Anesthesia & Analgesia Dec. 2007

Section Editor:Norig Ellison
Anesthesia in Cosmetic Surgery
Reviewed by L. Blinder Jordan, MD, and B. Gross Jeffrey, MD

Date Published: 
Sat, 2007-12-01

Anesthesia in Cosmetic Surgery, edited by Barry L. Friedberg is a comprehensive textbook for those who provide anesthesia services to patients undergoing cosmetic surgery. While much of its focus is on anesthesia for office-based cosmetic surgery, the scope is sufficiently broad to cover hospital-based practices, pediatrics, and related topics such as regional anesthesia.

Laid out in three distinct sections, the book is well organized. The first section thoroughly directs the practitioner through the specific practice of propofol-ketamine (PK) intravenous anesthesia. Dr. Friedberg painstakingly elucidates the "do’s" and "don’t’s" of his "minimally invasive anesthesia" (MIA) technique. He strongly recommends that the anesthesiologist develop a close working relationship with the surgeon, and that patients be carefully selected for these extensive and often lengthy procedures. At times, the author is self-promoting in suggesting that the benefits of MIA (a 0.5% incidence of postoperative nausea and vomiting) outweigh all other concerns. The recipe is somewhat formulaic. The author states without references that patients weighing between 90 and 250 pounds have an approximately equal number of NMDA receptors, and that therefore they all should receive the same 50-mg dose of ketamine at the onset of "minimally invasive anesthesia."

From the perspective of patient safety, one must be wary of Dr. Friedberg’s suggestion that 2000 mg of dilute lidocaine represents an appropriate dose for breast augmentation. The fact that 100 sequential patients received this dose without any adverse outcomes does not provide statistically sound evidence that the technique is safe. Fortunately, a later chapter by Dr. Adam Dorin succinctly reviews the safety issues surrounding megadose lidocaine for tumescent liposuction and body contouring. Dr. Dorin quotes conventional doses and reviews the toxic plasma levels and their clinical manifestations. Typical dilution quotients, peak serum levels, and pharmacokinetics are presented for doses as high as 35 mg/ kg! In these cases, total epinephrine doses may reach 5 mg, again emphasizing the need for careful patient selection. The second major section is entitled "Alternative Anesthesia Approaches in Cosmetic Surgery." The methods presented are neither unique nor alternative to most practicing anesthesiologists. They primarily resemble the typical practice of hospital-based anesthesia and are alternative only in the sense that they differ from Dr. Friedberg’s MIA technique. Perhaps a better title for this section would be "Non-MIA Anesthesia for Cosmetic Surgery." In this regard, Dr. David Barinholtz offers a refreshing look at intravenous general anesthesia. In contradistinction to the editor, Dr. Barinholtz does not hesitate to use opioids when clinically indicated. He accurately points out that many plastic surgeons are reluctant to infiltrate additional local anesthetics once the surgical procedure has started. In addition, he discusses the appropriate use of general anesthesia with muscle relaxation during abdominoplasty. There is also a thorough review of the indications, benefits, and risks of spinal, epidural, paravertebral, and intercostal blocks during cosmetic surgery. It is well referenced, and includes a discussion of the ASRA guidelines for patients receiving anticoagulant therapy. Finally, this section covers general inhalation anesthesia for cosmetic surgery and includes a review of risk stratification for perioperative thromboembolism.

The final section entitled "Other Considerations in Cosmetic Surgery" reviews preoperative patient assessment and selection. It contains a superficial review of common diseases, which seems more suitable for the lay public rather than for anesthesiologists. Highlights include a concise presentation of herbal medicines and a section dealing with psychiatric disease in cosmetic surgery. The discussion of body dysmorphic disorder is cogent and dispels many of the common myths associated with cosmetic surgery.

The last two chapters identify the current controversies surrounding performance standards in cosmetic surgery and discuss the various accreditation agencies that oversee freestanding surgical centers, hospitals, and office-based practices. There is a clear definition that "office-based surgery" refers only to procedures performed in private physicians’ offices; an important point is made that these offices are usually not licensed or regulated by the states in the same manner as hospitals and freestanding surgical centers. The authors clearly favor accreditation-based systems over legislative regulations. Nonetheless, they believe that the practice of anesthesia in an office-based setting can be safe.

The text is easy to read. Although generally well written, it suffers from a lack of editorial oversight. The authors and editor are self-promoting at times, and there are multiple typographical errors, inconsistencies, and factual errors. Typical examples include labeling "emergence" as "emergency" on a BIS tracing (page 30), giving a case history for a rhinoplasty and subsequently referring to patient immobility "for injection of her breasts" (page 40), "sermatologic" surgeons (page 208), and a liposuction mortality rate of "19 in 1,000" (page 161). Additionally, there are occasional major errors such as categorizing halothane as an ether rather than an alkane (page 113). Despite these shortcomings, the overall intent of the individual chapters remains clear.

The text is a suitable addition to the library of those who anesthetize patients for cosmetic surgery. The reader is urged to use the described techniques as guidelines rather than de facto rules and to disregard the bravado of the editor. Also, keep in mind that the dosage guidelines for local anesthetic are "generous." Putting these issues aside, the textbook serves as a useful primer in the practice of anesthesia for cosmetic surgery and deserves a place on one’s subspecialty bookshelf.

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