How you manage BIS monitoring during facelifts, browlifts and hair transplantations cases?

If one does not believe the BIS is useful, then these cases provide
ample reason not to use it.

If you believe, as I do, the BIS gives you information you cannot
obtain by vital signs monitoring, then one finds a way to use the
device.

For facelifts, my surgeons typically start on the right side of the
face. Therefore, I put the #3 tab of the montage on the left side of
the face.

N.B. If your surgeon is concerned about the sterility of the sensor,
PREP IT, taking care not to get the liquid into the junction of the
sensor and the cable.

If your scrub nurse is overly vigorous, it is possible to disrupt
the adhesion between the skin and the sensor. Just dabbing the sensor
will do fine.

Unless the patient is to receive some sort of facial implant along
with the facelift, then sterility is not a huge issue. It is very
difficult to get an infection in the facelift patient.

If, after the first side of the facelift, you want to continue to
monitor with the BIS, several options are available:

1. Remove the sensor and turn it around so the little tab is now on
the patient's right temple area.

Re-prep is one feels the need. I do not think it is necessary,
initially or secondarily.

2. Leave the first 3 sensor leads in place and move the #3 tab up,
down or anywhere it will be far enough away from the incision not to
disturb the surgeon.

Having done this several times, I have not observed any serious
degradation in the utility of the monitoring information.

If, on the other hand, the patient has been stable and you are
comfortable with your dosing regimen, one can always simply remove the
sensor and stop using the device.

Browlifts are a more interesting situation.

If you surgeon is still doing the coronal ear to ear incision with
full flap reflection down onto the nose, you will obviously lose the
usefulness of the monitor for the time the flap is completely
elevated until it is replaced.

Many surgeons around the world have abandoned this open style of
browlift in favor of the endoscopic style browlift.

Nicanor Isse, M.D., Oscar Ramirez, M.D., and Luiz Vasconez, M.D. are
the three plastic surgeons generally credited for the development of
this type of browlift.

As fate would have it, I had the opportunity to anesthetize most of
Dr. Isse's patients, including his endo-browlifts, for the 4 years
prior to beginning to writing Anesthesia in Cosmetic Surgery in
2004. Dr. Isse also had me lecture about MIA at several of his
Endoscopic Plastic Surgery Educational Seminars (EPSES) courses as
well as give the anesthesia for the demonstration cases. He is
pictured along side of me in an article I wrote for Outpatient Surgery
Magazine in February 2004 entitled 'Minimally invasive anesthesia for
minimally invasive surgery. Although the article is a trade journal,
non-peer reviewed one, it was cited on the Karolinska Insititute web
site.

During none of Dr. Isse's endo-browlift cases did we have to
discontinue BIS monitoring.

During the few moments the skin flap is entirely elevated from the
skull, obviously, one will lose input to the sensor/BIS.

Hopefully, knowing BS monitoring was good for Dr. Isse will be
sufficient to reassure your surgeons that it will be OK for them.

I dealt with the sensor issue for the endo-browlifts in the same way
I described above for the facelift cases.

Hair transplantations have not been as big an issue as either
facelifts or endo-browlifts. I would suggest putting the patient in
the prone position to whatever level of sedation you choose for the
harvest and disconnecting the sensor before turning the patient
supine. (If one does not detach the cable, one risks inadvertently
puling it off during the turning process.) In this manner one has only
to turn the patient once. One may even lighten the patient enough to
allow them to turn themselves and then deepen the sedation. They are
unlikely to have any recall when asked post-operatively.

EMG

If you are already trending the EMG as a secondary trace, please
accept my apology for being redundant.

If you are NOT trending EMG as a secondary trace, please do so.

BIS is 15-30 seconds delayed behind real time whereas, EMG is
instantaneous.

Titrating propofol with BIS only is much like trying to drive down the
street using only your rear view mirror.

EMG spikes will greatly increase the utility of the monitor to predict
patient movement and your ability to proactively manage the propofol
as opposed to perpetually playing 'catch-up.'

Table 1-9 Errors to Avoid

1. Ketamine before propofol: NO

2. Ketamine at BIS >75: NO

3. Bolus propofol induction: NO

4. Inadequate local analgesia: NO
BIS as fianchetto for adequate propofol and lidocaine

5. Opioids instead of more lidocaine: NO

6. Ketamine instead of more lidocaine: NO

7. >200 mg total ketamine or any in last 20 min. of case: NO

8. Tracheostomize patient for laryngospasm instead of IV lidocaine: NO

9. SCH instead of lidocaine for laryngospasm: NO