Evaluation of conscious sedation in facial plastic surgery

Local anesthesia and conscious sedation are important aspects of facial plastic surgery. The safe and effective application of these techniques is important to produce happy, satisfied patients as well as good surgical results. Local anesthetic and sedative drugs will be discussed with respect to their mechanisms of action, doses, toxicities and appropriate selection. We will discuss the techniques we have developed using fentanyl and Versed and our evaluation of their effectiveness. Twenty sequential facial plastic surgical patients undergoing a total of 30 procedures will be reviewed. The average dose of fentanyl was 70 mcg and Versed was 3.1 mg. Significant amnesia occurred in 60% of patients, 80% experienced little or no discomfort and 90% would have no hesitation to undergo another procedure with similar anesthesia and sedation.     

Lidocaine v bupivacaine in facial plastic surgery. A clinical trial

The ideal local anesthetic agent for facial plastic surgery should have rapid onset, good surgical anesthesia, and reasonably long duration. The purpose of this prospective, randomized, double-blind study was to compare 1% lidocaine hydrochloride with 1:200,000 epinephrine with 0.5% bupivacaine hydrochloride with 1:200,000 epinephrine, a newer, longer-acting local anesthetic, in different facial operations. The results suggest that bupivacaine is an effective and safe agent for these procedures.     

Clinical utility of local over general anesthetic tonsillectomy using the BiZact™ device

PurposeTonsillectomy under general anesthesia may be viewed preferentially to local anesthesia, due to mitigation of potential airway compromise secondary to intraoperative hemorrhage, patient discomfort and anxiety. However, this is offset by risk of increased trauma (via the endotracheal tube and gag), adverse medication reactions and cost. Here we evaluated the case for use of local anesthesia in tonsillectomy using the BiZact? (Medtronic) device by comparing surgical outcomes and cost factors across patients where either local or general anesthesia was employed.Materials and methodsRetrospective cohort study of 59 BiZact? tonsillectomy patients (38 under local anesthetic, and 21 under general anesthetic) from a single surgeon at Tauranga Hospital (public) and Grace Hospital (private) in New Zealand; March 2018 to June 2021.ResultsNeither patient group had any primary postoperative hemorrhage and there was comparable incidence of secondary hemorrhage (one case in each cohort). Local anesthetic tonsillectomy was well tolerated with only 2 patients requiring conversion to general anesthetic secondary to anxiety. Local anesthetic proved to be cost-effective, with a halving of hospital length of stay and significant associated overall cost saving, and did not add significantly to operating or total theatre time. Local anesthetic tonsillectomies where perioperative sedation was not required were associated with additional reductions in recovery and overall hospital stay, and cost.ConclusionsLocal anesthetic BiZact? tonsillectomy is evidently safe and cost-effective.     

Anaphylactic reaction to lidocaine

Lidocaine hydrochloride is an amide-type local anesthetic, commonly used for facial plastic as well as other surgical procedures. In an unusual case of reproducible anaphylactic reaction to lidocaine, early treatment with epinephrine, oxygenation, and intravenous fluid resuscitation resulted in relief of the symptoms. This case demonstrates the importance of sensitivity testing and choosing an appropriate alternative local anesthetic in a patient with a history of possible allergy to lidocaine.     

Use of dilute epinephrine as an aid in facial nerve monitoring.

Facial nerve monitoring during otologic and neurotologic procedures has been previously described, and its use is becoming routine. Although these procedures are done under general anesthesia, lidocaine is often used as a vehicle for epinephrine to aid hemostasis during the procedure. The routine use of lidocaine in these preparations presents the theoretical and sometimes real problem of anesthetizing the facial nerve at the start of the procedure, thereby invalidating subsequent attempts at monitoring and stimulation. We present the data from our experience with 74 patients using an epinephrine solution 1:100,000 for infiltration without any local anesthetic. We have found this procedure to be effective in maintaining hemostasis, quite safe and well tolerated, and without adverse effects on the desired monitoring of the facial nerve.     

Local anesthesia for soft-tissue surgery

The use of local anesthetics in soft-tissue facial surgery can be safe, efficient, economical, and convenient. Understanding these agents and using them with proficiency allows the surgeon to perform a variety of operative procedures with minimal anesthetic morbidity on patients who are relaxed, comfortable, and insensitive to pain.     

Lokalanästhesie an Gehörgang und Trommelfell mittels Iontophorese

Summary Operations to the external ear canal and tympanic membrane necessitate sufficient local anesthesia. The normal technique — also used for tympanoplastics — using general sedation (Atropin, Thalamonal, Atosil) followed by infiltration anesthesia, is rather time-consuming, can be painful due to the injection, and is not paeticularly satisfactory for the treatment of outpatients.The iontophoresis-technique, however, of local anesthesia, is applicable particularly for the treatment of outpatients. Principally, the local anesthetic is transported in ionisised form to the nerve membrane, by means of calvanic currents through the healthy surface epithelial tissue of the external ear canal or the eardrum.The technique described for the first time in 1911 no longer shows toxic side-effects since the introduction of improved electrodes and more modern local anesthetics.The anatomic, pharmacological, chemical and physical basics of the technique will be described. The lecture will be based on personal experience of the method, taken from large groups of patients over a period of more than two years, using equipment specially designed for this purpose.     

Myringotomy under topical anesthesia with phenol

Myringotomy is a common outpatient surgical procedure. It can be performed under general inhaled anesthesia, but it is usually carried out under local anesthesia by lidocaine infiltration or instillation of different anesthetic agents. We present our experience with myringotomy and tympanic tube placement using topical anesthesia with 88% phenol as an outpatient procedure. We report 55 patients in which we performed 81 treatments. In this series, only two ears (2.47%) did not tolerate the surgical procedure, tube insertion under general anesthesia being necessary in one case. Topical anesthesia with phenol facilitates the outpatient treatment of adult otitis media with effusion.     

Parotidectomy under local anesthesia—report of 7 cases

Objective

Parotidectomy is usually carried out under general anesthesia. We reported our early experience of performing parotidectomy under local anesthesia.

Study design

Case series reviewed.

Setting

Head and neck services of a regional hospital.

Patients, intervention, and results

Seven patients underwent parotidectomy under local anesthesia. The indications were high risk for general anesthesia due to co-morbidity in 2 patients and personal preference for the rest. The operations were performed by retrograde facial nerve dissection after superficial cervical plexus block and incision wound infiltration with local anesthetics. There was no conversion to general anesthesia. Six operations were carried out in the setting of ambulatory procedure and were discharged on the same day. Transient mild facial paresis occurred in 2 patients.

Conclusion

Parotidectomy under local anesthesia can be conducted successfully and avoid the adverse effect of general anesthesia.     

本可松对中耳-乳突手术面神经监测的影响

目的;评价中耳－乳突手术全麻时使用肌松剂本可松对面神经监测（ＦＮＭ）的影响。方法：对４４例（４５耳）中耳乳突患者进行手术治疗,术中均行ＦＮＭ。３８耳采用静吸复合全麻（全麻组）７耳采用局麻（局麻组）,并对全麻组中１０例应用加速度仪（ＡＣＣＧ）作神经肌肉传导监测,观察ＦＮＭ诱导出面肌动作电位与尺神经－肌肉阻滞 同恢复程度的相关性。结果：在尺神经－肌肉阻滞之不同程度恢复阶段内,都是可消除肌颤对ＦＮＭ干扰     

Malignant hyperthermia and the otolaryngologist

Malignant hyperthermia is a rare disorder that can occur in patients who are sensitive to certain agents used in general anesthesia. The treatment of malignant hyperthermia has not changed over the years, but prevention strategies have evolved. These strategies include an increased emphasis on how patients are managed prior to a surgical procedure, on the selection of the particular anesthetic agent, and on postoperative vigilance. Susceptible patients who undergo simple excisions or a low degree of surgical stress can receive treatment safely in the office or ambulatory surgery center and be discharged the same day, provided that all known triggering agents are avoided. For more extensive procedures that cause a moderate level of surgical stress to susceptible patients, facilities for managing malignant hyperthermia should be readily available. Susceptible patients who undergo high-stress invasive procedures should be hospitalized. Routine preoperative prophylactic drug administration, even with dantrolene, is no longer considered necessary for any susceptible patients. All local anesthetics--including lidocaine, which had been previously contraindicated--are now considered to be safe for use in patients who are susceptible to malignant hyperthermia. In this article, we review the prevention, diagnosis, and management of malignant hyperthermia. We also report our experience in anesthetizing a patient who had a history of malignant hyperthermia--a case that illustrates the uncertainty that can complicate the management of such patients.     

Myocardial infarction with topical cocaine anesthesia for nasal surgery

Cocaine, the active alkaloid in coca leaf, is widely used as local anesthetic for otolaryngologic procedures. Our patient suffered an acute nontransmural myocardial infarction following clinical use of cocaine as topical anesthesia for nasal surgery, the first such case to be documented, to our knowledge. Although evidence documenting its cardiovascular toxicity is listed in contemporary pharmacologic literature, clinical cardiac injury has been reported to date only with the recreational use of cocaine. Authentic documentation of drug composition when received through the intervention of illicit vendors is always difficult. The literature is reviewed, justifying the use of cocaine as the most popular topical anesthetic in otolaryngologic practice. However, we hope that awareness of this possible complication will create a resurgence of research interest in topical cocaine anesthesia.     

Quality of recovery and safety of deep intravenous sedation compared to general anesthesia in facial plastic surgery: A prospective cohort study

BackgroundFacial plastic surgical procedures are performed under either general anesthesia (GA) or sedation. GA is often associated with post-operative nausea and longer recovery, while deep sedation is thought to greatly facilitate perioperative patient comfort and expedite recovery. The objective of this study was to compare these two anesthetic techniques in a relatively healthy patient population undergoing facial plastic surgery and to discuss optimizing patient safety with a deep sedation technique.MethodsA non-randomized, prospective cohort study was conducted to evaluate patients undergoing facial plastic surgery with a focus on rhinoplasty under either deep intravenous sedation (DIVS) in an ambulatory surgery center or under GA in a community hospital. Patients were between ages 18–65 and agreed to participate in the study and complete a quality of recovery (QoR-40) survey. Two-tailed Student's t-test was done for numerical data and Chi-squared test for categorical data.ResultsTwenty-three patients and 16 patients had surgery under DIVS and GA, respectively. Compared to the GA group, the DIVS group had less post-operative nausea and vomiting (21.7% vs 50%, P = 0.04; 4.3% vs 37.5%; P = 0.004, respectively), shorter emergence time (4 vs 13 min, P < 0.001), and higher QoR-40 scores for almost all the categories except for physical independence. There were no post-operative medical or surgical complications.ConclusionDIVS appeared to be safe in the office-based setting and provided a higher quality recovery after a predominantly rhinoplasty-based practice compared to the GA group. Vigilant monitoring of the patient is crucial for careful titration of sedation to avoid respiratory depression and possible compromise of the surgical result from having to rescue the airway.     

Peripheral facial nerve paralysis after peritonsillar infiltration of bupivacaine: a case report

Peritonsillar infiltration of a local anesthetic solution for reduction of posttonsillectomy pain is commonly used although the benefit and complications of this technique have not yet been well established. We report a case of a 4-year-old boy who developed peripheral facial nerve paralysis after perioperative infiltration of bupivacaine and uneventful tonsillectomy. The paralysis was noticed a few minutes after extubation and resolved completely after 8 hours. We assumed this to be caused by the direct action of the local anesthetic agent on the facial nerve.     

Intraoperative adverse events in minor oral surgery. Risk analysis]

AIM OF THE STUDY: The aim of this prospective study was to evaluate oral surgical procedures performed as day surgery under local anesthesia. We examined patients' general condition, and besides checking for intraoperative complications we analyzed postoperative bleeding in patients with hemostatic disorders. PATIENTS: The patient population consisted of 1540 patients (797 female, 743 male), who underwent a total of 2055 minor oral surgical procedures over a 5-year period (1998-2002). Before the treatment started a data file was made for each patient, which contained information on his or her past medical history, concomitant medication, why the operation was indicated, premedication, anesthetic and surgical techniques applied, and postoperative treatment. RESULTS: Systemic pathologies influencing surgical decisions were found in 316 patients (20.5%), affecting 676 interventions (32.9%). In 109 patients (5.3% of the 2055) altered hemostasis was found. The surgical procedures recorded were: (operative) tooth extraction (n=394), interventions for surgical conservation of teeth (n=272), treatment for cysts (n=140), surgical revisions (n=46) and preprosthetic surgery (n=19). Passing complications, mostly systemic in nature, occurred during 27 sessions of local anesthesia (1.3%). There were 87 adverse events intraoperatively (4,2%), most of which were confined to the surgical field; specifically 15% of these complications took the form of hemorrhage. We observed no significant correlation between the occurrence of intraoperative complications and patients' gender, predisposing systemic pathologies including bleeding disorders, or age. Postoperative hemorrhage was observed significantly more frequently in patients with impaired hemostasis and required admission to hospital for inpatient treatment in 2 cases. CONCLUSION: According to our investigation, oral surgery can be performed in patients with compromised general condition with as few intraoperative complications as in patients with no general medical problems. However, in individual cases specific risk factors can be present and oral surgery may be temporarily contraindicated, at least as day surgery.     

Local anesthesia in rhinoplasty: a new twist?

Twenty volunteers were asked to compare pain upon injection during septorhinoplasty using buffered versus unbuffered local anesthetics. The concentration of the buffer was one part sodium bicarbonate to five parts local. The surgeons performing the operation were asked to identify any difference in hemostasis or duration of anesthesia. Eighteen of twenty patients found the buffered anesthetic to be less painful and better tolerated. No difference in hemostasis or duration of action was noted between the buffered or unbuffered solution, however, faster onset of action was noted with the buffered solution. The addition of sodium bicarbonate as a buffering agent to the local anesthetics lidocaine and bupivacaine can significantly reduce pain upon injection. A solution of 5cc 2% lidocaine with 1:100,000 epinephrine, 5cc 0.25% bupivacaine with 1:200,000 epinephrine, and 2cc of 7.5% sodium bicarbonate mixed just prior to injection is a safe, effective, less painful local anesthetic with rapid onset of action and full efficacy.     

Peripheral facial palsy after adenotonsillectomy in children

Transient facial palsy is a rare complication after adenotonsillectomy. In this study, we report two cases who developed unilateral peripheral facial palsy immediately after adenotonsillectomy. The facial palsy in both cases completely recovered in 6 and 3h respectively without any treatment. We assumed the possible mechanism was deep infiltration of the local anesthetics into parapharyngeal space and then the direct action on the facial nerve. Therefore, we suggest three policies to avoid this complication: (1) inject the local anesthetics exactly into peritonsillar space, (2) avoid repeated injections or overdose, (3) slowly and gently inject the local anesthetics.     

Primary and adjunctive uses of botulinum toxin type A in the periorbital region

Chemodenervation with botulinum toxin has become an integral part of the facial plastic armamentarium. Although eyebrow and eyelid cosmetic deformities and asymmetries have traditionally been treated by surgical intervention, Botox can now be incorporated effectively into the surgical plan. When the surgeon has a complete understanding of facial anatomy and muscular interactions, Botox can be used as a primary treatment of the periorbital region or as an adjunct to surgical procedures of the periorbital region.     

Chirurgische Korrektur des paralytischen Lagophthalmus

Impairment of the peripheral or central part of the facial nerve causes an ipsilateral peripheral facial nerve paresis. It is quite a common syndrome and affects 20–35 persons per 100,000 per year in Western Europe and the United States. A possible complication of facial palsy is paralytic lagophthalmos with aesthetic and functional impairment for the patient. Beside primary nerve reconstructive procedures plastic-reconstructive procedures play a major role in correcting paralytic lagophthalmos. The eyebrow, upper and lower lids, medial and lateral lid angle as well as the lacrimal system need to be seen as functional units and can be corrected with local surgical procedures. Restoration of eye closure is the most important goal in treating the affected eye. Due to the significant aesthetic limitations and resultant psychological stress for the patient cosmetic aspects must be included in the surgical concept.     

Preventing postoperative complications in the adult cystic fibrosis patient

Herein we report on a 27-year-old cystic fibrosis (CF) patient who developed bronchospasm, secretory plugging of the trachea, and pneumothorax following general endotracheal anesthesia for intranasal polypectomy and bilateral Caldwell-Luc procedures at an adult facility. Intranasal polypectomy and paranasal sinus procedures are the most common surgical procedures performed on cystic fibrosis patients, making the otolaryngologist a frequent member of the cystic fibrosis team [8]. As survival improves, the pediatric otolaryngologist will find himself following CF patients into their 20's and 30's. Adult care facilities may not be as familiar with these patients as the surgeon would like. The otolaryngologist's familiarity with the unique perioperative requirements of the CF patient can prove invaluable in such a setting. Preoperative assessment should identify any acute pulmonary changes, assess nutritional status, assure good control of blood glucose levels, and rule out clotting abnormalities. Good perioperative hydration and meticulous attention to pulmonary toilet are of foremost importance in the surgical care of the cystic fibrosis patient. Chest physiotherapy and suctioning of the tracheobronchial tree should precede arousal from anesthesia and extubation. By insisting on appropriate anesthetic and perioperative care, the knowledgeable otolaryngologist may circumvent potential postoperative complications in the cystic fibrosis patient.