PATIENT EVALUATION & SELECTION
Providing safe care to the patient who is undergoing plastic surgery is traditionally composed of two components: establishing quality of care and preparing the patient for the clinical procedure. This chapter will be separated based on that distinction. Establishing quality of care involves ensuring the safety of the facility, obtaining certification, retaining necessary equipment and personnel, as well as, being able to expeditiously transfer a patient to the next level of care for extended or emergency needs. Preparing the patient for the procedure involves preoperative testing, thorough medical evaluation, prophylactic therapies when indicated, and a comprehensive drug history that includes use of herbal agents and cosmeceuticals. The guidelines provided in this chapter are not rules but suggestions about how to maintain the highest level of patient safety. Only a small number of states have laws governing the practice of plastic surgery. The onus remains on the physician to uphold the Hippocratic oath to maintain patient safety as the first priority.
A. Facility and Procedure Selection
When deciding the location at which surgery can be performed safely, plastic surgeons need to consider the risk factors associated with each patient and each plastic surgery procedure. The American Society of Anesthesiologists (ASA) has developed a classification system to help categorize patients for surgery; it is useful in determining the appropriate facility setting for a cosmetic surgical intervention. This grading system was designed to categorize physiologic status of patients in order to create a uniform system of patient classification. Although not fully predictive of perioperative risk of complication, the classification helps define a level of systemic physiologic disease that may impact surgical morbidity. ASA category 1 defines patients as normal and healthy. ASA category 2 classifies patients as having mild systemic disease with no functional limitations. These two groups of patients are the preferred candidates for ambulatory cosmetic surgery and can safely undergo office-based procedures. Patients in ASA category 3 have moderate systemic disease with functional limitations and are acceptable candidates for local anesthesia with some level of moderate sedation. They may undergo office-based cosmetic surgery in an accredited facility. Patients in ASA category 4 have severe systemic disease that is a constant threat to life; these patients cannot be given anything more potent than local anesthesia in the office-based setting. More complex procedures in this group of patients must be done in a hospital setting.
When considering the number and type of cosmetic procedures to be performed on a patient, procedure morbidity must be assessed. Blood loss, potential for hypothermia, potential for circulatory stasis, and procedure duration may add to the risk of complications. Adding liposuction to other procedures results in prolonging hypothermia and anesthesia time, increasing operative morbidity.
There is significant risk of hypothermia when performing ambulatory surgery. Risk factors include a cold operating room, unclothed patient, intravenous fluids at room temperature, and the impairment of a patient’s ...