When Dr. Kenneth Hughes was a clinical instructor and fellow at Beth Israel Deaconess at Harvard University, he gave frequent presentations about all aspects of plastic surgery including safety for the office staff.
Aesthetic Plastic Surgery: Safety for the Office Staff
Kenneth Hughes, MD
Division of Plastic and Reconstructive Surgery Beth Israel Deaconess Medical Center
Harvard University
Intended Audience
- Office Staff
- Including nurses, surgical technicians, and office managers
- It is of paramount importance that all of the office personnel be focused on improving patient outcomes along with the plastic surgeon and anesthesia providers
Safety Measures Outline
- Preoperative Safety Measures
- Intraoperative Safety Measures and Protocols
- Postoperative Safety Measures
- Review Questions/Quiz
Preoperative Safety Measures
- Most aesthetic plastic surgery candidates should have good general health and few, if any, comorbidities if they are to be done in the office setting
- Additionally, some patient characteristics can disqualify the patient for the surgery, because the risk of complication is too high as to be acceptable to the plastic surgeon
- These characteristics may vary based upon an individual surgeon’s technique and perspective
Preoperative Safety Measures
- From the time the patient enters the office, certain key items should be identified
- Tobacco, alcohol, or drug use
- Nothing gets you taken off the OR schedule for a facelift faster than a smoking history
Preoperative Safety Measures
- Allergies (not just medication but adhesives, skin prep, and latex)
- It can be difficult to explain to a patient why she has partial thickness skin injury after a known offending adhesive was applied for dressings
Preoperative Safety Measures
- Medications including birth control products (BCP), over the counter drugs (OTC), vitamins, and herbal preparations
- Numerous herbal preparations can negatively impact clotting, while BCP put patients at risk for deep venous thrombosis and pulmonary thromboembolus
Immediate Preoperative Measures
- Patients should be free of ingestion of clear liquids for 2 to 3 hours and of solids for 6 to 8 hours prior to induction
- Patients should be normothermic prior to entering the operative suite
- Preoperative warming should be performed to achieve normothermia
- This issue is critically important in larger liposuction cases, body contouring cases, or during longer duration or multiple procedure cases
Immediate Preoperative Measures
- The patient’s risk factors for deep venous thrombosis have been documented and prophylaxis has been administered
- All patients should have some form of lower extremity venous compression devices that are started prior to induction of general anesthesia
- Any patients with multiple risk factors should receive additional chemoprophylaxis (eg. Lovenox)
Special Mention for Abdominoplasty
- This procedure is associated with the highest risk of deep venous thrombosis and pulmonary thromboembolus as reported in the literature
- This procedure performed by itself or in conjunction with other procedures in most cases requires some form of chemoprophylaxis
Intraoperative Safety Measures
- Assure that the compression devices continue to cycle
- Everyone should perform periodic checks of the blood pressure, heart rate, and oxygen saturation
- This is particularly true during and immediately following positioning changes and administration of local anesthesia
Fire Safety
Particularly during facial procedures, everyone must be aware of
- Electrocautery use
- Presence of combustible substances (i.e. drapes)
- Presence of Oxygen
Fire Safety
- If oxygen is being used, the source must be turned off for at least one minute before electrocautery is used
- In most circumstances when electrocautery is to be used frequently, it is probably safer to not administer oxygen unless the patient’s condition mandates
Fire Safety
- Skin preparatory agents should be dry or wiped dry
- Wet sponges or towels can alleviate some of the risk
Emergency Protocols
- There should be written protocols displayed prominently in the OR for cardiopulmonary emergencies
- Everyone should know the protocols for the expeditious transfer of patients
- Everyone should know the fire evacuation protocol
Postoperative Safety Measures
- Attention to detail in the immediate postoperative period can be just as important as intraoperative and preoperative safety measures
- The end of the surgery does not signal the end of vigilance for patient care
Postoperative Safety Measures
- High blood pressure must be recognized and treated as it can lead to hematoma formation
- Vomiting, coughing, as well as straining of any kind can lead to hematoma formation as well
Postoperative Safety Measures
- Patient positioning is critical as well
- Head elevation is important in any facial procedure (eg. facelift or rhinoplasty)
- Patient positioning is also critical after abdominoplasty
— patient should remain flexed at the waist to theoretically prevent wound separation
End of Presentation
Review Question #1
Lower extremity compression devices should be placed
- After induction
- Before induction
- on a case by case basis
- instead of Lovenox
Review Question #2
Fire safety involves awareness of all of the following except
- Electrocautery
- Oxygen
- Drapes
- Wet sponges
Review Question #3
High blood pressure has been shown to increase the rate of
- Vomiting
- Hematoma
- Straining
- Coughing
Review Question #4
Which of the following procedures has the highest risk of development of deep venous thrombosis?
- Liposuction
- Rhinoplasty
- Abdominoplasty
- Facelift
Review Question #5
Following the repositioning of the patient, which of the following should be closely monitored?
- Blood loss
- Urine volume
- Temperature
- Oxygen saturation