Anaesthesia in Plastic Surgery
Anaesthesia is a specialty area of medical practice.
A wide range of anaesthetic techniques and medications are available, chosen and used according to the procedure being undertaken and the patients own physical state.
In many cases anaesthesia will be administered by the plastic surgeon, and in some, under the supervision of a second doctor, a specialist anaesthetist, who has very specific training and who practices exclusively in this area.
On a broad basis, techniques can be broken down into Local Anaesthesia, Local Anaesthesia with Sedation, and General Anaesthesia.
Local Anaesthesia:
Local anaesthesia is very common, very safe and a familiar experience to most people. Its used commonly by GPs and dentists in the form of an injection or in the case of childbirth, can be administered as an epidural drip.
Local anaesthesia is used to block the sensation of pain in a particular body area. It works by preventing sensory nerves from transmitting pain information back to the brain. While the medicine is working, your brain gets no feedback from the anaesthetised area and all you feel is an absence of sensation, or numbness.
There are different families of local anaesthetic drugs, chosen for their effect in specific applications, but in general, all operate by blocking the minute electrical currents that normally travel up and down nerves. No current means no pain message gets through to the brain.
In the majority of plastic surgery procedures, local aneasthesia is all thats required. Removal of moles is an example. However it may be supplemented by sedatives or other medications in certain cases.
Beyond prevention of pain, local anaesthesia also works to prevent bleeding during surgery, so even if you are unconscious under general anaesthesia, the surgeon will typically administer it to the specific area of attention. Where bleeding is of particular concern, its effects can be boosted by a drug called Adrenaline, which constricts local blood vessels.
Local anaesthesia is also useful in eliminating, or vastly reducing, post operative pain.
The usual method of administration is with a sterile needle and syringe. This can sting for a moment, but rapidly numbs. Occasionally an anaesthetic cream (EMLA) is applied to the skin, sufficient for superficial laser treatments or other mild procedures.
Some treatments, such as Tumescent or wet liposuction treatments require substantial volumes of local anaesthetic, combined with sterile fluids and adrenaline.
As earlier mentioned, local anaesthetic agents are very safe drugs, have well-established safe dosage standards (calculated on a dose per kilogram basis) and allergic reactions are extremely rare. But that does not mean that complications cannot occur. Where patients have conditions such as a history of severe angina, chest pains or heart beat irregularities, local anaesthetic and particularly adrenaline will be used with caution.
Neurolept (Local Anaesthesia with Sedation):
This form of anaesthesia is also common, typically used in skin cancer removal and reconstruction, and eyelid surgery. In some cases, it is also used for facelifts and rhinoplasty. A specialist anaesthetist is present throughout procedures employing this form of anaesthesia.
Neurolept anaesthesia involves a cocktail of medications administered intravenously C usually a short acting painkiller (Fentanyl) and short acting sedative (Midazolam), which in combination, prevent pain and decrease the patients awareness. Frequent small doses maintain the effect while local anaesthetic is administered and the procedure completed. Patients remain conscious and can talk to the surgeon and anaesthetist, but commonly remember nothing at all of the procedure. It is well suited to day surgery cases with the advantages of better recovery time and less incidence of nausea.
General Anaesthesia:
General anaesthesia is usually reserved for larger procedures, such as breast, upper limb, hand and major reconstructive surgery, and is administered by specialist anaesthetists, all of who are fellows of the Australasian College of Anaesthetists. Following several years of general medical experience as a hospital doctor, they have a minimum five years full time specialist training supervised by the college.
There are two main aspects to general anaesthesia: airway management and control of conscious state.
Control of Conscious State:
Medicines are administered intravenously to make you unconscious so that you are totally unaware of what is happening to you. These always include pain medications to prevent pain while under anaesthesia. The most commonly used class of pain medications are narcotics (morphine, pethidine, fenantyl). The drug chosen, dose, and mesans of administration are tailored to suit both the individual patient and the planned procedure, to achieve optimal pain relief at commencement, while under way and afterward.
Airways Management:
Since you are unconscious, the anaesthetist must safeguard your breathing for you during general anaesthesia. This is usually achieved using a tube passed from your mouth into your throat (an endotracheal tube). A more recent innovation is the laryngeal mask, which inflates at the back of your throat to protect the airway but does not actually pass down the throat and this is now used quite commonly. The choice of technique is dictated by the planned procedure and patient factors such as how long it has been since eating or drinking, and history of heartburn and gastric reflux.
While it might be a little difficult to understand, in most cases the anaesthetist simply protects your breathing, while still allowing you to breathe for yourself. In rare instances, you might be given an additional medication that actually paralyses you breathing and the anaesthetist takes control on your behalf, with or without the use of a ventilator (a mechanical breathing machine). This technique is not usually required in plastic surgery and is more often used for major reconstructive surgery in cases where the surgeon needs your muscles relaxed, or in very long procedures.
Safety:
While general anaesthesia is safe, some risk does exist. There is a small but definite risk of death, brain damage and allergic reaction, or consequences of a poorly positioned or dislodged breathing tube can also be life threatening. Other risks are a product of the combination of anesthesia and the procedure being undertaken. Important examples are: - Deep vein thrombosis (blood clots in the legs) or pulmonary embolus (where this clot breaks free and lodges in the lung) - Severe allergic reaction to an antibiotic or other medicine administered for the procedure - Severe unexpected blood loss.
Summary:
The advances in modern anaesthesia have allowed surgery to evolve. Plastic surgeons and patients are fortunate to have a wide range of safe, flexible techniques so that anaesthesia can be tailored very specifically to meet your needs. Dependent on the procedure it can be very simple, or quite complex, and techniques are often combined to optimise pain relief and patient comfort.
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