• 2 (resting oxygen uptake in sitting position)


anesthetic preoperative evaluation described as:

Used as an indicator on Gupta Myocardial Infarction and Cardiac Arrest (MICA)
Perioperative Cardiac Risk Calculator22
Used as an indicator on ASC National Surgical Quality Improvement Program (NSQIP)
Surgical Risk Calculator11
Has been suggested as a useful adjunct in assessing ASA class II-IV patients and an
independent predictor of outcome and mortality23
Patient descriptors:
• Totally independent
• Partially dependent
• Totally dependent
POOR FUNCTIONAL STATUS
Has been suggested for use as an additional (downgrading) subset to the ASA PS criteria24
• <4 METs is of concern and indicates with

68
Part II Anesthesia
ASSESSMENT OF METS
Can you . . .

walk up a hill?
Walk on level ground at
4 mph (6.4 kph)?
Run a short distance?
Do heavy work around the
house such as scrubbing

heavy furniture?
Participate in moderate
recreational activities,
such as golf, bowling,
dancing, doubles tennis,
or throwing a baseball or
football?
Participate in strenuous
sports, such as swimming,
singles tennis, football,
basketball, or skiing?
Can you . . .
Take care of yourself?
Eat, dress, or use the toilet?
Walk indoors around the
house?
Walk one or two blocks on
level ground at 2-3 mph
(3.2-4.8 kph)?
Do light work around the
house, such as dusting or
washing dishes?
1 MET
4 METS
4 METS

Assessment of METs for poor functional status.

CONTINUUM
MONITORED ANESTHESIA CARE

Used for diagnostic or therapeutic procedures
Must include all aspects of anesthetic care
• Preanesthetic evaluation
• Intraprocedure care and monitoring
• Postanesthetic management
ASA standard monitors include ECG, noninvasive blood pressure (NIBP), pulse oximetry
(SpO2), end-tidal carbon dioxide (EtCO2) if greater than minimal sedation; temperature
available and used when indicated
GOALS
as a reduction in level of consciousness
in combinations with local, regional, or pharmacologic adjuncts

Amnesia

MEDICATION ROUTES
PO
IV
IM
Transcutaneous
Intranasal

69
Chapter 5 Basics of Anesthesia for the Aesthetic Surgery Patient
METHODS OF ADMINISTRATION
Intermittent IV bolus
Continuous infusion
Patient-controlled delivery
MEDICATIONS
Benzodiazepines (midazolam, diazepam, lorazepam)
Narcotics (fentanyl, alfentanil, remifentanil, sufentanil, meperidine, morphine)
Opiate agonist-antagonists (buprenorphine, butorphanol, nalbuphine)
Alpha-adrenergic agonists (dexmedetomidine, clonidine)
Sedative-hypnotics (propofol, ketamine, methohexital)
Common Drugs Used for Sedation During Monitored Anesthesia Care



Alfentanil
5-7 µg/kg or 0.2-0.5 µg/kg/min
Fentanyl
0.3-0.7 µg/kg or 0.01-0.02 µg/kg/min
Remifentanil
0.25-0.5 µg/kg or 0.025-0.1 µg/kg/min
Sufentanil
0.05-0.15 µg/kg or 0.1-0.5 µg/kg/h

Meperidine
0.2 mg/kg 10-20 mg
Morphine
0.02 mg/kg 1-2 mg

Buprenorphine
2-5 mg/kg
Butorphanol
2-7 mg/kg
Nalbuphine
0.07-0.1 mg/kg
Benzodiazepines
Diazepam
0.05-0.1 mg/kg

0.01-0.02 mg/kg
Midazolam
0.030-0.075 mg/kg

Dexmedetomidine
1 µg/kg or 0.2-0.7 mg/kg/min

Propofol
0.2-0.5 mg/kg or 10-75 µg/kg/min
Fospropofol
6.5 mg/kg

Methohexital
0.2-0.5 mg/kg

Ketamine
0.2-0.5 mg/kg
*Based on average weight of 70 kg. Doses may vary depending on age, gender, underlying health status, and
other concomitantly administered medications.

70
Part II Anesthesia
THE SEDATION CONTINUUM
The Sedation Continuum




Minimal
Normal response to verbal
stimulation; airway, ventilation,
cardiovascular function


preservation and maintenance of

1
Patent airway
Spontaneous respiration with
adequate oxygenation and
ventilation

Moderate
Purposeful response to verbal or
tactile stimulation; no airway
intervention; ventilation and
cardiovascular function adequate
Providers of moderate sedation need
ability to “rescue” should level
become deeper than intended.
Deep
Purposeful response with
repeated or painful stimulation;
possible need for airway
intervention; possible
inadequate ventilation;
cardiovascular function usually
maintained
When ability for purposeful response
is absent, sedation becomes
“general anesthesia” regardless of
need for airway instrumentation.
Transition to general
anesthesia
—
When ability for purposeful response
is absent, sedation becomes
“general anesthesia” regardless of
need for airway instrumentation.

analgesia. Available at
Continuum can be unpredictable, dynamic, and challenging to navigate.

Deeper levels may require airway or ventilatory support (Fig. 5-2).
Transition to general anesthesia level can include impairments, as described previously,
plus cardiovascular instability.
NOTE:
for conversion to general anesthesia.
Blow-by
oxygen devices
Oral airway
Natural
airway
Nasal cannula
Nasal airway
I-Gel

Endotracheal
tube
Tracheostomy
Supraglottic airway
devices
Cricothyroidotomy

Need breathing circuit/Anesthesia machine
Tools of the airway continuum.