into the postoperative period Levels of patient satisfaction before and after surgery are highly dependent on the patient’s experience throughout the entire clinical journey commencing from the initial consultation through to the final postsurgical consultation. It is vital, therefore, that the surgeon develops a good rapport with the patient from the outset in the first consultation. The strength of this early interaction provides the foundations for ongoing trust and understanding between the doctor and patient. Involving patients in their own management before surgery promotes understanding, empowers them to invest in their own results, and may help to manage expectations as well as deal more robustly with complications should they arise.1,2 Meticulous attention to detail during preoperative planning through surgery and beyond can help minimize complications; however, complications cannot be completely avoided. It is often said that only the surgeon who does not operate will have no complications. Complications may be inherent to a specific procedure, individual patients and their comorbidities, or a particular systems-based issue. There are general principles that may be applied preoperatively, intraoperatively, and postoperatively to decrease the potential complications. One such area is the strict management of blood glucose levels in diabetic patients as poor control is associated with increased risk of surgical site infection and delayed wound healing. A perioperative serum glucose of over 200 mg/dL results in higher rates of wound healing complications and so should be avoided.3,4 Other key risks to avoid are venous thromboembolic events (VTE) which include deep vein thrombosis (DVT) and pulmonary embolism (PE). All patients should be considered for VTE prophylaxis; however, only those considered to be at high risk, such as a strong history of previous embolic events, need preoperative review by a hematologist. Likewise, although preoperative blood tests are useful in many cases, low risk ambulatory patients probably do not benefit from routine preoperative laboratory tests and these only serve to increase costs and burden the health service.5
Smoking is one of the key lifestyle factors that can specifically increase the risk of postoperative complications including wound healing problems secondary to tissue hypoxia and ischemia.1 In addition, general anesthetic complications are more likely, such as postoperative pulmonary complications. Therefore, in the elective setting, smoking cessation is strongly advised prior to aesthetic or reconstructive surgery and for a sustained period afterwards. Although from an overall health perspective it may be ideal for a patient to stop smoking permanently, it would not be absolutely necessary for the purposes of surgery alone. Instead, smoking abstinence for a 4-week period both before and after surgery is generally accepted as a reasonable compromise to safely proceed with elective plastic surgery from a wound healing perspective (pulmonary is longer).2,3 Procedures most at risk of complications in smokers include face lifts with large areas of undermining, skin-sparing mastectomy, and abdominoplasty where large skin flaps are elevated reliant on altered blood supply. Patients willing to stop smoking can get benefits from both pharmacological and nonpharmacological interventions. Pharmacological interventions include nicotine replacement medicines and bupropion, which is a medication primarily used to treat major depressive disorder, but one that can help reduce cravings and withdrawal effects of smoking cessation. Nonpharmacological modalities include counseling, behavioral therapy, hypnosis, and psychotherapy. There are a number of reliable tests to assess for patient compliance with smoking cessation. These include urinary cotinine which is a byproduct of nicotine, or blood test measurement of multiple nicotine metabolites including cotinine, anabasine, and nornicotine. These tests can be performed preoperatively to ensure satisfactory compliance and allow for deferment of surgery if compliance is inadequate. As stated above, the negative effects of smoking are well described and not overstated. Hence, surgeons should routinely advise patients that smoking should be minimized or completely stopped in order to optimize postoperative outcomes and minimize complications.4
Surgical site infection can be a devastating complication in aesthetic and reconstructive surgery, particularly where an implant is used. Staphylococcus aureus is the leading cause of surgical site infection, and the prevalence of community-acquired methicillin-resistant S. aureus (MRSA) surgical site infection is increasing. Therefore, presurgical decolonization, skin antisepsis, and systemic antibiotic use perioperatively should be utilized in order to minimize risk of surgical site infections. In patients who have a history of previous MRSA infection and those who are carriers should receive vancomycin 1 g 60 minutes before surgery. All other patients (notwithstanding those with allergy status issues) should be prescribed IV cefazolin 30–59 minutes before surgery, but not specifically postoperatively in oral formulation. Alternatively, some surgeons/ centers may prefer to use flucloxacillin or amoxicillin/clavulanate instead. Most centers will routinely perform MRSA screening swabs on all patients prior to their undergoing elective surgery. Those who have a previous positive MRSA status or are at high risk, e.g., immunocompromised or a health care worker, must all be screened. Screening should normally be undertaken between 2 and 4 weeks before surgery. It involves taking swabs from the nasal mucosa bilaterally to assess nasal carriage, rather than groin swabs which were common previously. Both nares are swabbed with a single swab as the association with nasal carriage and subsequent infection is well established.1,2 Those patients who grow positive MRSA cultures are instructed to apply 2% mupirocin nasal ointment twice daily (not once) to both nares and to bathe with chlorhexidine (40 mg/mL Hibiscrub) daily for 5 days (not 1 month) immediately before the scheduled surgery. Patients who are not MRSA positive do not require these eradication therapies.
4. Guyuron B, Raszewski R. Undetected diabetes and the plastic surgeon. Plast Reconstr Surg 1990;86(3):471–474
5. Fischer JP, Shang EK, Nelson JA, Wu LC, Serletti JM, Kovach SJ. Patterns of preoperative laboratory testing in patients undergoing outpatient plastic surgery procedures. Aesthet Surg J 2014;34(1):133–141
The second phase of the WHO checklist is performed as a “time out” once the patient is anesthetized, if having a general anesthetic, or once the patient arrives in the OR prior to delivery of local anesthetic if having a local anesthetic. The time out is undertaken prior to commencement of surgery. The first action is to repeat the team member introduction to ensure all team members know each other and understand their respective roles. This can be particularly relevant where staff members have changed or have been added following the initial preoperative briefing. Once this introduction has been done, the patient’s identity is checked once more using the name band and cross referencing with the provided documentation. The surgical site, procedure, and consent are each checked and confirmed. Most teams will also recheck the patient’s allergy status at this time although it is not formally documented as part of the original WHO time out. A review of the critical or nonroutine steps is made by the lead surgeon, including anticipated blood loss and expected duration of surgery. The anesthetic team reviews any specific concerns the patient may have. Then the nursing team confirms the sterility and availability of instruments/equipment, and any other anticipated concerns. Antibiotic prophylaxis is confirmed to have been administered prior to making the first incision. All essential imaging results are confirmed to be present and correct. Once completed the procedure may be commenced.1
Routine postoperative prescription of antibiotics following septorhinoplasty is not indicated, even though intuitively it can be, given the potential for intranasal organisms to cause problems. A number of publications have explored the evidence for routine prophylactic antibiotics in rhinoplasty, including a recent systematic review and meta-analysis. Each of these have concluded there is no justification for routine postoperative antibiotic use in such cases based on the low incidence of infection. In those that compared patients having been given postoperative antibiotics and those who had not, there was no difference in the observed outcome. There may, however, still be an indication for their use in select cases such as more complex revision procedures particularly where infection has been an issue in the past, where nasal packs are left in situ for an extended time, or where patients have reduced immune system reserve.1–3 There is a role for prophylactic antibiotic use in the perioperative period for many different types of plastic surgery and in most cases, a single dose of intravenous antibiotic is administered 30–60 minutes prior to commencement of surgery. The precise timing of this will depend on the antibiotic chosen. For example, Ancef (cefazolin) and many others should be administered 30–60 minutes prior, whereas vancomycin and fluoroquinolones should be administered no less than 1 hour before surgery (typically 1–2 hours before incision). In some cases, it is acceptable to administer antibiotics postoperatively; however, many guidelines and protocols including those produced by the Surgical Care Improvement Project (SCIP) encourage clinicians to avoid prescription of antibiotics where not clinically indicated beyond the first 24 hours of surgery. The consensus position of the working group involved in SCIP concluded that infusion of the first antimicrobial dose should begin within 60 minutes before surgical incision and that prophylactic antimicrobial agents should be discontinued within 24 hours of the end of surgery. There is however no specific reference by SCIP to the use of postoperative antibiotics following breast implant use in either primary augmentation or reconstructive surgery settings.4 One study looked at the effects of changing antibiotic protocol to comply with the SCIP protocol (as described above) in breast reconstruction patients, and found that when postoperative antibiotics were omitted, the rate of postoperative infection increased.5 Therefore, the authors concluded that postoperative antibiotics should be used after augmentation surgery. Overall, there remains a paucity of robust evidence to guide the use of antibiotic prophylaxis in breast reconstruction and implant surgery and there is no specific consensus on this. In one systematic review of breast reconstruction patients, the infection rate was higher where no antibiotics were given, but there was no difference in infection rates where less than or more than 24 hours of antibiotics were prescribed. Therefore, it would seem that prophylaxis of up to 24 hours would be adequate.6 In contrast, another study compared the use of antibiotics (single dose cephalosporin before induction of anesthesia) with no antibiotics in primary breast augmentation and found no significant difference in infection rates or complications between the two groups. Although this was a smaller single operator study with 90 patients in each arm, it provides evidence to suggest that antibiotic use may not be indicated in primary augmentation.7 Intraoperatively, for longer procedures IV antibiotics may need to be redosed. The timings for this depend on the antibiotic. For example, Ancef should be redosed every 4 hours and clindamycin every 6 hours.
The combination of a 4% chlorhexidine gluconate (CHG) preparation with a 70% isopropyl alcohol (IPA) has the highest probability of being effective in minimizing surgical site infections (SSI) according to a recent Cochrane review.1 Another recent review of common skin preparation agents demonstrated that 2% chlorhexidine gluconate (CHG) and 4% CHG (Hibiclens) had inferior antimicrobial activity to isopropyl alcohol (IPA) (70%) or 2% CHG combined with IPA (ChloraPrep).2 In general, alcohol-based antiseptics are currently thought to be more effective than those with an aqueous base as the alcohol itself has antimicrobial qualities. This may be a factor of equal importance to the prep type itself. A further thing to consider when interpreting this evidence is that little of this actually relates to plastic and reconstructive surgical procedures, but is instead based on other specialty procedures such as general surgery and orthopedics. If it is accepted that alcohol-based skin preps are more effective and they are selected for use, caution must be taken when using them as if they are not completely dry, they risk ignition when using electrocautery leading to fires in the OR and patients with burn injuries. Chloroprep has a good evidence base to support its use and is marketed as a unit with a sponge applicator included. Although this may be advantageous for reducing SSI, it is a more expensive way of delivering the skin preparation and is limited in some regards by the small applicator sponge size and shape. Combining iodine and chlorhexidine has no proven antimicrobial benefits; however, it can be useful to perform a first prep with iodine before applying a second prep of alcohol bases chlorhexidine where detailed preoperative markings have been made (e.g., breast reduction/ mastopexy) as this seems to limit the removal of the marking ink.
9. Swanson E. The case against chemoprophylaxis for venous thromboembolism prevention and the rationale for SAFE anesthesia. Plast Reconstr Surg Glob Open 2014;2(6):e160 INTRAOPERATIVE MEASURES TO REDUCE COMPLICATIONS 5. When performing the World Health Organization (WHO) surgical checklist, which one of the following is true? The WHO checklist has been designed to reduce the risk of accidental error, mistakes, and adverse events occurring during surgery.1 In particular, things such as wrong site, wrong side, or wrong type of surgery, inadvertent drug administration where allergies are present, and other errors associated with surgery and anesthesia are targeted. It serves to ensure the team members caring for the patient understand the procedure planned and are all on the same page in terms of equipment required, potential or unusual risks specific to either the patient or surgery type, and key steps and duration of surgery. The implementation of this check-listing system has been shown to decrease both perioperative morbidity and mortality.2,3 The WHO procedure has 19 steps incorporated into three stages, not two, and the surgical procedure is described in each of the three stages. The first stage is the “sign in” phase and is undertaken prior to anesthesia, usually by the anesthesiologist and supporting team. The patient’s identity is confirmed in both this stage and the second stage which follows it, but not specifically the final stage as the identity has already been confirmed repeatedly by this time. The second stage is called the “time out” phase and is performed once the patient is anesthetized in the operating room (OR) prior to commencement of surgery. The “time out” is generally led and conducted by the lead surgeon with the intention of everyone pausing to focus that the correct procedure is being undertaken and that all team members are onboard with the surgical plan. The WHO checklist applies not only to general anesthetic cases, but also to both regional blocks and local anesthetic cases too. The third stage is the “sign out” phase. This is usually performed by one of the nursing team prior to the patient leaving the theater. In this phase, the procedure is again confirmed as is the postoperative plan and any concerns for the recovery team. Confirmation of needle, sponge, and instrument counts is made at this time, as well as correct labeling of specimens. Knowledge of the WHO checklist is vital for any surgeon and the team in order to minimize risks during and following surgery.
For patients undergoing rhinoplasty, perioperative corticosteroids can be indicated as they decrease postoperative edema and ecchymosis. Evidence suggests that preoperative use is superior to postoperative use, and extended dosing is superior to singular.1–4 The evidence that perioperative corticosteroids decrease facial swelling and ecchymosis following facelift remains anecdotal and unsubstantiated. Steroids may be associated with increased cost and risk of complications, including exacerbation of hypertension, deterioration of glucose control, increased rate of infection, and potential for avascular osteonecrosis.5–8 There is no evidence to support the use of steroids following otoplasty or blepharoplasty.
There are a number of adjuncts which may be used to help scar quality post surgery. Of these, silicone is the most widely accepted modality for high-risk patients such as this woman who is having surgery to a high-risk area for poor scars on the background of previous poor scarring. Steroid gel sheeting should be started once the wounds have fully epithelialized (i.e., at 1–2 weeks post surgery) and continued for at least 1 month. The sheets should be worn for a minimum of 12 hours per day. Although silicone gels may be effective, evidence supports the preferential use of the sheets over gel.1,2 Application of microporous tape onto wounds after closure in the OR has been shown to help improve scar quality. It most likely achieves this by supporting the wound externally during the healing phase and reducing swelling.3,4 It may be worthwhile using for the first few weeks following surgery for this patient, but a switch to silicone is probably indicated once epithelialization is complete. Topical vitamin E, cocoa butter, onion extract cream (e.g., Mederma), and glycosaminoglycan gel have not been shown to consistently improve scar appearance as single agents.5 Using skin glue can have benefits in terms of avoiding external sutures and providing a wound dressing that allows patients to shower the area; however, it is not proven to help the scars in the long term. Overall, the benefits of many topical agents could result from massage associated with their application and so firm wound massage therapy is commonly recommended by surgeons. The product used for the massage may have less impact on outcome than the massage procedure itself.
Hypothermia can result in increased wound infections by impairing immune defenses and decreasing local oxygen tension.1 Hypothermia is defined as a core body temperature of <36° C (not 35° C). Standards of the Surgical Care Improvement Project (SCIP) require that patients have at least one documented temperature of ≥36° C within 30 minutes before or 15 minutes after the documented anesthesia end time. Mild hypothermia may also affect coagulation, recovery time, and the rate of perioperative myocardial events.2 Very mild hypothermia (down to 35° C) doesn’t seem to affect any part of the coagulation cascade. In some patients, hypothermia below 35° C may cause a mild drop in platelet count and cause mild platelet dysfunction. Below 33° C, other steps in the coagulation cascade can also be affected and this is dramatic below 33° C.3 Anesthetic agents disrupt the body’s natural thermoregulatory mechanisms and can inhibit shivering, vasoconstriction, and sweating. Therefore, these signs cannot be relied upon during surgery as markers of body temperature. Instead, temperature can be accurately measured using thermometers contained within the endotracheal tube or passed intranasally or transrectally. Patient temperature can be maintained passively through blankets, surgical drapes, and humidified respiratory gases.