The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

All patients are given the opportunity to review our preoperative and postoperative
album. Most will have already seen similar images on our website. It is not unusual
for patients to even base their decision to come in for a consultation on the before
and after images that are posted on the website. Without exception, we show pre-
operative and postoperative reduction and mastopexy images so the patient will have
a clear understanding of the location of the scars. After the video imaging session,
I review the projected result and discuss with the patient whether that result is real-
istic and how close we can approximate it. No promise or implied guarantee of a re-
sult is made. At this time the preoperative and postoperative album is reviewed with
the patient if needed. Usually it is the patient coordinator and the photographer who
show the album to the patient. We do encourage our patients to bring in photographs
to demonstrate what they like. For example, rhinoplasty patients bring in pictures
of noses that they like and those they do not; the same is true for breast augmenta-
tion patients. Reviewing these pictures with the patient provides me with further in-
sight into the patient’s aesthetic goals. For facial rejuvenation patients, we ask that
they bring in photographs taken 5, 10, and even 15 or 20 years earlier so that we
can better assess their features.
At the end of the consultation, the patient spends additional time with the patient
coordinator, who will discuss fees, scheduling, and the preoperative routine to be
expected. The coordinator again describes the procedure, risks, likely outcomes, and
expected recovery. If an overnight stay is planned, an album containing images of
our overnight suites is shown to the patient. Occasionally the patient will ask to see
the operating rooms and overnight suites. If there is an unoccupied overnight suite
and the recovery room is empty, we will accommodate this request. A video tour of
our facilities is also available on our website. Most patients will, in fact, schedule or
at least ask to have time reserved at that initial visit. We do encourage them to think
about things and offer them a return visit before they schedule or the option to sched-
ule by telephone.
Financial Responsibilities
Although the major source of patient dissatisfaction is a result that does not meet
expectations, financial misunderstandings and problems with fees are also common
sources of patient anger. Far too many patients who were initially happy with their
excellent results become dissatisfied and find fault with their results if unexpected
charges appear long after the operation has been completed. Financial surprises
should be avoided if at all possible.
My patient coordinator clearly delineates the patient’s financial responsibilities dur-
ing the initial visit. The patient is given an itemized quote that includes the surgeon’s
fee, facilities fee (including anesthesia), charges for an overnight stay, and any im-
24
Part I  Fundamentals

plantable devices. It is also made clear that if other procedures are added between
the time the patient has prepaid for the procedure and the actual operation, there
will be additional fees. The coordinator also explains that if any specimens are re-
moved (such as moles, breast tissues, or breast implants) and sent to the pathologist,
there will be a separate bill from the pathologist. We cannot give them a quotation
for the pathologist’s services; this must come from the pathology laboratory.
In our own surgicenter we do not charge the patient extra if a planned procedure
takes longer than anticipated. However, this may not be the case if the procedure is
scheduled elsewhere. Far too many patients have prepaid for a 4-hour procedure in
a hospital-based surgicenter only to later be billed for extra time when the proce-
dure runs long. Under these circumstances it should be made clear to the patient that
although the surgeon’s fee is prepaid in full, the surgicenter facility fees are only an es-
timate, and the actual amount will vary according to the length of time, materials,
and equipment used in the surgicenter. The patient may, in fact, receive a bill for the
balance several days, weeks, or even months after the procedure. If this policy has
been clearly explained, patients are less likely to be dismayed and upset.
Another cause of confusion about financial responsibilities concerns cases in which
a combination of aesthetic and reconstructive procedures is performed (for exam-
ple, nasal airway surgery and cosmetic rhinoplasty or second-stage breast recon-
struction combined with aesthetic facial surgery or body contouring), where a third
party is responsible for the reconstructive portion and the patient for the aesthetic
portion. It may sometimes be difficult, if not totally impossible, to exactly delineate
the patient’s financial responsibility for these procedures. We have a person in our
practice who meets with patients to discuss insurance coverage and such financial
problems. Despite all of these efforts, patients must understand that the total cost of
all of these combined procedures and their specific financial responsibility may not
be determined until long after the procedure. If patients are prepared for a possible fi-
nancial surprise, they are less likely to become angry and find fault with the result.
The patient coordinator and I also discuss financial responsibilities in case of com-
plications, hospitalization, or consultation with other physicians.
Operating on Colleagues, Friends, and Family
As a practice is built and a reputation is gained, colleagues, coworkers, friends, and
family will seek your services. This is a tremendous compliment to you as a physi-
cian and to your skills as a surgeon. Although this is flattering, the surgeon should
understand that it can also be a significant financial drain, because this group of pa-
tients expects discounted or even complimentary surgery. Not only do such discounts
and complimentary procedures generate little or no revenue to help meet overhead
and malpractice costs, but also the time spent on such discounted procedures could
25
Chapter 1  The Patient

To My Dear Friends and Family:
During the many years that I have been in the practice of plastic surgery, I have extended full courtesy
fees to close friends and doctors as a matter of principle. Over the years, I have been fortunate to
gain more friends and to enjoy the professional confidence of doctors’ families, to the extent that a
significant part of my time is now consumed in performing such surgery.
Sadly, with the increasing costs of overhead in the practice of surgery today, not to mention the
excessive and growing premium for malpractice insurance, it is no longer possible for me to fully
extend such courtesies. Needless to say, it is embarrassing and distasteful for me to charge my usual
fees to close friends and colleagues. Therefore, I am pleased to be able to extend a modest courtesy
discount. Since all I have to offer is the expertise and skill I have developed as well as my time, I hope
you will understand.
Sincerely,
______________________________________, MD
(Physician Name)
26
Part I  Fundamentals

have been spent on patients who produce full revenue. Despite this, most surgeons
have a sense of obligation to discount services for this group or to selectively pro-
vide them on a complimentary basis. Your practice should have a clear policy for
such discounts and free services.
I routinely discount my surgical fee for fellow physicians and their families, nurses,
and other health care professionals. The amount of the discount will vary, depend-
ing on the closeness of my professional relationship with the individual in question.
The same is true in dealing with friends and family. Some colleagues and family come
in for a consultation expecting to pay full fees, yet others come in expecting free sur-
gery. It is somewhat embarrassing, if not difficult, to discuss this face-to-face with
colleagues, friends, and family. Years ago, Dr. Tom Rees shared with me a note that
he had colleagues, friends, and family read explaining his policy for extending pro-
fessional courtesy. I found the letter most useful, and to this day I use the modified
version shown on p. 26.
For our office staff, the procedures are usually provided free of charge on an indi-
vidual basis, reflecting the person’s length of service. Each practice should have a
clearly delineated policy on employee discounts. It is wise to avoid providing dis-
counted or free operations to patients who hold out the promise of future referrals.
These usually do not materialize once the operation has been completed and may
well raise ethical issues.
Patient Documentation
I make every effort to dictate the office notes as soon as I have concluded the initial
consultation. Although I take additional notes while I am talking to the patient,
I make every effort to maintain eye contact with my patient rather than spend the
entire time scribbling notes or being preoccupied with the chart. If at all possible,
I limit interruptions to those that are absolutely necessary, such as emergencies. I put
my cell phone on vibrate mode and ask all our nurses to do the same. It is not con-
ducive to a thorough initial evaluation to have constant interruptions, and I will not
leave a patient while I answer a phone call unless it truly is an emergency. It is im-
portant to sit down with the patient and focus your attention on him or her. You
want to leave the impression that you have plenty of time to talk. Therefore I do not
look at my watch or time myself when I am with a patient. I like to have a nurse or
assistant present in the room at all times, and I feel it is mandatory to have a female
nurse or assistant with me when I examine a female patient for breast augmentation or
body contouring, not only to put the patient at ease but also for my own protection.
27
Chapter 1  The Patient

Once the procedure is scheduled, the patient is given instructions in preparation for
the operation. These include prescriptions for skin preparation before chemical peels
and laser resurfacing and lists of medications and supplements to avoid taking pre-
operatively to minimize postoperative bleeding and bruising. We encourage patients
to take vitamin C. Patients are scheduled for a preoperative visit 1 or 2 weeks before
the operation. Patients who will undergo general anesthesia need to have a physical
examination, blood test, and clearance from their primary physician before surgery
is scheduled. During the preoperative visit, the patient will meet the anesthesiolo-
gist, who performs another preoperative evaluation. The patient also meets again
with the coordinator to review and sign the informed consent form and to have any
further questions answered. If preoperative photographs have not already been taken,
they are taken on this occasion. During this preoperative visit, the patient talks with
our financial counselor, who goes over the fees and collects prepayment for the full
amount of the procedure, including the surgeon’s fee, facility fee, and fees for the
overnight stay and materials. If there is any question that additional payments may
be necessary after the operation, such as a pathologist’s bill, this is clearly pointed
out to the patient.
The patient will be evaluating the level of service before the procedure, because it
serves as an indication of how well the practice will respond to her or his needs and
concerns after the operation. If the patient feels that the staff were not attentive
enough, slow to respond, and evasive before the operation, he or she will be con-
cerned this may well be what they should expect after the operation. Unfavorable
preoperative experience may justifiably lead the patient to cancel the procedure.
On the day of the operation, I review the patient’s record before I meet with the pa-
tient to discuss the planned procedures. I take my own finger or a cotton swab and go
over every proposed incision. I then mark the patient. If he or she is accompanied
by a family member and allows that person to remain in the room, I ask the patient
and the family member if they have any questions and inquire whether the patient
remembers the risks, possible complications, and length of recovery. It’s not unusual
for patients at the last minute in the preoperative area to ask whether we could take
off skin lesions, add an extra area for liposuction, or even add a completely new pro-
cedure. For that reason, and to avoid any postoperative misunderstandings, I con-
firm with the patient that we have neither left out any procedures nor added any-
thing. I explain that if the patient wishes to add extra procedures and operative time
is available, there will be an extra charge, and the patient will be billed for it. If he
or she requests excision of a skin lesion or two or a small additional area for lipo-
suction or fat injection, I often as a courtesy include that without extra charge. How-
ever, I mention that the pathologist will send a bill for examining the excised lesions.
We then proceed to the operating room. There is a special waiting area for family
members if they choose to wait; if not, I ask for a phone number so that I can per-
sonally call when the operation is finished and the patient is in the recovery room.
28
Part I  Fundamentals

29
Chapter 1  The Patient
I also inform the patient and the family that if the operation is completed in less time
than I had allotted, it does not mean that I rushed through it, and conversely, if it
takes longer, it does not mean that either the patient or I encountered a problem.
After the operation, patients either go home with a responsible adult or stay in our
recovery suites. If the patient goes home, I call that evening to inquire whether the
patient is comfortable and whether there are any questions. If I am greeted by the
answering machine, I leave a message that I called to make sure that the patient is
home and comfortable. I ask the patient to call if there are questions or problems. If
the patient remains in our suites, either I visit or someone on the team visits the pa-
tient. Two days postoperatively, all patients receive a follow-up phone call from our
surgicenter asking them how they are doing and inquiring about their experience
with the center.
Postoperative Visits
Follow-up visits are as important as the initial consultation. Most patients are con-
cerned that the red carpet and VIP treatment will be rolled out preoperatively so that
they will sign up for an operation, and that their postoperative care will be less at-
tentive, relegated to the nurses. It is important for them to have a favorable experi-
ence in their postoperative visits. We make every effort to usher postoperative facial
patients straight into a private waiting room or examination room to minimize their
time in our public places, such as the general waiting room. I go in and sit and greet
the patient, ask how he or she has been, and how the recovery is progressing. I ex-
plain that the nurses will clean the wounds, remove sutures, and change tapes, and
that our aesthetician will take care of the areas that may have been resurfaced. I in-
quire whether the patient needs more medication and explain that I will return for
a more thorough examination once the nurses have removed sutures and cleaned the
wounds. As with preoperative examinations, a nurse is present during the postopera-
tive examination of a breast augmentation or body-contouring patient, to put the
patient at ease and for my protection. It is important to close the door, sit down,
make eye contact, and talk to the patient. I do not flip through the chart, read through
it, or write in it. Leaving the door open, standing, reading, and writing in the chart
leaves the patient with the impression that you breezed in for a few seconds, wrote
in the chart, and left without examining him or her. When I return to see the patient,
I examine every suture line and express my own opinion about the early results and
stage of recovery. I then answer questions. If the patient is at the stage in a facial pro-
cedure where camouflage makeup can be applied, our aesthetician applies makeup,
and I see the patient after this application. For patients who have undergone breast
augmentation or body-contouring procedures and have recovered sufficiently, I go
back in and see them when they are fully dressed to make certain they are happy
with their appearance in their clothes.

30
Part I  Fundamentals
Occasionally, despite my best efforts, a patient complains to the nurse that I have
not been attentive enough or spent enough time after the operation. This is an im-
portant line of communication between the patient and me, and I listen to the nurse
and make every effort to resolve the situation. Very often a patient who is concerned
about the result may discuss it first with the nurse or patient coordinator for fear of
offending the surgeon: “I don’t want to hurt his feelings.” These communications are
important and are dealt with in a kind and understanding fashion. I explain to my
patients that I want them to be comfortable and open with me and discuss their con-
cerns. My feelings will not be hurt if I am told that a patient is less than satisfied
with the result. I tell patients that my feelings would be hurt if they felt that they
couldn’t communicate with me and chose to go elsewhere.
I rely heavily on the impressions of our nurse and patient coordinator. It is crucially
important to surround yourself with good people and to listen to them. I have turned
down patients based on recommendations from these professionals and have been
able to diffuse potentially unpleasant situations based on their input.
Management of Complications and Problems
No one wants complications. I take all complications personally and replay the en-
tire procedure in my mind, wondering how and why they occurred. Despite my ex-
planations to my patients that complications do occur, even in the best of hands, it
is difficult for me to accept that my patient has developed a complication. Regard-
less of these personal feelings and the sense of disappointment, it is necessary to deal
with these problems, and more important with the patient’s anxieties, concerns, and
possible resentment. Most patients feel that something went wrong, something was
not done properly—otherwise they would have sailed through the operation as
smoothly as their friend did, on whom your partner, your colleague, or even you op-
erated. I usually explain the nature of the complication to the patient. If I have any
idea why it happened, I explain that and outline our plan to take care of it. I usually
tell the patient, “I am sorry this happened; it isn’t anything you did; it isn’t anything
I did. Despite our best efforts, we have a problem. It is not the first time I have seen
it, and we know how to take care of it.” I then explain exactly what has to be done
and how long it will take.
In cases of postoperative hematoma in a face lift, I reoperate usually with the patient
under local anesthesia, but I use general anesthesia if needed, and I explain to the
patient that this will take care of the problem. It will not affect the results, but it will
leave more bruising than expected, and the affected side of the face (if unilateral) will
lag behind the other side in recovery.

31
Chapter 1  The Patient
Devastating complications, such as skin slough following a face lift, exposed breast
implants, and nipple-areola loss require a more prolonged plan for recovery. Fortu-
nately, these complications are extremely rare and are often associated with predis-
posing factors such as smoking. These patients require a great deal of attention. We
naturally have an instinct to avoid unpleasant situations and circumstances, but these
are times when our patients need us to be there for them. These patients must be
seen on an almost daily basis. If a strong bond already exists between the patient
and the surgeon before the complication develops, this will have a positive influence
on the outcome. However, if the surgeon’s relationship with the patient was already
less than ideal, these complications will serve to further undermine the relationship
and result in an unhappy situation for both the patient and the physician. This is
when people become angry and seek legal advice, especially if the complication adds
an additional financial burden to the patient. It may be tempting to abandon such a
patient and to blame him or her for the complication, but it would be unwise. If you
absolutely cannot continue with the patient, have a partner or trusted colleague as-
sume the care at your expense.
When I have been able to explain the reason for the complication, I have found that
patients have not only been surprised by this explanation but also have appreciated
my candor. This communication has further improved our physician-patient rela-
tionship and the patient’s confidence in me. To do anything less will confirm the im-
pression that “the medical profession covers up errors.”
There is no question that by offering to continue working with the patient to cor-
rect a complication, you send a reassuring message. I comfort patients by telling them
that I have seen these complications and know how to take care of them, and I will
not stop until we are both happy with the outcome.
The Dissatisfied Patient
Dissatisfied patients come in two varieties—your own and those of your colleagues.
Despite our best efforts in preparing and evaluating our own patients, screening
them, and discussing risks and complications and realistic expectations, we still have
patients who are not satisfied with their outcomes. Even though these patients may
have an average or good result, they are just not happy. This dissatisfaction may be
the result of inadequate or even poor communication between the surgeon and pa-
tient or patient expectations that were not met. Such patients are extremely difficult
to deal with and may never be satisfied. They will exhaust you and test your patience
and that of everyone in your office. They also have access to the Internet and the nu-
merous websites that grade or evaluate doctors. They have the freedom to say any-
thing they want about you, your staff, and their result. There are no checks and bal-
ances, and it is difficult, if not impossible, to respond to these allegations or comments

once they have been posted. Although most of the time these comments are posted
anonymously, most surgeons have a good idea who the patient may be, but are bound
by privacy rules from commenting. The best way to deal with these patients is not
to operate on them, and with maturity and experience, one should be able to iden-
tify them.
One of the most challenging problems in clinical practice is dealing with a colleague’s
dissatisfied patient. If the patient has an identifiable problem that is correctable and
the colleague has referred the patient to you for that purpose, this represents a rela-
tively straightforward situation, since all three parties are involved. However, most
of the time the patient is self-referred and would prefer that you not contact the orig-
inal surgeon.
I evaluate these patients in the same manner that I evaluate any patient. I then ex-
plain to them that the problem is correctable and how I would do it. I also explain
to them that I am flattered and honored that they have chosen to consult with me,
and I take that as an indication of their confidence in me as a surgeon. If the problem
is a recognized and not uncommon complication or sequela of the procedure, such
as implant malposition or even lid retraction, I explain that I have seen similar com-
plications in my own patients. If I am familiar with the other surgeon and believe
that he or she could just as easily correct the problem, I encourage the patient to re-
turn to the original surgeon, who may do the revision or correction at no charge or
at a discount. I explain that I would not charge my own patients for a similar revi-
sion. If the patient does not wish to return to the other surgeon, he or she will usu-
ally respond, “He doesn’t think there is a problem,” “I can’t communicate with him,”
or “He says there is nothing else he can do.” I then tell the individual that I would
have to charge my full fee for the revision and that it may take more than one pro-
cedure. I do ask all patients to have copies of their records forwarded to me, and
I ask their permission to communicate with the other surgeon. If the patient does
not grant permission, then it would be a breach of his or her privacy to obtain the
files, complicating the situation and putting me in an awkward position with my col-
leagues. These are extremely delicate situations, often involving litigation. It is para-
mount that the patient’s best interests be considered first and that everything possi-
ble be done to correct the problem, even at the risk of affecting a collegial relationship.
It is important to emphasize that complications do not necessarily indicate a devia-
tion from the standard of care and to refrain from inflammatory comments such as
“This is the worst I have ever seen,” or “Who did this to you?”
We are physicians and well-trained surgeons, highly skilled in the procedures we per-
form. Communication skills, however, were never part of our medical school or res-
idency curriculum; we were not taught bedside manner. Yet communication and bed-
side manner are as important as our skills in the operating room. Our patients expect
more than good results; they like to be listened to and cared for. They want a sur-
32
Part I  Fundamentals

geon who is responsive and makes them feel valued and respected. Good results and
satisfied patients will do far more than any advertising program to promote and grow
a practice.
Concluding Thoughts
The practice of cosmetic medicine and aesthetic surgery is satisfying and rewarding
for the surgeon. I am excited that it continues to evolve, and it is imperative that we
adapt to these changes so that we can provide the best for our patients. To our pa-
tients, aesthetic treatments are not a necessity but the fulfillment of a personal goal;
therefore their experience must be satisfying and rewarding as well. This is a part-
nership that at its best works smoothly and effectively for all involved.
In this chapter I have shared my approach, but in truth it is our approach—my part-
ners and staff are all intimately involved in making the experience for our patients a
positive one. Time spent with the patient by the surgeon and the staff is time well in-
vested. This is especially true today, when our patients have access to all kinds of in-
formation on the Internet. Our goal is to establish a long-term and trusting relation -
ship with our patients. We nurture an environment in which our patients can feel
that they are among friends when they visit us in our office. Patient satisfaction is
the best form of marketing available to us. Such patients are our best source of re-
ferrals and will themselves return if the initial experience was one worth repeating.
Clinical Caveats
 A well-informed patient is a happy patient.
 A well-motivated patient is a happy patient.
 Eliminate postoperative financial surprises, or at least warn the patient about them.
 Listen to your patients.
 Learn to say “no.”
 Spend time with your patients.
 Respect the patient’s privacy.
 First impressions last.
 Your website is the face of your practice to the world.
 The Internet can be a friend or foe.
33
Chapter 1  The Patient

Suggested Readings
Bennett AE, ed. Communication Between Doctors and Patients. London: Oxford University
Press, 1976.
Bennett G. Patients and Their Doctors: The Journey Through Medical Care. London: Bail-
lière-Tindall, 1979.
Bird B. Talking With Patients, 2nd ed. Philadelphia: JB Lippincott, 1973.
Goldwyn RM. The consultant and the unfavorable result. In Goldwyn RM, ed. The Unfa-
vorable Result in Plastic Surgery: Avoidance and Treatment. Boston: Little Brown, 1972.
Goldwyn RM. The dissatisfied patient. In Goldwyn RM, ed. The Unfavorable Result in Plas-
tic Surgery: Avoidance and Treatment, 2nd ed. Boston: Little Brown, 1984.
Goldwyn RM. The Patient and the Plastic Surgeon. Boston: Little Brown, 1981.
Kuechel MC. Aesthetic Medicine: Growing Your Practice. St Louis: Quality Medical Pub-
lishing, 2009.
Lewis W. The Beauty Battle: The Insider’s Guide to Wrinkle Rescue and Cosmetic Perfection
From Head to Toe. Berkeley, CA: Laurel Glen Publishing, 2003.
Lewis W. Plastic Makes Perfect. London: Orion Books, 2007.
34
Part I  Fundamentals

Patient Safety in Aesthetic Surgery

V. LEROY YOUNG
CHAPTER 2

N
ew concepts and advances in technology accumulate so quickly these days that
much of what plastic surgeons now need to know was probably not covered
in their days of medical school or residency. This applies particularly to patient safety,
which is becoming a medical discipline all to itself. Evidence is collected from mul-
tiple specialties—including anesthesiology, cardiology, pulmonology, endocrinology,
psychology, hematology, and infectious disease—and guidelines or recommendations
are developed based on that evidence.
If we plastic surgeons cannot keep up with reading our own specialty journals, when
are we supposed to delve into those from other disciplines? Yet that is what we must
do to keep our patients safe during what are typically elective procedures. Failure to
protect our patients from medical harm may lead to consequences ranging from rel-
atively minor postoperative vomiting or a small infection to a deep venous throm-
bosis (DVT) that produces lasting disability to the worst outcome of all—death.
The movement to improve patient safety began in 1999, when the Institute of Med-
icine issued its report, To Err Is Human: Building a Safer Health System. The re-
port, which focused on the types and frequency of errors associated with the deliv-
ery of health care, defined a medical error as “the failure to complete a planned action
as intended or the use of a wrong plan to achieve an aim.” An adverse event was de-
scribed as “an injury caused by medical management rather than by the underlying
disease or condition of the patient.” The public, medical professionals, and govern-
ment agencies were shocked by some of the IOM’s findings, including the fact that
more than half of surgical adverse events are preventable.
Some preventable surgical errors arise from policies and others from personnel who
deliver the care. Whatever the root cause, the surgeon is ultimately responsible. Con-
sider the example of a patient undergoing an abdominoplasty who does not receive
chemoprophylaxis to prevent a blood clot and dies of a pulmonary embolism (PE)
several days after she is sent home. If the surgeon had followed regularly updated ex-
pert recommendations for the use of chemoprophylaxis, this PE might have been
averted. Surgeons who claim ignorance of a safety practice that would have prevented
a complication are not in a defensible position, nor are those who choose to ignore
evidence-based recommendations because they think they know better.
After the IOM report, the professional societies of physicians, nurses, technologists,
and other groups began to disseminate patient safety information to their members.
Federal agencies and associated groups also make important contributions to the
patient safety movement, and their websites contain valuable resources. Some of the
partners for improving the quality and safety of health care include the following:
 The Agency for Healthcare Research and Quality (AHRQ), part of the U.S.
Department of Health and Human Services that takes the lead in evaluating
patient safety and health care outcomes ()
 The Centers for Disease Control and Prevention (CDC) ()
36
Part I  Fundamentals

37
Chapter 2  Patient Safety in Aesthetic Surgery
 The Centers for Medicare and Medicaid Services (CMS) ()
 The Joint Commission ()
 The American Association for Accreditation of Ambulatory Surgery Facilities
(AAAASF) ()
 The National Surgical Quality Improvement Program of the American Col-
lege of Surgeons ()
 The Institute for Healthcare Improvement (IHI) ()
 The World Health Organization (WHO) ()
 The National Patient Safety Foundation (NPSF) ()
Some of these groups have developed and continually revise evidence-based measures
that help streamline and standardize processes, decrease the variability of delivering
health care, and improve patient outcomes. More and more, those organizations re-
sponsible for the accreditation of hospitals as well as outpatient and office-based
surgery centers follow the evidence-based safety recommendations when measuring
facility compliance.
One example of an approach to guideline development is the Surgical Care Im-
provement Project (SCIP), which was formed as a collaborative effort between CMS
and the Joint Commission in 2003 with the goal of reducing preventable surgical
complications that have a high frequency and cost. The work of groups like this
makes issues such as prevention of surgical site infections and venous thromboem-
bolism (VTE) important measures of quality care, facility performance, and patient
outcomes in the surgical setting.
Improving Patient Safety in Plastic Surgery
The amount of information available to make our patients safer during encounters
with health care is almost overwhelming. Although plastic surgeons are responsible
for knowing at least the most basic recommendations for keeping patients safe dur-
ing surgery, these recommendations are continually evolving and changing as evi-
dence accumulates about safety issues. For example, at least some of the informa-
tion in this chapter will likely be outdated by the time this volume is published.
However, we are still responsible for knowing current safety standards not only for
the facilities where we work but also for our states and the national credentialing
organizations. We are helped in this by the national plastic surgery professional as-
sociations—the American Society for Aesthetic Plastic Surgery (ASAPS) and the
American Society of Plastic Surgeons (ASPS). Recently they have developed require-
ments for earning safety-related CME credits to retain board certification, which
should have the effect of forcing plastic surgeons to keep current with changes. Some
of the most important patient safety concerns related to plastic surgery are briefly
described in this chapter.

Prevention of Surgical Site Infections
Infection prevention efforts must be directed in multiple directions. Although surgi-
cal site infections (SSI) are a serious problem, so are infections spread by simple con-
tact with a health care facility. Health care–associated infections have become such
a problem that in 2008 Medicare began refusing to pay for many hospital-acquired
infections. Relatively simple measures can make a real impact, such as instituting
contact precautions, disinfecting the patient care environment and equipment, and
complying with hand hygiene guidelines established by the CDC or WHO.
Special attention must be directed to the prevention of infections caused by multi -
drug-resistant organisms (MDRO), including methicillin-resistant Staphylococcus
aureus (MRSA), Clostridium difficile (CDI), vancomycin-resistant enterococci (VRE),
and multidrug-resistant gram-negative bacteria. Although MRSA is perhaps the best-
known problem, other organisms pose greater threats, especially resistant gram-
negative bacteria and C. difficile, which recently overtook MRSA as the leading cause
of hospital-associated infections. C. difficile infections occur primarily in individu-
als taking antibiotics. Because bringing a new drug to market takes 8 to 10 years,
the introduction of new antibiotics will not come soon, and the pipeline is empty.
Practices and processes for reducing the risk of health care–associated infections, in-
cluding those related to surgical procedures, must address a spectrum of preventive
actions, because a variety of factors are known to contribute to SSIs. Some of the
risk factors for infection most likely to be encountered by plastic surgeons are shown
in the box.
38
Part I  Fundamentals
Risk Factors for Infection
Patient-Related Factors
 Diabetes mellitus
 Obesity
 Recent or current smoking
 Poor nutritional status
 Older age
 Previous site radiation
 Postoperative anemia
 Immunosuppression
Treatment-Related Factors
 Abdominal or emergency surgery
 Operation of 2 hours or more
 Inappropriate antimicrobial prophylaxis
 Hypothermia in the perioperative period
 Inadequate surgical scrub or skin antisepsis
 Preoperative shaving
 Poor operating room ventilation
Surgical Technique–Related Factors
 Poor hemostasis
 Failure to obliterate dead space
 Tissue trauma

Antibiotic Use
The overuse of antibiotics is largely responsible for the problem of resistant organ-
isms. It is the responsibility of all physicians to reduce the use of antibiotics in con-
texts in which they are of dubious value. In fact, many experts believe that antibi-
otics are unnecessary for clean surgeries without implants, which encompasses most
procedures that plastic surgeons perform, but this issue is still being debated. All
plastic surgeons should follow the evidence-based guidelines for administering an-
tibiotics in the surgical setting. For many, this will require changing long-standing
behaviors, which is never easy. However, the organizations that evaluate the clinical
evidence and establish recommendations for reducing the rate of SSIs all agree on
antibiotic delivery and timing.
USE THE CORRECT ANTIBIOTIC
Surgical patients should receive antimicrobials that
target the pathogens most likely to contaminate the wound. The most commonly
recommended antibiotic is a first-generation cephalosporin given intravenously in a
dose of 1 g (2 g if the patient‘s weight is more than 73 kg [160 pounds]). Another
dose should be given after 3 to 5 hours if the wound has not yet been closed or the pa-
tient has lost a large amount of blood. The drugs of choice for patients with a beta-
lactam allergy are clindamycin (600 to 900 mg intravenously, repeated at 6 to 12 hours)
or vancomycin (1 to 1.5 g intravenously, repeated at 6 to 12 hours).
DELIVER THE ANTIBIOTIC AT THE CORRECT TIME
A full dose of cefazolin or a sim-
ilar antibiotic should be delivered no less than 30 minutes and no longer than 60
minutes before an incision is made. Clinical trials have shown that drug delivery out-
side this window (too early, at the time of incision, or after the inci sion) is much less ef-
fective in reducing the rate of SSIs than using the appropriate tim ing. If a tourniquet
will be used, the antibiotic must be completely infused before tourni quet application.
Vancomycin and clindamycin must be administered slowly, over the course of 1 hour;
thus its administration should begin approximately 120 minutes before incision.
ADMINISTER THE ANTIBIOTIC FOR THE CORRECT DURATION
Antibiotics should
be administered for the shortest effective period possible; a single preoperative dose
is usually all that is needed. Most studies have determined that administration of an
antibiotic is unnecessary after wound closure. Unless there is a specific reason, an-
tibiotics should be discontinued within 24 hours after the surgical incision. The ex-
ception is in cardiac surgery, after which antibiotics may be given for up to 48 hours.
Some plastic surgeons typically overuse antibiotics and discharge patients with a 7-
to 10-day prescription for antibiotics. This has not been found effective for reducing
the risk of SSI; it does, however, contribute to drug resistance. Furthermore, there is
no evidence to suggest that antibiotics should be given as long as drains are in place.
In addition to the guidelines for using the right drug at the right time, some other
measures for reducing the risk of SSIs relate to proper hair removal, glucose moni-
toring, hypothermia prevention, and smoking cessation.
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Chapter 2  Patient Safety in Aesthetic Surgery

Hair Removal
Hair removal is unnecessary for most surgeries. If it is required, all infection pre-
vention guidelines agree that shaving should be avoided, because it significantly in-
creases the risk of SSI, with some studies reporting almost a tenfold increase. A ra-
zor makes microscopic cuts in the skin that invite bacterial growth. Many experts
recommend that all razors be removed from surgical areas. When necessary, hair
should be removed with electric clippers or a depilatory immediately before surgery.
Patients should be instructed not to shave during the 2 weeks before a surgery.
Glucose Control
Plastic surgeons do encounter patients with type 1 and type 2 diabetes in their prac-
tices, and they should therefore understand the importance of preventing hypo-
glycemia and hyperglycemia in the perioperative period. Maintaining tight glycemic
control may shorten recovery time and the time spent in the postanesthesia care unit
(PACU). More importantly, for patients with and without diabetes, hyperglycemia be-
fore, during, and after surgery is significantly associated with an increased rate of SSIs
and wound healing complications, more than a fourfold increase in some studies.
As part of the process for obtaining preoperative medical clearance for surgery, pa-
tients with diabetes should have their hemoglobin A1c level measured. The HbA1c
test indicates glucose status for the previous 3 months and, according to the Amer-
ican Diabetes Association, the level should be less than 7%. Recent studies, however,
suggest a level below 8% has some advantages, but as yet there is no consensus suf-
ficient to change the recommendations. A higher-value HbA1c suggests a need to ad-
just medications before surgery with the aim of achieving tighter glucose control.
The physician who manages the patient’s diabetes should be consulted about peri-
operative management, and, if warranted, should devise a plan to adjust the timing
and dosing of antihyperglycemic medication—insulin or oral—starting the day be-
fore surgery.
Preoperative staff must be aware when diabetic patients are expected, especially since
they will have been NPO for several hours. These patients should be scheduled for
the first surgical slot of the day. As soon as a patient with diabetes arrives at the sur-
gical facility, the blood glucose level should be measured and insulin administered if
the glucose level is 180 mg/dl or higher. Patients with insulin pumps may be en-
couraged to manage their pumps when conscious. Intraoperative hyperglycemia is
common and blood glucose must be monitored throughout the perioperative period
and treated with insulin. The common recommendation is for type 1 diabetics to be
given insulin if blood glucose exceeds 140 mg/dl. Patients with type 2 diabetes can
tolerate higher glucose levels, up to 200 mg/dl.
40
Part I  Fundamentals

Plastic surgery can be safely performed in patients with diabetes, but surgeons are
advised to seek guidance from physicians who know much more about diabetes man-
agement in the perioperative period.
Hypothermia Prevention
Since at least the mid-1990s, unplanned perioperative hypothermia has been viewed
as a major risk factor for surgical site infections and other wound healing compli-
cations in patients undergoing colorectal surgery. In 2010, groups that develop and
apply standards for improving patient safety and tracking outcomes (including SCIP,
the Joint Commission, CMS, and IHI) expanded the recommendation for prevent-
ing hypothermia to include all surgical patients receiving general or neuraxial anes-
thesia for a procedure lasting 1 hour or longer. Most guidelines suggest that nor-
mothermia be maintained with active warming methods, which consist of forced-air
warming systems, circulating warm water garments, and polymer-based conductive
fabric blankets. Regardless of the method used, its effectiveness cannot be measured
unless the core temperature is being monitored, preferably from the pulmonary artery,
distal esophagus, tympanic membrane, or nasopharynx. The skin, axilla, and mouth
are the least accurate measurement sites.
Hypothermia, which is defined as a core body temperature lower than 36° C (96.8° F),
has serious consequences, including a threefold increase in wound infections, de-
layed wound healing, a higher risk for bleeding and transfusion need, cardiac events,
altered drug metabolism, more difficulty obtaining hemostasis, coagulopathy disor-
ders, and longer times in the PACU. Some studies also show that hypothermia con-
tributes to postoperative nausea and vomiting. Surgical patients who are not actively
warmed during the perioperative period almost always become hypothermic. The
three stages of hypothermia development help explain why:
1. The body starts redistributing heat from the core to the periphery during the
first hour of general or regional anesthesia. After 1 hour the patient is hypo -
thermic.
2. The linear core temperature steadily declines.
3. The core temperature reaches a plateau between hours 2 and 4 of surgery
with general anesthesia. This plateau does not develop with regional anes-
thesia and the core temperature continues to decline.
When hypothermia is allowed to develop, returning to core normothermia may re-
quire 4 or more hours. Furthermore, waiting until a patient’s temperature begins to
fall before initiating active warming measures is too late.
Unless preventive measures are instituted, several plastic surgery procedures place
patients at high risk for developing hypothermia and all its harmful effects, espe-
cially procedures that require exposure of large body surface areas (for example, li-
posuction, abdominoplasty, and lower body lift). Postanesthetic shivering is com-
mon in hypothermic patients and carries its own consequences. Shivering seems to
41
Chapter 2  Patient Safety in Aesthetic Surgery

magnify postoperative pain and may play a role in postoperative nausea and vom-
iting. Bruising and/or hematoma may occur more often with shivering, which could
compromise the results of facial procedures such as face lift or blepharoplasty. Hy-
pothermia definitely complicates perfusion of any type of flap, and the addition of
shivering is likely to impair blood supply even more. For these reasons, postopera-
tive shivering should be treated aggressively with an active preventive measure.
Multiple techniques are available for preventing hypothermia in the perioperative
period. All clinical trials agree that active warming is necessary (using forced-air, cir-
culating water, or conductive fabric blankets). Moreover, prospective, randomized,
and controlled studies indicate that the key to maintaining normothermia is pre-
warming with an active method for about 1 hour before surgery begins. Surgeons
should use the evidence-based interventions that are proven to be most protective of
patients by extending active warming during and after surgery. Passive warming
methods may be used to supplement the active ones, especially when procedures
place patients at increased risk, as long as one understands that none of these can
add much heat content to a patient. Frequently used passive techniques include in-
sulation of patients with standard or even heated blankets or drapes, raising the am-
bient temperature of the operating room, and warming irrigation, intravenous, or
infiltration fluids. Warmed fluids should be delivered at core temperature (37° C
[98.6° F]). A temperature higher than 43° C (109.4° F) carries a risk of burns.
42
Part I  Fundamentals
Recommended Practices for Hypothermia Prevention During
General or Neuraxial Anesthesia
1. Actively prewarm patients in the preoperative area for approximately 1 hour with
forced-air heating, a resistive-heating blanket, or circulating water garment.
2. Keep the ambient temperature of the operating room at approximately 22.8° C
(73° F).
3. Monitor the core temperature throughout general and neuraxial anesthesia, and re-
spond to temperature drops with active warming methods.
4. Cover as much body surface area as possible with blankets or drapes to reduce radi-
ant and convective heat loss through the skin.
5. Actively warm patients intraoperatively with forced-air or other technology to prevent
heat loss and add heat content. Rearrange the cover or covers if patients are reposi-
tioned so as much surface area is warmed.
6. Minimize repositioning time as much as possible so an active warming method can be
quickly continued.
7. Warm intravenous fluids and/or infiltration fluids, especially if large volumes are used,
so that they are 37° C (98.6° F) when they enter the body. This may require a warm-
ing setting of 40° C to 42° C (104° F to 107.6° F), depending on the length and diam-
eter of the tubing/cannula. For large incisions, consider warming the irrigation fluids.
8. Aggressively treat postanesthetic shivering with a forced-air heater or resistive-heating
blanket and consider pharmacologic intervention.

Achieving the goal of always maintaining normothermia will require a change in
habits. Fortunately, keeping patients warm is relatively simple and can easily be in-
corporated into the perioperative routine.
Smoking Cessation
Today most plastic surgeons ask patients who smoke or use tobacco in another form
to stop before surgery. The majority of prospective studies conducted on this issue
indicate that smokers have a statistically significant increased risk of surgical com-
plications, especially infection and delayed wound healing, than nonsmokers and
former smokers. This may be a result of the fact that multiple agents contained in
smoke decrease the amount of oxygen available to tissues. Nicotine, for example, is
vasoactive and induces endothelial injury, inhibits capillary flow, and decreases ep-
ithelialization. Carbon monoxide causes tissue hypoxia. Some debate exists about
whether heavy smoking is more risky than light smoking, and whether a former
smoker has a complication rate more like a current smoker or one who has never
smoked. However, just about everyone agrees that procedures involving flaps or ex-
tensive undermining are much riskier for smokers. Aesthetic results are also more
likely to be compromised.
Most studies that compare complications in smokers and nonsmokers do not verify
smoking status, which is unfortunate, because patient self-reporting is unreliable.
Patients either say they are not smoking when they are, or they underreport the
amount they smoke. The safest way to address this problem is for surgeons to test
for recent smoking before and after surgery. The most common and inexpensive
method for verifying smoking status is to measure the levels of cotinine in the urine,
saliva, or blood. Cotinine persists in urine for up to 4 days and test results are avail-
able within about 10 minutes, at a cost of approximately $10 per test.
Plastic surgeons have every right to refuse to perform surgery on patients who smoke,
especially since not smoking makes surgery safer. A good approach to make certain
someone is not smoking is to test for cotinine a few weeks before surgery and again
on the morning of surgery. If a test is positive, the procedure should be delayed. An-
other test a few weeks after surgery proves whether someone has smoked recently.
If that test is positive, the documented result might prove valuable if postoperative
complications develop. The amount of time a smoker should abstain from smoking
is currently unclear, but the CDC recommends 4 weeks before surgery; 2 months
would be even better. By 30 days after surgery, fibroblast proliferation, collagen pro-
duction and deposition, and reepithelialization have reached their peak. Postopera-
tive abstinence is especially important if a smoker had little or no warning before
surgery, as is often the case with procedures such as breast reconstruction, traumatic
injury repair, or cancer resection.
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Chapter 2  Patient Safety in Aesthetic Surgery

Prevention of Venous Thromboembolism
In 2008, the Surgeon General’s office issued a report identifying deep venous throm-
bosis and pulmonary embolism as among our most serious public health problems
that demand attention, concerted action, and research to reduce their prevalence.
According to the Surgeon General, approximately 20% of people with a PE die al-
most immediately, and a fatal PE is often the first symptom of DVT. The period of
highest risk for a fatal PE in surgical patients is within 3 to 7 postoperative days, a
point at which many surgical patients are at home, but the risk for postoperative
VTE remains elevated for 3 months.
VTEs that occur in association with health care—and especially surgery—should be
the easiest to prevent, yet they continue to occur at alarming rates. The Million
Women Study recently reported its analysis of health records for 947,454 middle-
aged women in the United Kingdom regarding the incidence of VTE during the first
12 weeks after surgery and compared it to matched middle-aged women who did
not have surgery. The study determined that 1 in 140 women who had inpatient sur-
gery was hospitalized for or died from VTE, and 1 out of 815 women who had out-
patient surgery was hospitalized or died because of a VTE in the 12-week postop-
erative period. For women who did not undergo surgery, the incidence of VTE was
1 out of 6200. These rates seem even more disturbing when we consider that this
epidemiologic study could follow only women who were hospitalized with a diag-
nosed VTE. The number of diagnosed DVTs is believed to represent only about a
third (or less) of events, and not all people with diagnosed DVT are hospitalized.
To address the need for information about VTE development, the last several years
have seen the publication of educational articles in plastic surgery journals. Although
growing numbers of plastic surgeons report using VTE prophylaxis methods, the
majority employ only mechanical devices such as graduated compression stockings
(GCS) or intermittent pneumatic compression (IPC) applied to the calves or feet. The
value of GCS is highly questionable, because they are completely passive devices and
are unlikely to be fitted properly. In 2008, the eighth edition practice guidelines de-
veloped by the American College of Chest Physicians (ACCP) departed from its pre-
vious recommendations and determined that mechanical prophylaxis used alone is
appropriate only for surgeries lasting less than 1 hour or for patients who are at very
high risk for bleeding, as would be the case for a patient with an inherited or ac-
quired thrombophilia. For other surgical patients, mechanical prophylaxis may be
used in conjunction with an anticoagulant but is not recommended as the primary
means of VTE prevention. According to the ACCP, the efficacy of mechanical pro-
phylaxis methods has not been demonstrated in well-designed clinical trials; the vari-
ations in device sizes and pressures make IPCs difficult to study, and determining
44
Part I  Fundamentals

whether the devices are used properly and consistently is difficult to establish. Be-
cause IPCs work primarily in the calves, they also may be unable to prevent the most
dangerous clots, which propagate proximally and may be fatal if they reach the lungs.
Despite these problems, IPCs are not likely to cause harm, although they are con-
traindicated in patients with peripheral vascular disease. If ordered, IPCs should be
started in the preoperative area and worn until the patient is fully ambulatory.
Before 2008, the ACCP based its recommendations for VTE prevention on individ-
ual risk factors, an approach that has been presented in most of the plastic surgery lit-
erature related to VTE. A surgical patient’s risk for VTE is determined by assigning
points for every risk factor a patient has; the total number of points indicates the
level of risk (low, moderate, or high) and therefore the type of VTE prophylaxis. The
2008 guidelines departed from this model and instead based recommendations ac-
cording to type of surgical procedure rather than individual risk factors.
The change was made because randomized clinical trials of VTE prevention that pro-
vide the evidence for recommendations are based on group risk assignment, such as
VTE incidence in patients undergoing total hip replacement, abdominal procedures,
bariatric surgery, etc. Even though the new guidelines discuss a variety of surgical
disciplines, the conclusions of the guidelines are similar for all procedures: Surgery
patients should receive either low-molecular-weight heparin (LMWH), low-dose un-
fraction ated heparin (LDUH), or fondaparinux for VTE prophylaxis unless they
are under going a minor procedure or have a high risk of bleeding.
Even though evidence from other surgical specialties indicates that postoperative an-
ticoagulants significantly reduce the incidence of VTE, have a positive benefit-to-risk
ratio, and improve patient outcomes, chemoprophylaxis remains underused in plas-
tic surgery. However, many plastic surgery patients tend to have multiple risk fac-
tors that place them at moderate to high risk for VTE. Some of the most common
risk factors encountered are these:
 Major surgery that lasts longer than 1 hour (the risk rises with each hour)
 Age 40 years or older (the risk rises as age rises)
 General anesthesia
 Use of oral contraceptives, hormone replacement therapy, or selective estro-
gen receptor modulators (used for treatment of breast cancer and osteoporosis)
 Obesity
 Malignancy (active or in patient history)
 Abdominal surgery (carries higher risk than most other types of surgery)
 Varicose veins
 Smoking
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Chapter 2  Patient Safety in Aesthetic Surgery

Many plastic surgeons are reluctant to use anticoagulants for fear of causing bleed-
ing complications that may compromise results. However, most meta-analyses and
placebo-controlled randomized clinical trials from other surgical specialties have
found that the risk of clinically important bleeding does not increase if drug in-
structions are followed correctly. According to the Joint Commission and the Surgi-
cal Care Improvement Project (SCIP), a bleeding risk that is considered normal for
surgery is not an acceptable reason for not administering anticoagulants.
As a general rule, anticoagulants should be started at least 6 to 8 hours after surgery.
One common approach is to use a drug that can be subcutaneously injected by the
patient once a day beginning the morning after surgery. For the purpose of VTE pre-
vention (not treatment) enoxaparin is packaged in a 40 mg dose, and fondaparinux
syringes come in a 2.5 mg dose. The recommended duration of anticoagulant use is
between 7 to 10 days to ensure that patients are protected when the risk of VTE is
highest, during the first postoperative week.
The need for anticoagulants seems highest in procedures that involve the lower trunk
because patient positioning invites venous stasis of the lower extremities, and in-
creased intraabdominal pressure decreases blood flow in the femoral vein. In an analy-
sis of 2.4 million outpatient surgeries, the American Association for Accreditation
of Ambulatory Surgery Facilities (AAAASF) determined that the risk of death is 10
times higher in outpatient abdominoplasty patients than for any other outpatient
procedure. Although plastic surgeons have not yet conducted the types of prospec-
tive randomized clinical trials needed to evaluate the effectiveness of chemoprophy-
laxis in plastic surgery patients, some surgeons have begun to report data on this
question, particularly with respect to lower body–contouring procedures. In com-
parisons of patients receiving anticoagulants with those receiving mechanical pro-
phylaxis only, most recent studies (but not all) have found statistically significant
lower rates of VTE in patients receiving chemoprophylaxis.
With respect to bleeding, some studies have seen increased postoperative bleeding in
patients who received LMWH compared to mechanical prophylaxis. Among lower
body contouring patients, the incidence of hematoma and need for transfusion were
significantly higher when anticoagulants were used. However, other studies have
found no significant differences in bleeding complications when patients receiving
LMWH were compared with controls (no treatment).
Patients with cancer are also known to be at increased risk for VTE. When compared
to surgical patients without cancer, those with cancer have at least twice the risk of
developing a DVT in the postoperative period and three times the risk of a fatal PE.
Patients receiving chemotherapy have a risk for VTE that is 6 times higher than pa-
tients without cancer. Other treatment modalities (selective estrogen receptor mod-
46
Part I  Fundamentals

ulators like tamoxifen, angiogenesis inhibitors, and aromatase inhibitors) are also
associated with increased VTE risks. Plastic surgeons often treat cancer patients and
must consider the use of chemoprophylaxis in this patient population, especially
when performing reconstruction with flaps. One study of TRAM flap patients who
received D-dimer tests and lung scans to look for VTE found that 17% who received
no chemoprophylaxis had asymptomatic PEs, compared with no patients who re-
ceived LMWH.
The debate about using chemoprophylaxis in plastic surgery will likely continue for
the foreseeable future. Growing numbers of plastic surgeons seem to be adopting the
use of anticoagulants for patients undergoing lower body contouring procedures
such as abdominoplasty (with or without additional procedures), circumferential
body lift, panniculectomy, and large-volume liposuction in the lower trunk or thighs.
No studies have yet reported serious bleeding complications that were difficult to
manage in these patients. Thus, unless a patient is at high risk of excessive bleeding,
chemoprophylaxis currently seems to possess greater benefits than risks for many
plastic surgery patients. The issue may ultimately be resolved by groups such as the
Joint Commission, which has recently adopted guidelines regarding the timing of
chemoprophylaxis for VTE prevention among inpatient surgical patients as one of
its performance measures for determining a facility’s quality of care during the ac-
creditation process.
Prevention of Postoperative Nausea and Vomiting
Postoperative nausea and vomiting (PONV) is thought to affect up to 70% of sur-
gical patients unless preventive measures are instituted. Although a postoperative
complication itself, nausea and vomiting may contribute to additional complications
such as hematoma and wound dehiscence following procedures such as face lift, bleph -
aroplasty, breast surgery, or abdominoplasty. PONV may also delay discharge from
the surgical facility or lead to unplanned hospital admission. Postoperative nausea
and vomiting is often rated higher than pain as a source of discomfort associated
with surgery and can erode patient satisfaction.
Of all the patient safety concerns, PONV is perhaps the easiest to prevent in most
patients. Important risk factors for developing PONV are female gender, a history
of PONV or motion sickness, not smoking, and perioperative opioid treatment. None
of these risk factors is unusual in plastic surgery patients, but the risk for PONV
rises 20% with each additional factor; for example, a 40% increased risk in patients
with two risk factors and 80% when four risk factors are present. The key to pre-
vention and treatment is the use of pharmacologic agents to block neurotransmit-
ters that stimulate emesis. Some of the important receptors implicated in PONV are
serotonin (5-HT3), dopamine, histamine (H-1), neurokinin-1, cholinergic, and in-
flammatory receptors.
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Chapter 2  Patient Safety in Aesthetic Surgery

48
Part I  Fundamentals
No single receptor antagonist seems to be successful in blocking PONV in patients
who have two or more risk factors, but combinations of at least two drugs that tar-
get different receptors are known to be effective. When three or more receptors are
blocked, PONV can be prevented in up to 90% of patients. As a general rule, the
more risk factors a patient has, the more prophylactic antagonists will be needed.
Commonly used antagonists include combinations of a serotonin blocker (on-
dansetron), an antiinflammatory (dexamethasone), a dopamine antagonist (droperi-
dol), and/or an antihistamine (diphenhydramine) delivered intravenously, with some
given preoperatively and others near the end of surgery. A neurokinin-1 receptor
antagonist called aprepitant (Emend, Merck & Co., Whitehouse Station, NJ) is a
newer alternative that continues to act for 48 hours and is taken in pill form before
surgery.
If a patient develops PONV despite preventive efforts, the rescue should be ap-
proached using a different class of drug than was used as a prophylactic antiemetic
so that a different receptor is targeted. If PONV continues beyond 6 hours after sur-
gery, many drugs could be repeated, except for those that are long-acting, such as
dexamethasone, aprepitant, and scopolamine.
Obstructive Sleep Apnea
Elective surgery can be safely performed on patients with obstructive sleep apnea
(OSA), which is characterized by intermittent closure or narrowing of the upper air-
way during sleep that results in a 30% reduction in airflow for at least 10 seconds
and reduces oxygen saturation by at least 4%. To plan for potential complications
that may arise in OSA patients, the surgeon must first know the condition is pres-
ent. Unfortunately, estimates suggest that OSA is undiagnosed in at least 80% of in-
dividuals who have the disorder. The plastic surgeon must therefore be aware of OSA
risk factors, which include obesity (especially with a BMI greater than 35), men older
than 40 and women who are perimenopausal or postmenopausal, a neck circum-
ference larger than 17 inches in men and 16 inches in women, a positive family his-
tory, and hypertension. Experts speculate that 50% of hypertensive patients have
OSA; in addition, 60% to 90% of OSA patients are obese.
Because so many people are unaware they suffer from sleep apnea and deny its symp-
toms, the best source for identifying patients with OSA is the spouse or another per-
son who lives in the home. A simple screening tool called STOP has been developed
to assist with identifying OSA. Sleep apnea should be suspected in a patient who has
two of these four symptoms:
1. Snoring loud enough to be heard through a closed door
2. Tiredness or daytime hypersomnolence (falling asleep easily in a nonstimu-
lating environment, such as watching television or riding in a car)
3. Observed pauses in breathing during sleep
4. Pressure reading or history of hypertension

Diagnosis is confirmed with multiple-channel polysomnography performed in a sleep
laboratory. The most important OSA treatments are weight loss, elevating the head
of the bed to 30 degrees to 60 degrees, using an oral appliance, and wearing a con-
tinuous positive airway pressure (CPAP) device.
Anesthesia Management
Patients with OSA typically require special anesthesia management. If OSA has been
diagnosed or is suspected, the anesthesiologist should evaluate the patient before
surgery because the airway may be difficult and require fiberoptic intubation. Sur-
gery in an outpatient setting with local or regional anesthetic should be safe, but the
facility should have the equipment and expertise to carefully monitor patients and de-
liver advanced respiratory care if needed. Longer surgeries, especially those which can-
not be done with regional blocks or light sedation, should be performed in a hospital.
Extubation should not be done until the patient is fully awake. Postoperative mon-
itoring and attentive staff are essential for recognizing respiratory depression and ab-
normal heart rhythms. Monitoring should be continued for at least 3 hours longer
than patients without apnea would receive, and an overnight stay would be prefer-
able. Patients who used a CPAP before surgery should bring the device to the surgi-
cal facility so it can be used in the postoperative period. If possible, the supine po-
sition should be avoided; instead, the head of the bed should be elevated to a 30- to
45-degree angle. Patients with OSA are very sensitive to sedatives and opioids, which
should be sparingly used or avoided altogether. Supplemental oxygen can help main-
tain SpO2 higher than 90%.
Perioperative Beta-blockers and Other Cardiac Issues
It is not unusual to encounter patients with some degree of cardiovascular disease,
especially hypertension, in plastic surgery practices. Individuals seeking body con-
touring after weight loss, obese patients inquiring about liposuction, and women
who want to undergo breast reconstruction are among those more likely to be tak-
ing beta-blockers. The withdrawal of beta-blockers for surgery has been found to
carry a much higher risk of mortality than continuation of the drug. Consequently,
the American College of Cardiology/American Heart Association (ACC/AHA) and
SCIP recommend that surgical patients who take daily beta-blockers continue the
therapy throughout the perioperative period to reduce the risk of cardiovascular
complications during and after surgery. If beta-blocker therapy is not continued peri -
operatively, the surgeon should document the reason (or reasons).
The ACC/AHA also recommends that surgeons not order perioperative beta-blockers
for all patients in an effort to reduce perioperative cardiac risks. Starting a patient
on beta-blockers requires monitoring by a cardiologist, internist, or other specialist.
Plastic surgeons are not trained to diagnose and/or treat cardiovascular disease and
49
Chapter 2  Patient Safety in Aesthetic Surgery

should consult with cardiac specialists about patients who have risk factors for ma-
jor cardiac complications associated with surgery:
 A high-risk operation (intraperitoneal, intrathoracic, vascular)
 A history of ischemic heart disease or heart failure
 A history of cerebrovascular disease
 Diabetes requiring insulin
 A preoperative serum creatinine level above 20 mg/dl
If a patient is taking antiplatelet drugs, such as clopidogrel bisulphate (Plavix) or as-
pirin, the plastic surgeon needs to know why. Surgery increases the risk of coronary
stent thrombosis, especially early after stent placement. Stopping an antiplatelet drug
should not be recommended by a plastic surgeon if a stent is present unless the pa-
tient’s cardiologist approves.
Office-Based Surgery
All board-certified plastic surgeons who perform surgery in their offices have a re-
sponsibility to make sure their facilities are accredited by AAAASF, the Joint Com-
mission, or some other recognized credentialing organization. Gaining certification
requires meeting certain safety practices and tracking all surgical complications and
adverse events. Whenever a surgical patient is on the premises, someone trained in
advanced cardiac life support must be present, and all personnel who work in the
surgical area should be trained in basic cardiopulmonary resuscitation. The types of
routine monitoring and emergency equipment and supplies needed at the facility are
usually mandated by accrediting agencies.
In a review that compared surgical outcomes in offices and ambulatory surgery cen-
ters in Florida, the risk of adverse incidents and death was 10 times higher in offices
than surgery centers. Thirteen deaths occurred in office facilities, only 15% of which
had an anesthesiologist present, with only 38% of offices accredited for surgery. This
study highlights the fact that a surgeon is not an anesthesiologist. The AAAASF re-
quires that general anesthesia be administered by an anesthesiologist or certified reg-
istered nurse anesthetist (CRNA). A surgeon may give intravenous sedation but may
not deliver Propofol because it requires careful monitoring.
Evidence-based initiatives such as those that call for changes in infection prevention
protocols tend to arise in hospitals first, but they eventually spread to office settings
and outpatient surgery centers. Ultimately, quality and performance reporting re-
lated to complications will be required by agencies such as AAAASF during a facil-
ity’s accreditation process. Every site at which surgery is performed should have doc-
umented policies and procedures that directly address patient safety concerns.
Moreover, those policies should be routinely reviewed and, if needed, modified to
50
Part I  Fundamentals

51
Chapter 2  Patient Safety in Aesthetic Surgery
reflect the best evidence available at the time. Sometimes the adoption of guidelines
requires changing long-standing habits.
Building a Culture of Safety
In recent years, the value and applications of checklists in medicine, especially sur-
gery, have been proved worthwhile. The measures contained in national guidelines
are reviewed and revised as evidence warrants in an effort to reflect the state of the
science. Ultimately, such guidelines are used as a way to measure facility quality and
patient outcomes.
Another method of improving patient safety is growing in popularity, especially in
larger facilities: opting out of safety recommendations. Instead of writing orders to
have something done, “opt-out” requires physicians to explain why a safety practice
is not being followed. For example, an order does not need to be written for an an-
tibiotic to be administered, but if it was not given—and at the recommended time—
the reason must be documented. Some newer recommendations from the Joint Com-
mission pertaining to VTE prophylaxis (both mechanical and pharmacologic) require
the surgeon to specify why preventive measures were not ordered; likewise, a bleed-
ing risk considered normal for surgery is not an acceptable reason for not using anti -
coagulants.
The Surgical Safety Checklist developed by the WHO presents a list of actions that
should always be performed by the surgical staff (see p. 52). This protocol, or a vari-
ation of it, may be posted in operating rooms around the country, yet it is ignored
daily. Although surgeons and other members of the perioperative team know their
responsibilities without having to be reminded, preventable errors still occur. Thus
reminders are crucial to keeping patients safe.
The Surgical Safety Checklist has been prospectively examined in eight countries at
different stages of development before and after the checklist intervention was in-
troduced. The preintervention group consisted of 3733 patients undergoing non-
cardiac surgery, and the intervention group had 3955 patients. When the checklist
was used, the patient rate of death significantly declined (p  0.003), as did the num-
ber of inpatient complications (p 0.001). The reasons for the improvement in patient
outcomes may go beyond use of a checklist. In several of the hospitals, adhering to the
checklist required changing some systems (for example, when antibiotics are ad-
ministered before surgery) and behaviors (operating room staff must communicate
about the patient during the surgical time-out and again at the debriefing). Designed
as a sequence of tasks to perform, the checklist resulted in better team communica-
tion and awareness of safety practices.

52
Part I  Fundamentals
PATIENT HAS CONFIRMED
• IDENTITY
• SITE
• PROCEDURE
• CONSENT
SITE MARKED/NOT APPLICABLE
ANAESTHESIA SAFETY CHECK COMPLETED
PULSE OXIMETER ON PATIENT AND FUNCTIONING
DOES PATIENT HAVE A:
KNOWN ALLERGY?
NO
YES
DIFFICULT AIRWAY/ASPIRATION RISK?
NO
YES, AND EQUIPMENT/ASSISTANCE AVAILABLE
RISK OF >500ML BLOOD LOSS
(7ML/KG IN CHILDREN)?
NO
YES, AND ADEQUATE INTRAVENOUS ACCESS
AND FLUIDS PLANNED
NURSE VERBALLY CONFIRMS WITH THE
TEAM:
THE NAME OF THE PROCEDURE RECORDED
THAT INSTRUMENT, SPONGE AND NEEDLE
COUNTS ARE CORRECT (OR NOT
APPLICABLE)
HOW THE SPECIMEN IS LABELLED
(INCLUDING PATIENT NAME)
WHETHER THERE ARE ANY EQUIPMENT
PROBLEMS TO BE ADDRESSED
SURGEON, ANAESTHESIA PROFESSIONAL
AND NURSE REVIEW THE KEY CONCERNS
FOR RECOVERY AND MANAGEMENT
OF THIS PATIENT
SIGN IN
CONFIRM ALL TEAM MEMBERS HAVE
INTRODUCED THEMSELVES BY NAME AND
ROLE
SURGEON, ANAESTHESIA PROFESSIONAL
AND NURSE VERBALLY CONFIRM
• PATIENT
• SITE
• PROCEDURE
ANTICIPATED CRITICAL EVENTS
SURGEON REVIEWS: WHAT ARE THE
CRITICAL OR UNEXPECTED STEPS,
OPERATIVE DURATION, ANTICIPATED
BLOOD LOSS?
ANAESTHESIA TEAM REVIEWS: ARE THERE
ANY PATIENT-SPECIFIC CONCERNS?
NURSING TEAM REVIEWS: HAS STERILITY
(INCLUDING INDICATOR RESULTS) BEEN
CONFIRMED? ARE THERE EQUIPMENT
ISSUES OR ANY CONCERNS?
HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN
WITHIN THE LAST 60 MINUTES?
YES
NOT APPLICABLE
IS ESSENTIAL IMAGING DISPLAYED?
YES
NOT APPLICABLE
TIME OUT
SIGN OUT
Before induction of anaesthesia
Before skin incision
Before patient leaves operating room
SURGICAL SAFETY CHECKLIST (FIRST EDITION)
THIS CHECKLIST IS NOT INTENDED TO BE COMPREHENSIVE. ADDITIONS AND MODIFICATIONS TO FIT LOCAL PRACTICE ARE ENCOURAGED.
An analysis of closed malpractice claims determined that failures in communication
can lead to injury in surgical patients. In addition, root cause analysis has revealed that
communication errors played a role in 80% of wrong-site surgeries reported to the
Joint Commission. The factors most commonly associated with a breakdown in com-
munication are ambiguity about responsibilities in 73% of cases and “status asym-
metry” in 74% (the surgeon has the highest status in the operating room). A good
opportunity for soliciting input from all team members is a preoperative briefing,
the surgical time-out, or a debriefing at the end of a procedure. A surgical time-out
that uses a checklist is known to reduce failures in team communication. For exam-
ple, before a time-out intervention was introduced in one study, 3.95 communica-
tion failures per procedure were documented by trained observers; after instituting
the intervention, the failures declined to 1.31 per procedure (p 0.001).

Many elements of an effective preoperative briefing (as staff gather in the operating
room) or time-out (just before making the incision) have been identified. The obvi-
ous elements are staff introductions and identification of the patient, the procedure,
and the laterality (if applicable). This pause should also outline the surgical plan and
its critical steps, as well as potential patient safety risks or hazards and equipment
problems. Identification of issues that might arise in advance can prevent or mini-
mize adverse events. In addition, any medical concerns, such as a comorbid condi-
tion, should be specified and patient positioning explained.
Checklists and Guidelines
Anesthesiology used to have one of the highest rates of error in medicine, estimated
to be 25 to 50 per million. Development of standardized protocols and equipment
has reduced the error rate in anesthesiology to 5.4 per million. Anesthesiologists took
their cue from the written protocols and checklists used by such high-risk profes-
sions as aviation, the military, and nuclear power engineering. Checklists—concise
lists of action items—are essential for ensuring that patient safety procedures are fol-
lowed. Some may think that going through a checklist and written protocol multi-
ple times a week is boring, repetitive, and a waste of time and effort. Do we want
airline pilots to have similar complacent attitudes, or do we want all checklists to be
completed before take-off and landing? Checklists can have great value when tasks be-
come so automatic that nobody pays attention.
Just as each patient is an individual, every surgery is a unique and complex process,
even if the procedure is simple. At any point a crisis can arise, and a life can be lost
or damaged. Every person in an operating room has his/her individual responsibil-
ities, and all are focused on different tasks that must be completed at the same time.
Staff must also remain aware of the “big picture” and know what everybody else in
the room is doing. The surgeon has the greatest responsibility in this process because
he or she will ultimately receive the praise or the blame.
Despite their limitations, several guidelines that span the time between initial screen-
ing and postoperative follow-up are presented below. Although more extensive than
the WHO Surgical Safety Checklist, these guidelines do not pretend to be all inclu-
sive. It is hoped that these guidelines may serve as prompts for important issues plas-
tic surgeons should think about.
53
Chapter 2  Patient Safety in Aesthetic Surgery

Getting Patients Ready for Surgery
An emphasis on ensuring a patient’s safety should begin with the initial consulta-
tion, when the surgeon first meets a patient and begins to establish a relationship.
The surgeon and his/her staff must explain that a patient’s own safety may depend
on the extensiveness and truthfulness of answers to questions about medical and sur-
gical history. For example, patients rarely give you their actual weight, and some
smokers will not tell you they smoke. One reason that patients are sometimes less
than truthful is because they do not want to give the surgeon a reason to refuse to
perform a desired procedure.
Patients may be more accurate with health and medication history if they complete
medical/surgical questionnaires at home rather than in the waiting room. Once you
have the health history questionnaire, the physician must not glance through it and
assume that this provides all that is necessary of a patient’s medical history. Probing
questions should be asked about everything checked “yes” on the form, and why all
of a patient’s medications were prescribed. It is important to determine whether other
medications have been prescribed but not taken or were taken in the past but are no
longer needed. Listening closely to what the patient says and asking follow-up ques-
tions when necessary are essential. For example, if a patient mentions that a parent
or sibling once had a problem with general anesthesia, the physician should ask for
an explanation. If patients can recall only sketchy details, they should be asked to
provide the information when they learn more. Such information could prevent the
development of a potentially fatal episode of malignant hyperthermia.
The items listed in the box are essential to preparing patients for surgery.
54
Part I  Fundamentals
Text continued on p. 59

Suggested Guidelines for Preparing Patients for Surgery
 Obtain a complete medical and surgical history. Consider asking what, where, when, and
why questions.
 Record all medications currently taken or taken in the recent past. Include over-the-counter
drugs and supplements (some of which can affect blood-clotting). Ask whether any medica-
tions have changed every time a patient is seen in the preoperative period.
 Stop estrogen-containing drugs (birth control and hormone replacement therapy) 4 weeks
before major surgical procedures because they raise the risk for DVT.
 Stop all selective estrogen-receptor modulators (used for breast cancer or osteoporosis pre-
vention and treatment) at the time recommended by the manufacturer of the specific drug.
This may vary from a few days to a few weeks.
 Some patients who take clopidogrel, daily aspirin, or other antiplatelet drugs may need to
stop these medications 1 to 2 weeks before surgery. Others should continue them through-
out the perioperative period. Consult with the prescribing physician to determine the wisest
option. Antiinflammatory drugs also elevate the risk of bleeding and ideally should be
stopped 2 weeks before surgery.
 Patients who are 50 years of age or older should obtain an electrocardiogram and the fol-
lowing laboratory tests: complete blood cell count, basic metabolic panel, prothrombin time,
and partial thromboplastin time. Test results from within the past year may be acceptable if
there have been no health changes.
 Order blood tests needed to evaluate the nutritional status of patients who have had bar -
iatric surgery.
 Consult with specialists if a patient has any chronic condition to determine how surgery
might impact the disease or how their conditions might influence perioperative care. This
is especially important for cardiovascular and pulmonary disorders, including hypertension
and asthma.
 Determine whether a patient with a chronic condition should have surgery in an office
setting versus ambulatory center versus hospital operating room.
 Have patients with chronic illnesses, massive weight loss, or any medical issues you are not
comfortable with obtain medical clearance for surgery from the primary care physician.
 Determine whether a patient’s expectations are realistic. Get psychiatric clearance if the
patient has a history of serious pathology. For those suffering from depression (now or in
the past), make sure the disease is well controlled (contact the mental health professional
or ask for a letter of clearance).
 Have patients with diabetes get a hemoglobin A1c test, which measures glucose status for
the past 3 months. Consult with the physician who manages the diabetes to determine what
modifications in the insulin or other medication regimen might be needed the night before
and day of surgery.
 Explain the need for abstinence from smoking for 1 month before and after surgery and tell
patients they will have a urine cotinine test at least 2 weeks before surgery, the morning of
surgery, and at some point after surgery to verify that they are not smoking.
 Be attentive to indications that a patient may (knowingly or unknowingly) have obstructive
sleep apnea. Patients diagnosed with OSA should have a preoperative consult with an anes-
thesiologist.
 Tell patients who use a continuous positive airway pressure (CPAP) device for OSA at home
to bring the unit to the surgical facility for use after the procedure.
 Instruct patients not to shave the surgical area for 2 weeks before surgery as a way to lower
risk of infection.
 Check for bacterial and yeast infections in the skin folds of massive-weight-loss patients and
treat such infections before surgery with fluconazole or nystatin.
 Make certain that all consent documents have been fully discussed and are properly signed.

56
Part I  Fundamentals
Suggested Preoperative Preparation Guidelines
 Patients should shower with a 4% chlorhexidine gluconate (CHG) product on the
morning of surgery to reduce microbial colony counts. Those with skin folds should
additionally shower the evening before surgery. A second cleansing of the operative
site should be performed in the preoperative area using cleansing wipes that contain
2% CHG.
 Verify the patient’s current medications and identify patients with allergies.
 Mark the patient while he or she is awake to confirm the correct operative site.
 Perform urine cotinine testing or some other reliable test to ensure the patient has not
smoked if appropriate to the surgical procedure.
 Attach the patient’s pulse oximeter and other vital signs monitors and make sure they
function properly.
 Begin hypothermia prevention 45 to 60 minutes before surgery by prewarming the pa-
tient with a forced-air heating blanket or some other active warming device. (Warmed
cotton blankets are not sufficient.)
 Begin DVT/PE prophylaxis with intermittent pneumatic compression (IPC) or sequen-
tial compression devices (SCD) at least 30 minutes before surgery.
 When indicated, administer cephalosporin or another appropriate parenteral antibiotic
no sooner than 30 minutes or longer than 60 minutes before the incision. Adjust the
dosage according to patient weight. Clindamycin is usually preferred for patients aller-
gic to penicillin. If clindamycin or vancomycin is used, its administration should begin
2 hours before incision. Timing of the dose may depend on whether a surgical delay
is possible.
 Begin the drug protocol for prevention of postoperative nausea and vomiting (PONV)
in patients with two or more risk factors. High-risk patients may benefit from a
prescription for aprepitant, a 40 mg pill taken the morning of surgery that provides
48 hours of protection.
 All patients with diabetes, especially those who have been without oral medication
or insulin since the evening before, must have their glucose checked on arrival in the
preoperative area. Tight glucose control (80 to 120 mg/dl) should be maintained with
insulin titrated to blood sugar levels throughout the perioperative period or according
to his/her physician’s advice.
 If hair removal is necessary, have the nurse use clippers rather than a razor.

57
Chapter 2  Patient Safety in Aesthetic Surgery
Suggested Intraoperative Guidelines
 Set the operating room temperature to approximately 23° C (73.4° F) to help maintain
normothermia.
 Continue IPCs or SCDs for DVT prophylaxis.
 Place the patient beneath a forced-air warming blanket to actively warm nonsurgical
areas and maintain a body temperature of 36.1° C (97° F) or higher throughout sur-
gery. Consider warming the irrigation, tumescent, and intravenous fluids so they are
delivered at approximately 37° to 41° C (98.6° to 105.8° F). If the patient is reposi-
tioned during surgery, continue active warming methods after each position change.
 Use proper padding and gel heel protectors to prevent traction, pressure, or nerve in-
jury. Recheck with every change in patient position.
 Have preoperative photographs and/or imaging results posted for reference.
 Reinforce the patient’s markings.
 Place a Foley catheter if needed (large-volume liposuction, or major body contouring
such as a lower body lift).
 Take the surgical time-out as close as possible to making the incision, when all staff are
present and are not distracted by other matters. Use a standard time-out routine and
make certain all operating room staff are involved and all equipment and supplies are
available and functional.
 Continue glucose monitoring at least every 60 minutes and treat to prevent hyper-
glycemia.
 Consider supplying increased oxygen (80% FiO2) to reduce the incidence of wound
infections and possibly PONV.
 Administer ondansetron (4 mg intravenously) less than 2 hours before the end of sur-
gery for patients at highest risk of PONV.
 Use a standard sign-out routine to make certain all counts are correct and all speci-
mens are properly labeled. Also summarize any issues or concerns pertinent to the spe-
cific patient’s postoperative care. This may include the need for extended postoperative
monitoring if any cardiac or respiratory events occurred during the procedure.
 Remove the Foley catheter at the end of the procedure (if applicable).

58
Part I  Fundamentals
Suggested Postoperative Guidelines
Recovery Area or Postanesthesia Care Unit
 Continue patient warming with forced air in the recovery area or PACU if the patient
is hypothermic. If shivering develops, intensify warming efforts and consider medica-
tion with meperidine or other drug.
 Consider continuing 80% FiO2 for 2 hours with a non-rebreather mask.
 Continue IPCs or SCDs for DVT prophylaxis until discharge.
 Do not extubate OSA patients until they are fully awake. Transfer them to a unit where
their vital signs can be frequently monitored. Continue supplemental oxygen through-
out hospitalization to maintain SpO2 above 90%. Use a continuous positive airway
pressure (CPAP) device in the hospital if a patient uses one at home. A 45-degree modi-
fied sitting position will improve ventilation. Use sedatives and pain medicine judi-
ciously in OSA patients.
 Continue close glucose monitoring in patients with diabetes and have insulin avail -
able for injection or infusion. Determine when and how patients should resume self-
monitoring.
 Manage fluids to maintain a urine output of 50 to 100 ml/hr.
 Discontinue antibiotics within 24 hours unless there is a specific reason to continue.
 Use a patient-controlled analgesia (PCA) pump for pain control with inpatients unless
analgesia was provided with an epidural or nerve block.
 If a patient develops PONV despite preventive efforts, do not repeat the same drug or
drugs; order a drug that blocks a different receptor.
 Begin ambulation on the evening of surgery.
 Order incentive spirometry for all inpatients.
 Make certain that printed postoperative instructions are given to the patient or a fam -
ily member.
 When indicated, begin chemoprophylaxis on the first postoperative day after checking
the patient for any bleeding complications. Have the patient trained in the use of
self-administered enoxaparin or fondaparinux, which should be continued for 7 to
10 days, especially with lower body procedures.
Postdischarge Recommendations
 Remove drains when output drops below 30 ml/24 hr.
 Minimize the use of liposuction compression garments to prevent permanent horizon-
tal creases in the skin.
 Instruct patients not to exercise or have sex for at least 3 weeks following major
procedures.
 Reinforce the idea that patients should avoid cigarette smoke. Repeat cotinine testing
within 2 to 4 weeks when appropriate and document the results in the medical
records.

Crisis Situations
Beyond the information presented in this chapter, plastic surgeons need to know how
to manage life-threatening complications that may occur suddenly during surgery—
malignant hyperthermia (MH) and local anesthetic systemic toxicity (LAST). These
situations are quite rare but can develop in any surgical setting: the hospital, outpa-
tient center, or office. The drugs, supplies, and treatment protocol needed to prevent
death are discussed next. Successful recovery from MH or LAST requires rapid recog-
nition of the problem, knowledge of what to do in the crisis, immediate action, and
the availability of the treatment and monitoring equipment necessary. Neither con-
dition can be studied with the types of clinical trials that underlie the safety recom-
mendations described throughout this chapter, because treatment cannot ethically
be withheld. Consequently, the treatment protocols described represent the current
state of knowledge.
Malignant Hyperthermia
MH is a life-threatening, pharmacogenetic disorder of skeletal muscle metabolism
triggered by volatile inhalation (gas) anesthetics and/or the depolarizing muscle re-
laxant succinylcholine. MH occurs only in people with a genetic trait that makes
them susceptible, yet few people planning surgery would know they carry the trait
for this inherited myopathy, which is detected by genetic testing or muscle biopsy.
Consequently, every surgical patient should be presumed to be susceptible to MH.
An episode of MH begins when a triggering agent disturbs calcium homeostasis. If
not quickly diagnosed and treated, MH may lead to sudden cardiac arrest and death
during or after general anesthesia with any of these agents:
 Succinylcholine
 Halothane
 Sevoflurane
 Desflurane
 Isoflurane
 Enflurane
 Methoxyflurane
A surgeon may not intend to use any of these agents, but plans may change, regard-
less of the type of facility where surgery is performed. For example, the use of suc-
cinylcholine may be needed in an emergency situation to establish an airway. Con-
sequently, all procedures that require more than local anesthesia should be performed
in an accredited facility with staff who know what to do if MH develops.
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Chapter 2  Patient Safety in Aesthetic Surgery

60
Part I  Fundamentals
The incidence of MH is unknown, but the Malignant Hyperthermia Association of
the United States (MHAUS) estimates that 1000 cases occur each year. This would
mean that two or three MH episodes happen every day in the United States. In an
MH episode, intracellular free calcium is released in striated skeletal muscle and sus-
tained muscle contraction is activated. The rapid escalation of muscle metabolism
increases oxygen consumption, produces excess carbon dioxide, and breaks down
ATP (adenosine triphosphate), which stores the energy of muscle cells. As more en-
ergy is expended, more heat is produced. The cell membranes eventually collapse
and high levels of potassium (K) and creatine kinase (CK) are released into the blood-
stream.
MH develops without warning. Unfortunately, its signs and symptoms are inconsis-
tent, may appear in a different order, and are not all present in every patient in cri-
sis. Important signs of MH include unexplained tachycardia, a rise in expired car-
bon dioxide, hypercarbia, hypoxemia, generalized or masseter muscle rigidity, cardiac
arrhythmias, metabolic acidosis, and hyperkalemia. A rise in body temperature of-
ten occurs late in the episode, as does rhabdomyolysis, which is usually identified by
high serum levels of creatine kinase, excretion of myoglobin in the urine (myoglo-
binuria), and renal failure.
Because MH may escalate into a life-threatening crisis within minutes, all operating
room personnel must be quick to recognize it and initiate treatment with dantrolene
sodium, which directly relaxes skeletal muscle and reduces the release of calcium
within muscle cells. MHAUS is the best single source of information on MH, its de-
velopment, symptoms, diagnosis, and treatment, and surgeons should familiarize
themselves with its excellent website at MHAUS also maintains a
hotline that is staffed 24 hours a day, 365 days a year to help with diagnosis and
treatment of MH. The hotline will put callers in touch with an on-call anesthesiol-
ogist who specializes in MH crises and can advise operating room staff throughout
the treatment process. A call to the hotline should be one of the first actions taken if
MH is suspected.
MH Hotline: 1-800-644-9737
(1-800-MH-HYPER)
Outside the US: 001-315-464-7079
Surgeons should download the treatment instructions for MH from the MHAUS
website (see p. 61) and also order these guidelines in larger format wall posters.

61
Chapter 2  Patient Safety in Aesthetic Surgery
EMERGENCY THERAPY FOR
MALIGNANT HYPERTHERMIA
MH Hotline
1-800-644-9737
Outside the US:
001-315-464-7079
DIAGNOSIS vs. ASSOCIATED PROBLEMS
ACUTE PHASE TREATMENT
POST ACUTE PHASE
Signs of MH:
• Increasing ETCO2
• Trunk or total body rigidity
• Masseter spasm or trismus
• Tachycardia/tachypnea
• Mixed Respiratory and
Metabolic Acidosis
• Increased temperature (may
be late sign)
• Myoglobinuria
Sudden/Unexpected Cardiac
Arrest in Young Patients:
• Presume hyperkalemia and initiate treatment
(see #6)
• Measure CK, myoglobin, ABGs, until
normalized
• Consider dantrolene
• Usually secondary to occult myopathy (e.g.,
muscular dystrophy)
• Resuscitation may be difficult and prolonged
Trismus or Masseter Spasm with Succinylcholine
• Early sign of MH in many patients
• If limb muscle rigidity, begin treatment with dantrolene
• For emergent procedures, continue with non-triggering agents,
evaluate and monitor the patient, and consider dantrolene
treatment
• Follow CK and urine myoglobin for 36 hours.
• Check CK immediately and at 6 hour intervals until returning to
normal. Observe for dark or cola colored urine. If present, liberalize
fluid intake and test for myoglobin
• Observe in PACU or ICU for at least 12 hours
Hyperkalemia – Treat with hyperventilation,
bicarbonate, glucose/insulin, calcium.
• Bicarbonate 1-2 mEq/kg IV.
• For pediatric, 0.1 units insulin/kg and 1 ml/kg 50%
glucose or for adult, 10 units regular insulin IV and
50 ml 50% glucose.
• Calcium chloride 10 mg/kg or calcium gluconate
10-50 mg/kg for life-threatening hyperkalemia.
• Check glucose levels hourly.

Follow ETCO2, electrolytes, blood gases, CK, core
temperature, urine output and color, coagulation
studies. If CK and/or K+ rise more than transiently or
urine output falls to less than 0.5 ml/kg/hr, induce
diuresis to >1 ml/kg/hr and give bicarbonate to
alkalanize urine to prevent myoglobinuria-induced
renal failure. (See D below)
• Venous blood gas (e.g., femoral vein) values may
document hypermetabolism better than arterial
values.
• Central venous or PA monitoring as needed and
record minute ventilation.
• Place Foley catheter and monitor urine output.
7
6
• Each 20 mg bottle has 3 gm mannitol for
isotonicity. The pH of the solution is 9.
Bicarbonate for metabolic acidosis
• 1-2 mEq/kg if blood gas values are not yet
available.
Cool the patient with core temperature
>39ºC, Lavage open body cavities, stomach,
bladder, or rectum. Apply ice to surface.
Infuse cold saline intravenously. Stop cooling
if temp. <38ºC and falling to prevent drift
< 36ºC.

Dysrhythmias usually respond to treat-
ment of acidosis and hyperkalemia.
• Use standard drug therapy except calcium
channel blockers, which may cause
hyperkalemia or cardiac arrest in the
presence of dantrolene.
3
4
5
GET HELP. GET DANTROLENE – Notify
Surgeon
• Discontinue volatile agents and succinylcholine.
• Hyperventilate with 100% oxygen at flows of 10
L/min. or more.
• Halt the procedure as soon as possible; if emer-
gent, continue with non-triggering anesthetic
technique.
• Don’t waste time changing the circle system
and C02 absorbant.
Dantrolene 2.5 mg/kg rapidly IV
through large-bore IV, if possible
To convert kg to lbs for amount of dantrolene, give
patients 1 mg/lb (2.5 mg/kg approximates 1 mg/lb).
• Dissolve the 20 mg in each vial with at least 60
ml sterile, preservative-free water for injection.
Prewarming (not to exceed 39º C.) the sterile
water may expidite solublization of dantrolene.
However, to date, there is no evidence that such
warming improves clinical outcome.
• Repeat until signs of MH are reversed.
• Sometimes more than 10 mg/kg (up to 30
mg/kg) is necessary.
1
2
CAUTION:
This protocol may not apply to all patients; alter for specific needs.
Observe the patient in an ICU for at least 24
hours, due to the risk of recrudescence.
Dantrolene 1 mg/kg q 4-6 hours or 0.25
mg/kg/hr by infusion for at least 24 hours.
Further doses may be indicated.
Follow vitals and labs as above (see #7)
• Frequent ABG as per clinical signs
• CK every 8-12 hours; less often as the values
trend downward
Follow urine myoglobin and institute therapy to prevent myoglobin precipitation in renal tubules and the
subsequent development of Acute Renal Failure. CK levels above 10,000 IU/L is a presumptive sign of rhabdomy-
olysis and myoglobinuria. Follow standard intensive care therapy for acute rhabdomyolysis and myoglobinuria
(urine output >2 ml/kg/hr by hydration and diuretics along with alkalinization of urine with Na-bicarbonate
infusion with careful attention to both urine and serum pH values).
Counsel the patient and family regarding MH and further precautions; refer them to MHAUS. Fill out and send
in the Adverse Metabolic Reaction to Anesthesia (AMRA) form () and send a letter to the patient
and her/his physician. Refer patient to the nearest Biopsy Center for follow-up.
A
D
E
B
C
Non-Emergency Information
MHAUS
PO Box 1069 (11 East State Street)
Sherburne, NY 13460-1069
Phone
1-800-986-4287
(607-674-7901)
Fax
607-674-7910
Email
info@mhaus.org
Website

ORPO 5/08/5K
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Effective May 2008

62
Part I  Fundamentals
Another valuable resource available from the MHAUS website is the description of
the supplies needed for stocking the MH cart or kit that should be readily available
at every surgical facility. The most important drugs needed for an MH kit are shown
below.
Supplies for rapid patient cooling should also be readily available, such as a mini-
mum of 3000 ml refrigerated saline solution and large and small plastic bags that
can be filled with ice.
MH is rare, but all surgeons and anesthesiologists should be prepared to manage an
MH crisis. Rescue from MH may take hours and requires the efforts of a large team.
As an example, 3 or 4 people are needed to reconstitute Dantrolene for infusion.
Early recognition and preparation is the key to successful treatment of MH. Having
a protocol in place and all the many supplies available may make the difference in
saving a patient’s life or reducing the chance of long-term morbidity.
Local Anesthetic Systemic Toxicity (LAST)
and Lipid Infusion
The use of local anesthetics and regional blocks is common among plastic surgeons,
but knowledge of what to do if toxicity develops and leads to cardiovascular col-
lapse is not. Although all types of local anesthetics are capable of reaching toxic lev-
Important Drugs for the MH Kit*
 Dantrolene sodium for injection—at least 36 vials* (each to be diluted with 60 ml ster-
ile water at time of use).
 If surgery is performed on obese patients, 36 vials will be insufficient. For example, if a
patient weighs 100 kg (220 pounds), 1000 mg of dantrolene may be needed (50 vials).
The amount of sterile water for reconstitution and all other drug ingredients will also
require adjustment.
 Sterile water for injection USP (without a bacteriostatic agent) for reconstitution of
dantrolene: Two 1000 ml bags.
 Five sodium bicarbonate (8.4%): 50 ml syringes.
 Two dextrose 50%: 50 ml vials.
 Two calcium chloride (10%): 10 ml vials.
 Four furosemide 40 mg ampules.
 One regular insulin: 100 units/ml (refrigerated).
 Lidocaine for injection: 100 mg/5 ml or 100 mg/10 ml in preloaded syringes.
*A complete list of required drugs, general equipment, monitoring equipment, nursing supplies, laboratory testing sup-
plies, and forms required for an MH kit is available at
OnlineBrochures.Display/BrochurePK/B5DBDF12-20C3-4537-948C098DAB0777E3.cfm.

els, the aminoamides, which are metabolized in the liver, seem to be more often im-
plicated in toxicity of brain and heart tissue. The aminoamides include bupivacaine,
ropivacaine, lidocaine, levobupivacaine, mepivacaine, prilocaine, and etidocaine.
There are some indications that levobupivacaine and ropivacaine may be less likely
to cause cardiac toxicity.
Detection of LAST
Successful treatment of LAST greatly depends on its prompt diagnosis. Toxicity is
not always immediately evident after anesthetic injection and may take up to 60 min-
utes to manifest, especially if tumescent solutions are used. Intoxication may develop
at any time when local anesthetic is delivered through a catheter. Signs of minor sys-
temic toxicity are usually neurologic and may include perioral numbness, facial tin-
gling, restlessness, confusion, muscle twitching, drowsiness, tinnitus, metallic taste,
dizziness, and slurred speech. Major toxicity is accompanied by sudden loss of con-
sciousness, tonic-clonic seizures, hypertension followed by progressive hypotension,
tachycardia, ventricular arrhythmias, bradycardia or asystole, ventricular fibrilla-
tion, and cardiac arrest. The cardiovascular signs are not always preceded by neu-
rologic signs, and cardiac arrest may be the first indication of LAST.
Treatment of LAST
Evidence indicates that the infusion of lipid emulsion (20% Intralipid) can effectively
reverse anesthetic toxicity, whether the anesthetic is delivered locally or regionally.
Every facility where local anesthetic is used in large doses should have a stocked
Lipid Rescue Kit immediately available if a crisis arises. The same applies for cardiac
monitors and supplies needed for Advanced Cardiac Life Support (ACLS), which
should begin as soon as the need is recognized, before lipid rescue is attempted. Ar-
rhythmias may be refractory to treatment and resuscitation measures will likely be
needed for a prolonged period, perhaps 1 hour or more.
A Lipid Rescue Kit should be clearly marked and contain these supplies:
 1000 ml of 20% Intralipid
 Intravenous tubing (for lipid infusion)
 60 ml syringes and needles (for lipid bolus doses)
 A printed protocol
The protocol on pp. 64-65 was developed by the Association of Anaesthetists of
Great Britain and Ireland (AAGBI) and is available at
cations/guidelines/docs/la_toxicity_2010.pdf.* The American Society of Regional
Anesthesia and Pain Medicine has a similar, though less detailed, protocol (www.
rapm.org).
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Chapter 2  Patient Safety in Aesthetic Surgery
*The British use a superscript negative number (ml.kg–1) to denote what North Americans would re-
fer to as “per” (ml/kg).

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Part I  Fundamentals

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Chapter 2  Patient Safety in Aesthetic Surgery

66
Part I  Fundamentals
The timing of lipid infusion delivery is still being debated. It is probably unwise to
wait until ACLS has been determined ineffective, because early treatment of LAST
with lipid infusion can prevent cardiovascular collapse. However, only a small por-
tion of patients will advance to life-threatening toxicity. The midpoint between the
two extremes may be to start lipid rescue when LAST seems clinically severe and is
progressing rapidly. Cardiac life support should continue throughout the lipid res-
cue treatment.
Additional Points to Remember
High doses of epinephrine can impede the effectiveness of lipid rescue. Low doses in
the range of 1 g/kg can be safely used for hypotension.
Continue to monitor patients who had indicators of cardiac toxicity for at least 12
hours after they are stable. Cardiac depression can return after successful treatment.
Report LAST events and treatment at If lipid emulsion is used,
register the event at
Concluding Thoughts
A culture of safety cannot emerge as long as there is a culture of blame and unwill-
ingness to change behaviors and processes. Part of building a successful team requires
overcoming cultural barriers that impede some members of the surgical team from
speaking up because they are intimidated, are afraid of seeming foolish, or do not
think the surgeon values their opinions. Every staff member in an operating room
probably has something important to say about how safety practices could be im-
proved, but nothing will change unless these ideas are shared among surgical team
members.
According to AHRQ, the main component needed to improve patient safety is some-
one who will champion necessary changes. If a single surgeon seriously commits to
the need for change in safety practices, others will follow this leadership when prop-
erly educated about the evidence behind the change. Thus frequent in-service train-
ing, effective reminder systems, and prominent, well-designed checklists are essen-
tial. Progress should be recognized. In addition, plastic surgeons must perform more
thoughtful research to identify potential problems and solutions that will improve
our safety processes and practices. We also need to do a better job of tracking outcomes.
Surgical patients have every reason to assume their safety will be protected and they
will not be harmed. Adverse events are almost always a surprise to everyone involved
in a procedure. The best way to prepare for them is to be proactive and take the ac-

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Chapter 2  Patient Safety in Aesthetic Surgery
tions necessary to prevent the error in the first place. Keeping up with the latest lit-
erature related to patient safety could be practically a full-time job, and most plas-
tic surgeons are so busy that they rarely sample the literature of other medical spe-
cialties, such as anesthesiology, where much of the patient safety research is published.
Even so, we have a responsibility to keep pace with evidence-based patient safety
guidelines and protocols and turn them into actual practice.
Suggested Readings
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tion of postoperative nausea and vomiting. N Engl J Med 350:2441-2451, 2004.
Chung F, Yegneswaran B, Liao P, et al. Development and validation of STOP questionnaire:
an obstructive sleep apnea (OSA) screening tool. Anesthesiology 107:A938, 2007.
Davison SP, Venturi ML, Attinger CE, et al. Prevention of venous thromboembolism in the
plastic surgery patient. Plast Reconstr Surg 114:43e-51e, 2004.
Dronge AS, Perkal MF, Kancir S, et al. Long-term glycemic control and postoperative infec-
tious complications. Arch Surg 141:375-380, 2006.
Feldman D. The inside of a time-out. AHRQ WebM&M, May 2008. Available at

Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American
College of Chest Physicians evidence-based clinical practice guidelines (eighth edition).
Chest 133(6 Suppl):381S-453S, 2008.
Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns
resulting in injury to surgical patients. J Am Coll Surg 204:533-540, 2007.
Haeck PC, Swanson JA, Iverson RE, et al. Evidence-based patient safety advisory: patient
selection and procedures in ambulatory surgery. Plast Reconstr Surg 124(Suppl):6S-27S,
2009.
Hales B, Terblanche M, Fowler R, et al. Development of medical checklists for improved
quality of patient care. Inter J Qual Health Care 20:22-30, 2008.
Hales BM, Pronovost PJ. The checklist—a tool for error management and performance im-
provement. J Crit Care 21:231-235, 2006.
Hatef DA, Kenkel JM, Nguyen MQ, et al. Thromboembolic risk assessment and the efficacy
of enoxaparin prophylaxis in excisional body contouring surgery. Plast Reconstr Surg
122:269-279, 2008.
Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and
mortality in a global population. N Engl J Med 360:491-499, 2009.
Horton JB, Reece EM, Broughton G II, et al. Patient safety in the office-based setting. Plast
Reconstr Surg 117:61e-80e, 2006.
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tem. A Report of the Committee on Quality of Health Care in America. Washington,
DC: Institute of Medicine, National Academy Press, 2000.
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venous thrombosis prophylaxis after TRAM flap breast reconstruction. Plast Reconstr
Surg 121:1101-1107, 2008.
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Surg 143:12-17, 2008.
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635, 2006.
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systemic toxicity. Reg Anesth Pain Med 35:152-161, 2010.
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Chapter 2  Patient Safety in Aesthetic Surgery
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Sedation and Anesthesia
for Aesthetic Surgery

DONALD W. BUCK II, THOMAS A. MUSTOE
CHAPTER 3

72
Part I  Fundamentals
A
ccording to the American Society of Plastic Surgeons (ASPS), more than 80%
of all aesthetic surgery procedures are performed outside the hospital setting.
As the number of office-based surgical procedures continues to rise exponentially,
plastic surgeons have begun to embrace a less-invasive means for providing effec-
tive anesthesia: local anesthesia with sedation. There are two major states of seda-
tion used for procedural anesthesia: (1) deep sedation (DS), or monitored anesthe-
sia care (MAC), and (2) conscious sedation (CS). The success of both techniques has
been well described in the literature, spanning numerous surgical and nonsurgical
specialties, including plastic surgery, oral and maxillofacial surgery, otolaryngology,
cardiology, gastroenterology, pulmonology, interventional radiology, and dermatol-
ogy. A critical component of successful sedation is achieving effective local anesthe-
sia, which we will emphasize in this chapter.
Conscious sedation is defined as an altered state of consciousness leading to a com-
fortable state of relaxation while maintaining airway patency and respiratory drive.
During CS, the patient is capable of responding to verbal and physical stimuli. This
is the hallmark difference between CS and DS techniques. During DS, the patient
maintains airway patency and respiratory drive but is often unresponsive to stimuli.
Sedation techniques have many proven advantages over traditional general anes-
thetic techniques. In contradistinction to general anesthesia, patients under CS and
DS are capable of generating respiratory drive and protecting their airway, thereby
obviating the need for intubation. This fact alone prevents the development of air-
way complications such as pain, edema, injury, and pneumonia that are often asso-
ciated with mechanical ventilation. In addition, although patients under general anes-
thesia are immobile and lack lower extremity muscle tone, patients under CS and
DS maintain the ability to contract lower extremity musculature, thereby eliminat-
ing the venous stasis that can lead to deep venous thrombosis (DVT) and pulmonary
embolus. This is especially true in CS patients, who are in a much lighter state of
sedation, which allows them to shift their position throughout the procedure. It
has been reported in the literature that the risk of DVT is up to threefold greater in
patients undergoing general anesthesia compared with those receiving conscious
sedation.
Other important advantages of sedation techniques include a lower incidence of post -
operative nausea and vomiting and fewer unplanned hospital admissions, because
inhalational anesthetics and/or high-dose narcotics are not used. In addition, post-
procedure recovery is more rapid as a result of the short half-life of most sedative
medications used in CS and DS techniques.
Although sedation techniques offer many advantages over general anesthesia, they
are not without a few important disadvantages. Because patients are not entirely
asleep, there is the risk that they will recall the procedure and the experience of pain