CHAPTER 23
23
pressure and the hepatic metabolism of the drugs ad- ministrated increase. Then more or repetitive seda- tion should be administered and vasoconstriction does not last long.
When the patient is under deep sedation, breath- ing spontaneously, the blood pressure remains low and so does the hepatic metabolism of drugs. Under deep sedation, the patient can have problems with the airways, because the neck tilts, and the tongue relaxes and obstructs the pharynges. In some cases, an oral or pharyngeal tube is needed. As oxygen is adminis- trated through a nasal tube, it has to be moved from the frontal area to the neck when each area is ap- proached.
The association of midazolan–fentanyl is the best combination to keep the patient asleep. Midazolan should be administered in a small bolus so that no re- spiratory depression arises. Fentanyl should be ad- ministered before the infiltration. When the surgery lasts for some hours, complementary ketorolac injec- tions help to keep the patient free of positional pains.
One hour before surgery, complementary sedation with propofol helps a prompt postoperative recovery [8]. Nausea and vomiting should be prevented during surgery by administering metoclopramide or ondase- stron, because after surgery these are undesirable ef- fects.
Sedation can be conducted by an anesthesiologist, by a well-trained nurse or by a technician. The last two can keep the patient under control during sur- gery but the anesthesiologist manages a wider range of drugs and options. In the case of an anesthetic problem, the anesthesiologist has more possibilities to reverse it and the surgeon is legally better protected.
23.4 Anesthetic Drugs
Lidocaine is a very old and safe anesthetic drug that allows 90 min of numbness. Its standard dose is 7 g/kg, or 25 ml of 2% lidocaine (500 mg) for a 70 kg person, but it is known that this dose can be aug- mented many times; some papers mention about
23.1
Introduction
Local anesthesia has been used in facial cosmetic sur- gery for decades [1–4]. The anesthetic drugs allow op- erating without general anesthesia; the addition of bupivacaine gives some hours of postoperative pain relief; adrenaline produces vasoconstriction for some hours and a profuse infiltration separates the planes of dissection, thus facilitating the surgery. For local anesthesia, light or deep sedation is always necessary.
For this kind of anesthesia, four steps should be con- sidered [5].
23.2
Selection of the Patient
There are both calm and relaxed patients and very nervous ones. This last kind of patient is conflictive and needs a different preparation and possibly a deeper sedation. Smokers, alcoholics, hypertensive patients and tranquilizer users have their hepatic me- tabolism accelerated and will probably need a differ- ent plan for sedation [6].
23.3 Sedation
To bring a patient to the operating room in the opti- mal condition, an appropriate preparation should be followed. There are calm and relaxed individuals who need less care, while others need sedation for some days before surgery. But it is extremely important that the patient has a relaxing sleep the night before. When patients have had a bad night, adrenaline is secreted and they enter the surgery not totally relaxed [7].
There are two methods of sedation. The patient can be superficially sedated and the surgeon or the anesthesiologist can have verbal contact with the pa- tient or, in contrast, the patient is operated on under deep sedation. In the former case, when the patient wakes up adrenaline is secreted; therefore, the blood
Local Anesthesia for Facial Surgery
A. Aldo Mottura
106
seven times the maximum recommended dose [9]
(Fig. 23.1).
Bupivacaine is a long-lasting anesthetic that is largely used in block anesthesia. Its dose is 1.25 mg/
kg, 25 ml of 0.50% bupivacaine for a 70 kg person and its action lasts 6 h.
The standard concentration of adrenaline is 1:1,000 and it can be diluted in 100 or 500 ml, obtaining a dilution of 1:100,000 to 1:500,000 [10]. This drug’s va- soconstrictive action lasts 5–7 h and causes brief side effects like tachycardia and hypertension.
If the patient is awake and the surgeon needs to neutralize the acid anesthetic solution, then the addi- tion of bicarbonate is indicated. If the patient is under deep sedation, bicarbonate is unnecessary.
For a coronal lift, I use approximately 200 ml, for a facelift 150 ml and for the neck 150 ml depending on the size of the head and neck of each patient.
23.5
Technique of Infiltration
The infiltration should begin with a very fine needle, injecting slowly, because rapid distension of tissues is painful. Once the skin has been anesthetized, the fine needle is changed for a longer one or for a cannula.
The inner side of an Abbocatt no. 16 or a spinal needle are also very useful.
In general, I infiltrate the whole forehead, face and neck at the beginning of the surgery. This way, when the second or third region is approached, it already has an appropriate vasoconstriction. The infiltration is begun at the facial region where the surgeon will first start. If the surgeon begins at the forehead, this area is infiltrated first.
I start with the face and, in general, I infiltrate 1–
2 cm outside the whole marked area of the face and neck, because the dissection can cross the premarked limits. In the central part of the neck, I infiltrate the skin and the posterior aspect of the central fat so as to facilitate its dissection [11, 12].
With use of 200 ml of the same solution, the scalp is infiltrated first with a long needle in the hypoder- mis underneath the incision line and 2 cm behind the marked line, and deep into the frontal muscle or into the galea. Then I infiltrate the forehead, in the subga- leal plane up to the orbital rim and the nasal dorsum
Fig. 23.1. Five hundred anesthetic solutions are prepared
Fig. 23.2. Distribution of the infiltration for a forehead–face–neck-lift
107 23 Local Anesthesia for Facial Surgery
to assure a better vasoconstrictive effect of the plane to be undermined (Fig. 23.2).
When I finish the infiltration, 15 min has already elapsed and I can start surgery on the region that was firstly infiltrated. I usually begin with the face and then go on with the neck. Before the superficial mus- culo-aponeurotic system dissection, I infiltrate this plane for vasoconstriction and for hydraulic dissec- tion and separation of the planes. The whole surgery takes me 3–4 h. I never have to reinject while I am finishing with the sutures.
A pale color of the skin shows a well-infiltrated area, while an island of reddish skin means an area that has not been infiltrated, such as often happens in postacne scarred skin.
When I have already dissected one side of the face and neck, I introduce two compresses under the skin and I go to the contralateral side, where I repeat the procedure. Then I come back to the first side and I remove the compress slowly while doing the coagula- tion of the vessels.
23.6 Discussion
I have more than 25 years’ experience using local an- esthesia for facelift. At the beginning of my practice, I personally did the sedation using a premedication with morphine–prometazine–atropine, but postop- erative recovery was not fast. Then I used valium–ket- amine, but later changed to midazolan–fentanyl. For 10 years ago I have had an anesthesiologist in each surgery and he combines midazolan–propofol–fen- tanyl according to the case. He also uses flumazenyl to wake up the patient at the end of the surgery. Using metoclopramide and ondasestron, I have a rate of less than 10% postoperative vomiting.
The argument that after using adrenaline there is a vasodilatation is against the experience of most of fa- cial surgeons. Bleeding does not occur because after some hours of vasoconstriction, the sealing of the sec- tioned arteries and veins and the clot of the intravas- cular coagulation are firm.
It is often heard that surgeons say they use a tu- mescent infiltration in the face and neck. As the tu- mescence is massive, tense, or hard like a ball infiltra- tion and this does not happen on the face and neck, the use of the term tumescence is totally inappropri- ate for this surgery.
The doses of anesthetic drugs are well tolerated when used much diluted. Big faces and heads need a greater amount of infiltration, while small ones need less. Hydraulic distension of local anesthetics reduces the bleeding and facilitates the undermining.
I routinely use bupivacaine, which gives 3–4 h pain relief after surgery. I have not had a single problem with this drug in my experience of more than 3,000 aesthetic surgeries.
23.7 Conclusions
Local anesthesia and deep sedation is a good combi- nation for ambulatory surgery. With local anesthesia, there is no intubation and a low rate of vomiting. With bupivacaine, there are some hours of postoperative pain relief. The cost of anesthesia is also lower.
References
1. Mottura A.A.: Local Anesthesia in Reduction Mastoplas- ty for Out-patient Surgery. Aesth Plast Surg 16:309–315, 1992.
2. Mottura A.A.: Local Anesthesia for Abdominoplasty, Li- posuction and Combined operations. Aesthetic Plast Surg 17:117–124, 1993.
3. Mottura A.A.: Local Anesthesia was Developed in Ger- many One Century Ago. Aesthetic News 2:7, 2004.
4. Mottura A.A.: Local Infiltrative Anesthesia for Trans- axilary Subpectoral Breast Implants. Aesthetic Plast Surg 19:37, 1995.
5. Mottura A.A.:.Lokalanästhesie in der äesthetishen Chirur- gie. In: Lemperle G, ed. Aesthetische Chirurghie. 1st edn.
Ecomed, Grand Werk; 1998:II-1.
6. Mottura A.A.: Local Anesthesia: The Selection of the Ideal Patient. Lpoplasty 12:13–15, 1995.
7. Mottura A.A.: Cirugía Estética Ambulatoria: Drogas Usa- das en Anestesia. Local Rev Cir Plast Ibero Lat 19(3):263, 1993.
8. Mottura A.A: Face Lift: Postoperative Recovery. Aesthetic Plast Surg 26:172, 2002.
9. Mottura A.A. and Procickieviez O.: The Fate of Lidocaine Infiltrate During Abdominoplasty and a Comparative Study of Absortion of Local Anesthetics in 3 Different Re- gions: Experimental Studies in a Porcine Model. Aesthetic Surg J 21:418, 2001.
10. Mottura A.A.: Epinephrine in Breast Reduction. Plast Re- const Surg 110:705, 2002.
11. Mottura A.A.: Tumescent Technique for Liposuction. Plast Reconst Surg 94:1096, 1994.
12. Mottura A.A.: The Tumescent Technique for Facelift?
Plast Reconst Surg 96:231, 1995.
