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Major Ambulatory Surgery of the Plastic Surgical Patient
Major Ambulatory Surgery
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Major Ambulatory Surgery of the Plastic Surgical Patient Erle E. Peacock, Jr., M.D. *
Plastic surgery is probably the ideal major surgical specialty to practice in an ambulatory setting. Indeed, for many years when hospital beds in the United Kingdom were difficult to obtain, one of the largest plastic surgery teaching services in existence was conducted entirely without inpatient facilities. Even large head and neck extirpative and reconstructive procedures, including jaw-neck dissections, were performed as outpatient procedures, at least to the extent that patients were transferred to nursing homes on the evening after a morning procedure. In the final analysis, a patient who does not require any more in the way of postoperative nursing care than bed rest and administration of food, water, and pain medication should be able to have surgery in an outpatient facility as safely and successfully as in an inpatient facility. The occasional patient who cannot be moved safely, such as after massive flap repair of a decubitus ulcer, or the patient who has had a restoration with tissue that postoperatively has reduced or questionable circulation, are two obvious exceptions to the general statement that most plastic surgery patients can be operated on as effectively and safely in an ambulatory setting as in a hospital. A large, general plastic surgery practice in an ambulatory center creates unique problems, but most of these problems are solvable and have not prevented many plastic surgeons from conducting an ever increasing volume of their work in an ambulatory setting.
ADVANTAGES AND DISADVANTAGES The obvious advantages of performing plastic surgery in an ambulatory setting are essentially the same as expressed in the recent book Small Is Beautiful. 2 The major problems involved in performing surgery in a hospital setting are problems caused by bigness. The conversion of the community *Courtesy Staff, North Carolina Memorial Hospital, Chapel Hill; Attending Staff, Durham County General Hospital, Durham; and Private Practitioner, Chapel Hill, North Carolina
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or university hospital into a medical center usually involves creation of independent departments, many of which operate autonomously and make it impossible to provide strong leadership in protecting patients' interests. In a properly administered ambulatory care facility, however, anesthesia, nursing, and surgical personnel can interact on a much closer level than in a typical hospital. This factor alone makes it possible to focus on the best interests of the patient as the paramount goal for the institution. As a result, starting times are realistic and usually accurate, time lost between patients is reduced to a minimum, and patient delays because of personnel problems are reduced significantly. Every plastic surgeon the author has interviewed on the subject prefers to work in an ambulatory rather than in an inpatient hospital setting because of the ability to take care of patients more personally than is possible in a large medical center. Because most plastic surgery patients are not sick, ancillary factors such as availability of parking, waiting and dressing room comfort and decor, and friendliness of supporting staff are major attractive features. Such considerations undoubtedly weigh heavily in the increasing popularity of ambulatory surgery for plastic surgery patients. An additional factor for patients undergoing cosmetic surgery is protection of privacy. Because ambulatory patients spend less time in an outpatient facility and come in contact with fewer people than they do in a large hospital, it is easier to protect privacy and give the patients the feeling that they can keep their surgery confidential. There are some general disadvantages for surgeons and for patients in an ambulatory surgical center. For plastic surgeons the major disadvantage is isolation. Particularly for plastic surgeons who develop office operating room suites that they use exclusively for their own patients, ambulatory surgery results in loss of professional contacts, particularly with other disciplines. There is no way to measure the exact amount of postgraduate education that is obtained by changing clothes in the presence of others who are discussing medical questions; however, such experiences, sometimes prolonged while waiting for a room to be changed, have contributed in the past to professional comradery and are a potential source of graduate education that may be reduced or eliminated entirely by the ambulatory care facility, particularly when it serves a small group. It is not unusual now to see plastic surgeons literally withdraw from the medical community, including administrative, social, and professional activities, because they are able to take care of their patients entirely within an isolated and often secluded facility. Professional isolation must be listed, therefore, as a negative feature of ambulatory surgical care. General disadvantages for patients receiving ambulatory care are a feeling of too much and too little security. It comes as a surprise to some surgeons developing practice in an ambulatory center to see the way patients prepare and often react to outpatient surgery. Expressed simply, patients equate going to the hospital with being sick and requiring detailed preoperative and postoperative care, whereas the same surgery performed in an ambulatory care center may be viewed more as a single event not requiring preoperative preparation or postoperative care. Strangely, patients are not as diligent about such basic factors as refraining from taking
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food or water if they are to have ambulatory surgery as they are in a hospital, where it seems the ~business of the hospital for the patients to be NPO after midnight. Patients who would never think of driving themselves to a hospital, parking in the hospital parking lot, and driving home several days later after major surgery will often show up at an ambulatory care center with no one to take them home or look after them postoperatively. Seemingly intelligent patients plan business or social activities up to the very moment before surgery and often plan to pick up such activities, including travel to some distant vacation site, immediately after surgery. Of course, it is the responsibility of the surgeon and anesthesiologist to educate patients against this type of activity and help them plan intelligently for postoperative care. The point, however, is that in spite of such planning and preparation, the ambulatory setting mitigates against getting through to the patient, whereas the hospital setting seems to reinforce the importance of preoperative and postoperative care. One of the disadvantages of performing plastic surgery in an ambulatory setting, therefore, is the necessity to take special precautions to educate patients about the seriousness of surgery and the need for attention to details of preoperative and postoperative care. It is also necessary to be continually alert for failure of patients to understand and follow directions in the ambulatory setting. It is not unusual for a surgeon to look out a window and see a patient who has just had a major hand reconstructive procedure release the parking brake of his truck with the bandaged hand while it is still anesthetized. Sometimes an anesthesiologist must take a patient home in his or her own car and stay with the patient until help arrives even though it was believed that the patient understood completely the danger of being left alone immediately after general anesthesia. A second disadvantage to ambulatory plastic surgery is exactly the opposite of too much confidence-too little confidence. Too little confidence reveals itself primarily after sunset. What is missing, of course, is evening rounds. House officers think of evening rounds in a hospital as necessary to be sure that tests performed during the'day are recorded, dressings are not too tight, wounds dry, and so forth. Experience in an ambulatory setting emphasizes, however, that one of the greatest benefits of evening rounds is the knowledge by the patient that the doctor has checked everything and that all is well. Without such reassurance, although all of the important factors are perfect, the slightest unexpected occurrence can cause a sense of panic; there is not even a nurse to consult. Successful practice of plastic surgery in an ambulatory setting demands, therefore, that patients be given the most detailed and comprehensive instructions including a complete review of all of the observations they may make during the ensuing 24 hours after surgery. For instance, most patients undergoing a blepharoplasty in a hospital are warned not to worry if there is ecchymosis around the eyes and eyelids. In an ambulatory setting, however, such patients also have to be warned that the eyelids may stick together the first evening after surgery. Separation of the lids the next morning, when there is coagulation of serum holding them lightly together, often seems like a formidable, if not impossible, undertaking unless a doctor
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or nurse is there to reassure the patient that permanent blindness is not occurring. It is almost impossible to anticipate all of the inconsequential sensations or observations that postoperative patients experience. As a result, in addition to making clear all of the important problems that can arise such as swelling, constriction of an extremity by a circular bandage, bleeding, and so on, special measures have to be taken not only to be available or have some medical personnel available but also to have the patients and their families know that continual coverage is no farther away than the telephone. Reassuring a patient that, even though he or she is not being retained in a hospital, medical attention is available day and night' is probably more important than the information that actually is dispensed. Such coverage can be arranged in a number of ways. A hotel, motor inn, or some other reasonably quiet first-class tourist facility as close as possible to either the surgeon's office or a clearly identified hospital is more desirable than similar facilities distant from a medical complex. The knowledge that the patient's own surgeon is working close by or that, if some catastrophic complication arises, a hospital emergency room is near does much to relieve anxiety, which in turn raises the threshold for postoperative pain. A visit to the patient's room on the way home in the evening serves the same purpose as evening house officers' rounds in a hospital and may prevent a summons at a more inconvenient time later in the evening. Even a visit by an office nurse or a physician's assistant is all that may be necessary to help a patient through the first night after an outpatient surgical procedure. Any arrangement that can be made to have first-hand contact with the patient the first evening after ambulatory plastic surgery is superior to a telephone call and is usually all that is required to prevent the familiar linear increase in anxiety during daylight hours from becoming exponential after darkness occurs. The need for evening rounds is universally appreciated in a hospital setting but it may be overlooked under ambulatory conditions, although a few moments of reflection reveal that contact between surgeon and patient is even more necessary when the patient is not surrounded by the general hospital scenario and the reassurance such surroundings provide. In addition to the general considerations just outlined, there are special considerations when specific plastic and reconstructive procedures are performed in an ambulatory setting. Some of these considerations follow.
HEAD AND NECK SURGERY Tumors The major consideration in selecting patients for ambulatory surgery with head and neck tumors is the danger of postoperative respiratory complications. Obviously, procedures that require dissection of the lower jaw and major changes in the stability of the floor of the mouth, posterior tongue, and suspension of the glottis should not be performed in an ambulatory setting. Skilled postoperative observation and immediate operative intervention when airway disasters occur are mandatory following
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such procedures. Operations that may be complicated by severe postoperative hemorrhage, such as r~construction of the palate, resecting of the maxilla, and nasopharyngeal surgery, also should not be performed in an ambulatory setting. Only those procedures in which respiratory complications and hemorrhage are not significant factors during postoperative care can be performed on an outpatient basis. Excision of lip tumors, resurfacing the vermilion border of the lower lip, resection of small portions of the alveolar ridge or a torus palatinus, resection of some parotid tumors, and excision of scalp lesions are examples of tumors that can be excised safely in an ambulatory setting. Excision of anything more than very small tongue lesions should not be performed in an ambulatory setting because of the danger of postoperative swelling and hemorrhage. It is not wise to remove deep tumors high in the neck because of the threat that such tumors may involve the internal carotid artery. Tumors in the upper neck that are not freely movable, particularly in a vertical direction, can involve the carotid vessels. Removal of these tumors can be more complicated than is sometimes anticipated and the complications include potentially fatal hemorrhage and hemiplegia. Any deep tumor in the neck, particularly one that is not freely movable in a vertical plane, is best handled in a hospital setting where vascular expertise and skilled postoperative care are available. Blepharoplasty
Most eyelid procedures, including restoration of the lids, can be performed safely in an ambulatory setting. The major complication that must be allowed for is loss of visual acuity. Patients undergoing eyelid surgery must be warned of the importance of continually evaluating vision and reporting any loss of vision immediately. Such instructions include directions to a suitable hospital emergency room if contact with the surgeon cannot be made. The most dangerous procedure in an ambulatory setting is removal of fat from beneath the lower eyelids and suborbital spaces. This procedure is best performed under local .i;mesthesia and patients should remain in a recovery area for at least 1 hour after surgery so that visual acuity can be checked by professional personnel. In addition, immediate application of cold compresses for at least an hour in the ambulatory center is desirable to reduce ecchymosis. Patients should never be allowed to drive home alone from an ambulatory center after eyelid surgery. Patients who may accurately evaluate acuteness of vision often do not realize that peripheral vision is compromised due to ecchymosis and swelling of the eyelids, particularly in the canthal regions. Patients should not leave an ambulatory center with bandages covering the eye if there has been extensive suborbital or retro-orbital dissection. These patients must have vision evaluated almost continually for at least 24 hours after surgery. Blindness can develop beneath a bandage without the patient being aware of anything wrong. Lid adherence and subconjunctival hemorrhage are the most alarming observations that patients make after leaving an ambulatory care center. Warning the patient about such occurrences can prevent anxiety and attempts to contact the surgeon in the evening or early morning hours.
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Rhytidectomy Most rhytidectomies aJ:e performed now in an ambulatory setting for economic, convenience, and privacy reasons. The major concern, of course, is bleeding and possible airway obstruction. The use of drains has not prevented hemorrhagic complications, although some surgeons utilize Penrose drains and even suction drains on an outpatient basis. The general consensus at this time, however, is that drains do not protect against development of a hematoma and it is not possible to drain the neck and face satisfactorily through a posterior scalp incision. Special precautions should be taken during surgery to obtain the best hemostasis possible in outpatients; these precautions include leaving a large segment of the posterior scalp or retroauricular incision open on the first side so that the wound and flaps can be inspected after the second side is finished. The central or submandibular wound is particularly susceptible to hematoma formation and should be closed only partially if this stage of the rhytidectomy is performed first, so that blood that collects during the face and neck dissection can be removed by suction just before the bandage is applied. An evening visit by someone capable of evaluating the dressing, reassuring the patient, and evaluating respiratory and swallowing functions is desirable. Many patients begin to feel tightness beneath the chin and become anxious by 7:00 P.M. on the night after surgery. It is usually a good idea to cut through the entire thickness of the chin bandage and inspect the neck. This can be done in a hotel room or nursing facility by carrying the proper materials and instruments to the room. The neck bandage can be replaced less tightly by reapplying adhesive tape beneath the chin. This maneuver gives the surgeon and the patient confidence that the first night will be safe and comfortable. It is extremely important not to overmedicate patients following rhytidectomy performed in an ambulatory setting. A small dose of codeine or similar synthetic analgesic is all that should be required for relief of pain. If pain is not relieved after this level of medication, the dressing and wounds must be inspected; suspicion that a hematoma may be forming must be relieved. Patients should spend 48 hours in close proximity to the surgeon after rhytidectomy. On the second postoperative day, the dressing should be removed and flaps inspected. After redressing with a similar head bandage, patients can return a reasonable distance to their home with instructions to return in 4 or 5 days for removal of sutures. Most hemorrhagic problems develop in the first 6 hours after the adrenaline effect on small vessels wears off. It is not too much to perform a four-lid blepharoplasty and bilateral rhytidectomy in one ambulatory procedure. Forehead and brow corrective procedures add more to rhytidectomy and blepharoplasty than is desirable for most patients. The same precautions regarding the eyes must be exercised as when blepharoplasty alone is performed. Because rhytidectomy and blepharoplasty performed at the same time is such a long procedure, general anesthesia is particularly unsuitable for ambulatory care patients. Serious, unrecognized, retrobulbar hemorrhage and permanent loss of visual acuity can occur in a patient under general anesthesia who has had a four-lid blepharoplasty followed by bilateral rhytidectomy.
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Nasal Surgery Practically all nasal procedures can be performed efficiently in an ambulatory setting. An anesthesiologist or anesthetist is usually not needed. If proper preoperative preparations are made to be certain that patients are driven to and from the ambulatory center by a responsible person, pentobarbital, diazepam, or other such agents can be taken orally at home so that proper preanesthetic sedation is present soon after arrival in the ambulatory center. A supplement of intramuscular meperidine just before entering the operating room can provide the last additional sedation and considerable amnesia without the necessity of utilizing intravenous medication. Patients and the person who will be taking care of them after they leave the ambulatory center should have postoperative measures such as application of cold compresses to the eyes and changing of the drip pad beneath the tip of the nose demonstrated by a nurse or surgeon before the patient departs. It is important not to underestimate the mistakes untrained people make applying ice or changing a bandage when only verbal instructions are given. Hemorrhage, of course, is the complication patients fear most after nasal surgery; reassurance that hemorrhage, if it occurs, is not going to be a serious threat to life or health should be given repeatedly during preoperative counseling. Such first aid measures as staying calm, assuming a head elevated position, pressing on the upper lip, and applying a cold towel to the posterior neck should be reviewed with the patient and his or her attendants as often as necessary. Finally, patients undergoing nasal surgery should be given day and night emergency telephone numbers and instructed to make contact with the proper person any time hemorrhage lasts more than 30 minutes. Pedicle flaps to the nasal area are easily performed and taken care of under ambulatory conditions. Local forehead and cheek flaps are the best restorations for ambulatory patients to take care of, but distant flaps such as an arm flap also can be attached and detached in an ambulatory surgical setting if satisfactory postoperative care at 'bome can be arranged. If nasal packs remain longer than 24 hours, most surgeons prescribe oral antibiotics such as tetracycline to prevent maxillary or other sinus infection. Patients with nasal packs cannot take their temperature orally and may not recognize the symptoms of early sinusitis. Detailed instruction concerning care of ecchymotic and edematous eyelids can prevent an anguished cry for help in the morning after surgery when patients find it difficult to open their eyes by normal levator function. Ears All ear procedures, including complex second stage cartilage grafts, can be performed nicely in an ambulatory setting. Removal of costal cartilage for head and neck procedures is not dangerous in an ambulatory setting provided that proper precautions are taken, including careful dissection in a subperichondrial plane, particularly on the posterior surface of the cartilage. After cartilage has been removed, the wound should be filled with saline solution while the anesthetist produces forced inspiration. If air does escape and a small hole in the pleura is identified, it should be closed
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with a few silk sutures while air is aspirated and the lung is overinflated. A postoperative x-ray can be obtained to be certain that pneumothorax does not recur or is not present to a significant degree. It is possible most of the time to remove cartilage without producing a pneumothorax; the possibility that a pneumothorax might be produced is not a sufficient reason to admit patients to a hospital for cartilage grafts. Other stages in the reconstruction of an ear and cosmetic otoplasty are performed very satisfactorily in an ambulatory setting.
BREASTS Reduction mammoplasty and modified or radical mastectomy are about the only procedures that cannot be performed on the breast in an ambulatory care facility. Reconstruction of the breast after mastectomy can be carried out well in an ambulatory center if an inflatable prosthesis or expander is used; transverse abdominal or latissimus dorsi flaps require hospitalization. Open Biopsy One of the more frequently performed procedures in ambulatory centers is open biopsy of a calcified suspicious area detectable by a mammogram. Many patients are still admitted to the hospital for this procedure under the mistaken notion that hospital radiology services are needed to locate the suspicious area. Similar services can be performed on an outpatient basis if a radiology unit is reasonably nearby. Inserting a needle under fluoroscopic control before the patient is taken to the operating room is the preferred procedure. Experience reveals, however, that insertion of a needle by a radiologist seldom is necessary. Consultation with the radiologist usually makes it possible to identify the area topographically with remarkable accuracy. Because a quadrant resection or slightly less than a quadrant resection can be carried out without deforming the breast significantly, the area removed after gross topical localization almost always contains the calcified area. Thus, a surgeon who goes over the mammogram carefully with the radiologist prior to surgery will find the suspicious area in the specimen when it is looked at by x-ray examination postoperatively 95 per cent of the time without the use of a needle. The specimen can be taken to the radiologist while the wound is being closed. Only rarely does the specimen not contain the calcified area; in this event the surgeon simply has to reopen the wound and excise a little more tissue in the direction the radiologist directs. Good hemostasis is difficult through a circumareolar incision. Either a Penrose or small Jackson-Pratt suction drain is helpful in preventing large mammary hematomas. Augmentation Mammoplasty Augmentation mammoplasty is performed ideally in an ambulatory setting. General anesthesia is preferred, unless economic factors are a major consideration, as they frequently are. It is very difficult to anesthetize completely the large area on both sides of the thorax required to insert a
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prosthesis without pain. Particularly when a submuscular pocket is developed, detachment of the origin of the pectoralis major muscle from the sixth rib produces considerable discomfort. The amount of local anesthetic needed to block both sides of the thorax simultaneously approaches toxic levels. Bilateral augmentation mammoplasty can be performed in an ambulatory center under local anesthesia but considerable skill and patience are required and general anesthesia usually is better. Mastopexy Mastopexy, including simultaneous insertion of a silicone prosthesis, also can be performed in an ambulatory setting. The major disadvantage is the length of the procedure and the need for general anesthesia. It requires 2.5 to 3 hours of anesthesia to perform bilateral mastopexy and augmentation at the same time. Recovery time is prolonged, particularly if postoperative nausea and vomiting are encountered. When breast tissue 'is not removed, postoperative hemorrhage of a significant degree is not likely to occur. The same type of fitted elastic brassiere used following augmentation mammoplasty provides excellent outpatient compression and virtually eliminates postoperative hemorrhage as a significant problem. Reduction Mammoplasty The major reason reduction mammoplasty is not recommended in an outpatient ambulatory setting is the problem of operative hemorrhage and blood replacement. There is a great variation in the amount of hemorrhage encountered. Cutting through breast tissue causes intraoperative hemorrhage of a type that is not encountered during simple mastectomy or dissecting beneath the breast during augmentation procedures. Because of the length of the procedure it is advisable to have two teams when possible. Operating on both breasts simultaneously adds to the magnitude of blood loss, however, and often makes transfusion necessary. Theoretically, reduction mammoplasty can be performed in an.,outpatient ambulatory setting, provided that blood replacement can be arranged if needed. At least two units of blood are needed in some patients. The problem can be solved by bleeding patients several weeks before operation and storing the blood in a local approved blood bank or by making arrangements for delivery of whole blood or packed cells to the ambulatory care center from a licensed blood bank in the area. 1 By the time such arrangements are made and adequate protection assured and such time-consuming procedures as crossmatching and typing are carried out, it usually is not worthwhile to try to perform reduction mammoplasty in an ambulatory setting. If the problem of blood replacement can be solved, however, there is no reason why reduction mammoplasty should not be performed on outpatients. Mastectomy Simple mastectomy, including removal of the first and second line of lymph nodes in the axilla, can be performed without difficulty in an ambulatory setting. Suction drainage, when needed, does not complicate the situation for intelligent patients and their attendants. The complication most likely to occur in outpatients having major breast surgery, including
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simple mastectomy, is pulmonary atelectasis. Atelactasis is especially frequent when a tight elastic brassiere or a circular compression dressing is utilized. When compression dressings can be avoided, such as those following simple mastectomy, lumpectomy, quadrant resection, and so on, a suction drain r~ther than circular compressive dressings protect the patient against postoperative atelectasis. When compression is mandatory, for example, after augmentation mammoplasty, mastopexy, or breast reconstruction, special emphasis and warning must be given to the patient and attendant to encourage deep breathing on a regular basis. Temperature should be taken at home approximately every four hours and the physician notified if temperature becomes elevated. Such patients need to be seen the day after surgery to be certain that pulmonary complications are not developing. Reconstruction of Nipple and Areola Reconstruction of the nipple and areola should be performed in an outpatient setting. Local anesthesia suffices and postoperative care is not complicated. Full thickness pigmented grafts from the junction of the posterior thigh and buttock make superb areolar grafts and can be performed under local anesthesia without significant disability. Paper tape utilized to maintain the nipple and areolar restoration in outpatients can be left in place for 3 weeks and is not disturbed by bathing. Operative correction of inverted nipples and exploration of a bleeding duct to locate an intraductal papilloma are performed efficiently in an ambulatory setting. RECONSTRUCTIVE HAND SURGERY With the obvious exception of microvascular transfer of tissue or replantation procedures in which blood How must be monitored continuously, almost all reconstructive hand surgery can be performed in an ambulatory setting. Control of pain, monitoring the constrictive nature of circular dressings, and maintenance of elevation are the major problems of performing plastic surgery in an ambulatory setting. Pain Control Satisfactory relief of pain is the most difficult problem. Acetaminophen with codeine and virtually all non-narcotic drugs are not adequate for most patients on the first night following reconstructive hand surgery. Unless there is a specific allergy or hypersensitivity, meperidine or pentazocine is needed and should be prescribed in sufficient doses from the beginning of the postoperative period. These drugs have to be given more often than every 4 hours to relieve pain effectively in most patients. After a relatively small procedure, such as decompression for de Quervain's disease, carpal tunnel release, or tenovaginotomy, 50 mg tablets of meperidine or pentazocine every 3 hours as needed for pain usually is adequate. Occasionally a major exception is carpal tunnel release. Although the reason is not clear, some patients who have had nothing more done to them than incision of the transverse carpal ligament have what they describe as
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excruciating pain the first night after surgery. It is helpful, therefore, to write a meperidine prescription for two tablets (100 mg) every 3 hours if needed. The prescription should be given to the patient 1 or 2 days before surgery so that the drug will be available immediately, if necessary, rather than after a trip to the drugstore or waiting for someone else to perform that service after postoperative pain begins. Regardless of the operative procedure, any patient who has not obtained relief for at least 2 hours after taking 100 mg of meperidine by mouth should be seen by the surgeon. These patients may have an enlarging hematoma or a dressing complication that requires physical manipulation rather than larger does of narcotics. In summary, pain following reconstructive hand surgery is substantial. It is tolerated less gracefully in an ambulatory setting than in a hospital room and will almost always require at least 50 mg of meperidine every 3 hours to control. Extensive procedures, such as joint replacement, tendon grafts, open reduction of fractures, and treatment of crushing fingertip injuries, should be followed by 100 mg of meperidine by mouth every 3 hours if needed and, if pain is still intolerable, local adjustments of the bandage or cast are in order. There is a fine line between the minimal dose of a narcotic required for even stoical individuals with a high pain threshold after a relatively minor procedure and extremely anxious patients, with a low threshold of pain, following a major procedure. The surgeon has only about 50 mg of meperidine or pentazocine to work with over the whole range of patients having everything from minor surgery to major procedures. Because it is not good judgment to administer more than 100 mg of meperidine or pentazocine by mouth every 3 hours to a patient in an ambulatory setting, relief of pain has to be obtained in other ways in some patients. Adjustment of the bandage is the most frequently useful procedure. Dressings Whether changing a dressing in the evening after surgery actually relieves compression on tissue and thus relieves the intensity of peripheral painful stimuli, or whether the observation of merely seeing the dressing removed and knowing that the doctor has inspected what lies beneath reassures the patient and thus raises the threshold for painful stimuli, is often a moot question. The inescapable conclusion is that the dressing must be removed on the evening after ambulatory surgery if a patient does not achieve relief of postoperative pain with 100 mg of meperidine. It is mandatory, therefore, to have access to a hand dressing tray so that the second dressing will not be compromised in quality because it was performed outside of the operating room. The tray must include sterile gloves and a mask as well as all of the dressing materials needed. Circular plaster should not be applied during the first 48 hours after ambulatory hand surgery. If rigid immobilization is required, a volar or dorsal plaster splint should be utilized so that it can be removed and reapplied in a hotel room if necessary. The dressing material most often appearing too tight on the first postoperative night is Conform (Kendall Co., Boston, Massachusetts). Conform, a semielastic woven cotton roller gauze, makes a superb external dressing for plastic surgery procedures on the limbs or head. However, it
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is very easy to apply Conform too tightly as a circular dressing around the hand, and so special precautions must be taken for ambulatory patients. Fingertip injuries are some of the most painful procedures treated on an ambulatory care basis. Application of a finger to a curved metal splint may not be tolerable in an ambulatory setting. Uncontrollable extensor spasm causes the patient to try to straighten the finger in spite of the restraining dressing holding it against a metal splint. It may be necessary in such patients to allow the finger to rest in complete extension for 24 or 48 hours until anxiety and early postoperative pain subside. Joints can be placed in a more functional position several days later. Anesthesia The type of anesthetic also influences postoperative pain and the control of postoperative pain. Contrary to what might be predicted, it is not a good idea to use long-acting, local anesthetics when reconstructive hand surgery is performed in an ambulatory setting during morning hours. It actually is preferable to have the local anesthetic wear off and the patient pass through the first hour or two of most severe pain before evening hours and darkness appear. When a long-acting agent is used late in the morning, it may be 7:00 or 8:00 P.M. before the anesthetic wears off and the first severe pain occurs. Long-acting anesthetics are very useful, however, in the late afternoon or evening hours for exactly the same reason. One very helpful maneuver is to perform a metacarpal block or local infiltration of a wound with a long-lasting anesthetic such as bupivacaine when a postoperative dressing is performed early in the evening. Local anesthesia during the early evening hours or until the patient falls asleep may be exactly what is needed to help them through the first night after ambulatory plastic surgery. Disappearance of local anesthesia and appearance of the first wave of relatively severe postoperative pain during the early evening hours may set the stage for a sleepless and painful first night. Metacarpal blocks and brachial blocks are the two best methods for providing anesthesia for the patient undergoing ambulatory reconstructive hand surgery. Ulnar nerve block at the elbow or wrist and median nerve block at the wrist and digital finger blocks both seem to be less desirable as far as pain control during the first 24 to 36 hours. However, utilization of brachial block raises several questions. The most frustrating problem regarding brachial block anesthesia in an outpatient setting is determining who is going to perform the block and what should be the standard of ancillary care. In a hospital setting, the standard usually is that an anesthesiologist performs the block; patients are prepared as for a general anesthetic, including nothing by mouth, preanesthetic medication, and the usual laboratory determinations such as electrocardiograms, chest x-ray, blood and urine analysis; an anesthetist, anesthetic resident, or anesthesiologist monitors the patient during surgery; and the patient stays in the hospital overnight. The cost of such a procedure obViously is the same as for any general anesthesia. It is customary in most institutions for the department of anesthesia to make the same hospital and profeSSional charges for a brachial block as for general anesthesia. The rationale is that an untoward reaction caused by allergy, hypersensitivity,
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or intra-arterial or intravenous injection of drugs can be handled most efficiently under hospital conditions and by anesthesia personnel. If other complications, such as peripheral neuritis, hematoma, or pneumothorax occur, the medicolegal risk is minimal because maximal preventive measures were taken. In the experience of the author, brachial block anesthesia can be administered in an ambulatory care center without sacrificing Significant patient safety and at considerable reduction in cost. The dilemma this statement exposes can be expressed in the question "How much safety can patients afford?" There is some risk in any operative procedure, including the risk of an anesthetic of any kind; it is unthinkable to subject patients to irresponsible risk, but equally irresponsible in 1987 to provide all of the safety measures that money can buy to cover every theoretical or practical consequence without concern about such practical matters as burgeoning cost. The author respectfully recognizes that most anesthesiologists do not agree with the standard that is recommended in this chapter. Over 3000 brachial block anesthetics have been performed by the author, however, under conditions ranging from a university hospital setting to a tent in the jungle without a fatality or a single permanent or serious complication. Brachial block anesthesia can be performed safely and effectively by a surgeon who has been properly trained and has experience performing the procedure under supervision. If a preoperative history and physical examination are normal, it is not necessary to perform preoperative laboratory tests. Brachial block anesthesia can be performed safely on patients who have not fasted and who do not wish to have preoperative sedation. An intravenous line should be in place so that emergency drugs can be administered easily if an untoward reaction occurs. Continuous electronic monitoring or a nurse performing the same service normally is mandatory. Resuscitation equipment and sufficient ancillary help should be available for an emergency. Obviously, the surgeon must be trained and currently proficient in cardiopulmonary resuscitation. The foregoing procedure for adminisi:ering brachial block anesthesia provides a practical, responsible standard of safety and can result in over $500 in savings to the patient by eliminating laboratory tests, an anesthetist or anesthesiologist sitting with a patient through a 2 to 3 hour procedure, and the various inflated hospital charges for the use of anesthesia equipment and supplies. Many thousands of brachial block anesthetics have been administered under similar conditions; there are no data to suggest that a significant or irresponsible risk occurs when the procedure described is followed. Drainage Continuous suction drainage seldom is needed following ambulatory hand surgery. A Penrose drain placed in a palmar wound following an extensive dissection of the palmar fascia is helpful, and it can be removed by the patient if a large silk ligature is tied to the exposed portion of the drain and brought out along the skin beneath the proximal end of the dressing in the forearm. Patients can remove their own drains at an
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appointed time by pulling the suture and sliding the drain out beneath the undisturbed bandage.
LIPOSUCTION The major consideration in performing liposuction procedures in an ambulatory setting is blood loss or fluid replacement, or both. Most surgeons have arbitrarily adopted a rule that no more than 3000 ml of aspirate should be removed in an ambulatory facility. Because the aspirate has a 20 per cent hemoglobin level, this rule is conservative and usually good judgment. Fluid replacement is important and most centers anticipate fluid loss by giving a preoperative load of 1000 to 1500 ml of balanced salt solution containing 5 per cent ethyl alcohol. Addition of alcohol is theoretically useful for prevention of fat emboli; in practice the procedure is probably of more medicolegal than medical value. Patients should remain in the recovery area until total fluid replacement has been achieved. Patients usually do better if kept in a few degrees of Trendelenburg position for approximately 6 hours after major lipolysis procedures. Both hips and lateral thighs can be treated in a single procedure. Both buttocks and abdomen also can be treated by suction lipectomy as a single procedure in an ambulatory setting. Small procedures such as submental lipectomy are ideal for ambulatory centers. Massive procedures in which thighs, abdomen, and buttocks are suctioned should not be performed in an ambulatory setting. Prefitted elastic garments commercially available make ideal postoperative dressings. Suction drainage can be utilized on an outpatient basis, but it is usually not necessary unless a major vessel is inadvertently damaged or some hemorrhagic complication occurs. The same suction pump and some of the large cannulas used for suction evacuation of the uterus can be utilized satisfactorily in ambulatory centers to perform suction lipolysis. Postoperative care is exactly the same as when lipolysis is performed in a hospital environment. General anesthesia is almost always preferable when a relatively large area is treated. Postoperative pain is not severe; narcotics usually are not necessary for most patients. At most 2 or 3 days bed rest is all that is required, even for patients having both thighs or both buttocks treated.
CONCLUSION Plastic surgery is one of the most ideal surgical specialties to utilize ambulatory surgery facilities. With the exception of patients who have had complicated transfer or replantation of composite tissue and patients who might have significant hemorrhage, airway obstruction, or major vascular complications, plastic surgery can be performed safely and efficiently on an outpatient basis. The critical factor in postoperative care is whether anything more than rest, nourishment, fluids, and relief of pain will be needed. Most procedures in plastic surgery do not require postoperative care other than nourishment and relief of pair and can be performed in an outpatient
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setting less expensively and more conveniently than in the hospital. Local conditions including proximity of radiology, emergency room, and major hospital facilities influence tire decision to perform surgery in an ambulatory center. In most areas, the protection that established medical facilities offer is available, and the plastic surgeon has been able to conduct most of his or her work outside of a medical center. The major disadvantage has been the effect on the surgeon of being removed from the mainstream of medical thought and practice; patients, for the most part, respond favorably to outpatient surgery and will continue to encourage plastic surgeons to give them the opportunity to avoid hospitalization.
REFERENCES 1. Mandel MA: Autotransfusion in elective plastic surgical operations. Plast Reconstr Surg 77:767, 1986 2. Schumacher EF: Small is Beautiful: Economics as if People Mattered. New York, Harper & Row, 1973 Suite 2204 Professional Village 109 Conner Drive Chapel Hill, North Carolina 27514
0039-6109/87 $0.00
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Major Ambulatory Surgery of the Plastic Surgical Patient Erle E. Peacock, Jr., M.D. *
Plastic surgery is probably the ideal major surgical specialty to practice in an ambulatory setting. Indeed, for many years when hospital beds in the United Kingdom were difficult to obtain, one of the largest plastic surgery teaching services in existence was conducted entirely without inpatient facilities. Even large head and neck extirpative and reconstructive procedures, including jaw-neck dissections, were performed as outpatient procedures, at least to the extent that patients were transferred to nursing homes on the evening after a morning procedure. In the final analysis, a patient who does not require any more in the way of postoperative nursing care than bed rest and administration of food, water, and pain medication should be able to have surgery in an outpatient facility as safely and successfully as in an inpatient facility. The occasional patient who cannot be moved safely, such as after massive flap repair of a decubitus ulcer, or the patient who has had a restoration with tissue that postoperatively has reduced or questionable circulation, are two obvious exceptions to the general statement that most plastic surgery patients can be operated on as effectively and safely in an ambulatory setting as in a hospital. A large, general plastic surgery practice in an ambulatory center creates unique problems, but most of these problems are solvable and have not prevented many plastic surgeons from conducting an ever increasing volume of their work in an ambulatory setting.
ADVANTAGES AND DISADVANTAGES The obvious advantages of performing plastic surgery in an ambulatory setting are essentially the same as expressed in the recent book Small Is Beautiful. 2 The major problems involved in performing surgery in a hospital setting are problems caused by bigness. The conversion of the community *Courtesy Staff, North Carolina Memorial Hospital, Chapel Hill; Attending Staff, Durham County General Hospital, Durham; and Private Practitioner, Chapel Hill, North Carolina
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or university hospital into a medical center usually involves creation of independent departments, many of which operate autonomously and make it impossible to provide strong leadership in protecting patients' interests. In a properly administered ambulatory care facility, however, anesthesia, nursing, and surgical personnel can interact on a much closer level than in a typical hospital. This factor alone makes it possible to focus on the best interests of the patient as the paramount goal for the institution. As a result, starting times are realistic and usually accurate, time lost between patients is reduced to a minimum, and patient delays because of personnel problems are reduced significantly. Every plastic surgeon the author has interviewed on the subject prefers to work in an ambulatory rather than in an inpatient hospital setting because of the ability to take care of patients more personally than is possible in a large medical center. Because most plastic surgery patients are not sick, ancillary factors such as availability of parking, waiting and dressing room comfort and decor, and friendliness of supporting staff are major attractive features. Such considerations undoubtedly weigh heavily in the increasing popularity of ambulatory surgery for plastic surgery patients. An additional factor for patients undergoing cosmetic surgery is protection of privacy. Because ambulatory patients spend less time in an outpatient facility and come in contact with fewer people than they do in a large hospital, it is easier to protect privacy and give the patients the feeling that they can keep their surgery confidential. There are some general disadvantages for surgeons and for patients in an ambulatory surgical center. For plastic surgeons the major disadvantage is isolation. Particularly for plastic surgeons who develop office operating room suites that they use exclusively for their own patients, ambulatory surgery results in loss of professional contacts, particularly with other disciplines. There is no way to measure the exact amount of postgraduate education that is obtained by changing clothes in the presence of others who are discussing medical questions; however, such experiences, sometimes prolonged while waiting for a room to be changed, have contributed in the past to professional comradery and are a potential source of graduate education that may be reduced or eliminated entirely by the ambulatory care facility, particularly when it serves a small group. It is not unusual now to see plastic surgeons literally withdraw from the medical community, including administrative, social, and professional activities, because they are able to take care of their patients entirely within an isolated and often secluded facility. Professional isolation must be listed, therefore, as a negative feature of ambulatory surgical care. General disadvantages for patients receiving ambulatory care are a feeling of too much and too little security. It comes as a surprise to some surgeons developing practice in an ambulatory center to see the way patients prepare and often react to outpatient surgery. Expressed simply, patients equate going to the hospital with being sick and requiring detailed preoperative and postoperative care, whereas the same surgery performed in an ambulatory care center may be viewed more as a single event not requiring preoperative preparation or postoperative care. Strangely, patients are not as diligent about such basic factors as refraining from taking
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food or water if they are to have ambulatory surgery as they are in a hospital, where it seems the ~business of the hospital for the patients to be NPO after midnight. Patients who would never think of driving themselves to a hospital, parking in the hospital parking lot, and driving home several days later after major surgery will often show up at an ambulatory care center with no one to take them home or look after them postoperatively. Seemingly intelligent patients plan business or social activities up to the very moment before surgery and often plan to pick up such activities, including travel to some distant vacation site, immediately after surgery. Of course, it is the responsibility of the surgeon and anesthesiologist to educate patients against this type of activity and help them plan intelligently for postoperative care. The point, however, is that in spite of such planning and preparation, the ambulatory setting mitigates against getting through to the patient, whereas the hospital setting seems to reinforce the importance of preoperative and postoperative care. One of the disadvantages of performing plastic surgery in an ambulatory setting, therefore, is the necessity to take special precautions to educate patients about the seriousness of surgery and the need for attention to details of preoperative and postoperative care. It is also necessary to be continually alert for failure of patients to understand and follow directions in the ambulatory setting. It is not unusual for a surgeon to look out a window and see a patient who has just had a major hand reconstructive procedure release the parking brake of his truck with the bandaged hand while it is still anesthetized. Sometimes an anesthesiologist must take a patient home in his or her own car and stay with the patient until help arrives even though it was believed that the patient understood completely the danger of being left alone immediately after general anesthesia. A second disadvantage to ambulatory plastic surgery is exactly the opposite of too much confidence-too little confidence. Too little confidence reveals itself primarily after sunset. What is missing, of course, is evening rounds. House officers think of evening rounds in a hospital as necessary to be sure that tests performed during the'day are recorded, dressings are not too tight, wounds dry, and so forth. Experience in an ambulatory setting emphasizes, however, that one of the greatest benefits of evening rounds is the knowledge by the patient that the doctor has checked everything and that all is well. Without such reassurance, although all of the important factors are perfect, the slightest unexpected occurrence can cause a sense of panic; there is not even a nurse to consult. Successful practice of plastic surgery in an ambulatory setting demands, therefore, that patients be given the most detailed and comprehensive instructions including a complete review of all of the observations they may make during the ensuing 24 hours after surgery. For instance, most patients undergoing a blepharoplasty in a hospital are warned not to worry if there is ecchymosis around the eyes and eyelids. In an ambulatory setting, however, such patients also have to be warned that the eyelids may stick together the first evening after surgery. Separation of the lids the next morning, when there is coagulation of serum holding them lightly together, often seems like a formidable, if not impossible, undertaking unless a doctor
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or nurse is there to reassure the patient that permanent blindness is not occurring. It is almost impossible to anticipate all of the inconsequential sensations or observations that postoperative patients experience. As a result, in addition to making clear all of the important problems that can arise such as swelling, constriction of an extremity by a circular bandage, bleeding, and so on, special measures have to be taken not only to be available or have some medical personnel available but also to have the patients and their families know that continual coverage is no farther away than the telephone. Reassuring a patient that, even though he or she is not being retained in a hospital, medical attention is available day and night' is probably more important than the information that actually is dispensed. Such coverage can be arranged in a number of ways. A hotel, motor inn, or some other reasonably quiet first-class tourist facility as close as possible to either the surgeon's office or a clearly identified hospital is more desirable than similar facilities distant from a medical complex. The knowledge that the patient's own surgeon is working close by or that, if some catastrophic complication arises, a hospital emergency room is near does much to relieve anxiety, which in turn raises the threshold for postoperative pain. A visit to the patient's room on the way home in the evening serves the same purpose as evening house officers' rounds in a hospital and may prevent a summons at a more inconvenient time later in the evening. Even a visit by an office nurse or a physician's assistant is all that may be necessary to help a patient through the first night after an outpatient surgical procedure. Any arrangement that can be made to have first-hand contact with the patient the first evening after ambulatory plastic surgery is superior to a telephone call and is usually all that is required to prevent the familiar linear increase in anxiety during daylight hours from becoming exponential after darkness occurs. The need for evening rounds is universally appreciated in a hospital setting but it may be overlooked under ambulatory conditions, although a few moments of reflection reveal that contact between surgeon and patient is even more necessary when the patient is not surrounded by the general hospital scenario and the reassurance such surroundings provide. In addition to the general considerations just outlined, there are special considerations when specific plastic and reconstructive procedures are performed in an ambulatory setting. Some of these considerations follow.
HEAD AND NECK SURGERY Tumors The major consideration in selecting patients for ambulatory surgery with head and neck tumors is the danger of postoperative respiratory complications. Obviously, procedures that require dissection of the lower jaw and major changes in the stability of the floor of the mouth, posterior tongue, and suspension of the glottis should not be performed in an ambulatory setting. Skilled postoperative observation and immediate operative intervention when airway disasters occur are mandatory following
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such procedures. Operations that may be complicated by severe postoperative hemorrhage, such as r~construction of the palate, resecting of the maxilla, and nasopharyngeal surgery, also should not be performed in an ambulatory setting. Only those procedures in which respiratory complications and hemorrhage are not significant factors during postoperative care can be performed on an outpatient basis. Excision of lip tumors, resurfacing the vermilion border of the lower lip, resection of small portions of the alveolar ridge or a torus palatinus, resection of some parotid tumors, and excision of scalp lesions are examples of tumors that can be excised safely in an ambulatory setting. Excision of anything more than very small tongue lesions should not be performed in an ambulatory setting because of the danger of postoperative swelling and hemorrhage. It is not wise to remove deep tumors high in the neck because of the threat that such tumors may involve the internal carotid artery. Tumors in the upper neck that are not freely movable, particularly in a vertical direction, can involve the carotid vessels. Removal of these tumors can be more complicated than is sometimes anticipated and the complications include potentially fatal hemorrhage and hemiplegia. Any deep tumor in the neck, particularly one that is not freely movable in a vertical plane, is best handled in a hospital setting where vascular expertise and skilled postoperative care are available. Blepharoplasty
Most eyelid procedures, including restoration of the lids, can be performed safely in an ambulatory setting. The major complication that must be allowed for is loss of visual acuity. Patients undergoing eyelid surgery must be warned of the importance of continually evaluating vision and reporting any loss of vision immediately. Such instructions include directions to a suitable hospital emergency room if contact with the surgeon cannot be made. The most dangerous procedure in an ambulatory setting is removal of fat from beneath the lower eyelids and suborbital spaces. This procedure is best performed under local .i;mesthesia and patients should remain in a recovery area for at least 1 hour after surgery so that visual acuity can be checked by professional personnel. In addition, immediate application of cold compresses for at least an hour in the ambulatory center is desirable to reduce ecchymosis. Patients should never be allowed to drive home alone from an ambulatory center after eyelid surgery. Patients who may accurately evaluate acuteness of vision often do not realize that peripheral vision is compromised due to ecchymosis and swelling of the eyelids, particularly in the canthal regions. Patients should not leave an ambulatory center with bandages covering the eye if there has been extensive suborbital or retro-orbital dissection. These patients must have vision evaluated almost continually for at least 24 hours after surgery. Blindness can develop beneath a bandage without the patient being aware of anything wrong. Lid adherence and subconjunctival hemorrhage are the most alarming observations that patients make after leaving an ambulatory care center. Warning the patient about such occurrences can prevent anxiety and attempts to contact the surgeon in the evening or early morning hours.
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Rhytidectomy Most rhytidectomies aJ:e performed now in an ambulatory setting for economic, convenience, and privacy reasons. The major concern, of course, is bleeding and possible airway obstruction. The use of drains has not prevented hemorrhagic complications, although some surgeons utilize Penrose drains and even suction drains on an outpatient basis. The general consensus at this time, however, is that drains do not protect against development of a hematoma and it is not possible to drain the neck and face satisfactorily through a posterior scalp incision. Special precautions should be taken during surgery to obtain the best hemostasis possible in outpatients; these precautions include leaving a large segment of the posterior scalp or retroauricular incision open on the first side so that the wound and flaps can be inspected after the second side is finished. The central or submandibular wound is particularly susceptible to hematoma formation and should be closed only partially if this stage of the rhytidectomy is performed first, so that blood that collects during the face and neck dissection can be removed by suction just before the bandage is applied. An evening visit by someone capable of evaluating the dressing, reassuring the patient, and evaluating respiratory and swallowing functions is desirable. Many patients begin to feel tightness beneath the chin and become anxious by 7:00 P.M. on the night after surgery. It is usually a good idea to cut through the entire thickness of the chin bandage and inspect the neck. This can be done in a hotel room or nursing facility by carrying the proper materials and instruments to the room. The neck bandage can be replaced less tightly by reapplying adhesive tape beneath the chin. This maneuver gives the surgeon and the patient confidence that the first night will be safe and comfortable. It is extremely important not to overmedicate patients following rhytidectomy performed in an ambulatory setting. A small dose of codeine or similar synthetic analgesic is all that should be required for relief of pain. If pain is not relieved after this level of medication, the dressing and wounds must be inspected; suspicion that a hematoma may be forming must be relieved. Patients should spend 48 hours in close proximity to the surgeon after rhytidectomy. On the second postoperative day, the dressing should be removed and flaps inspected. After redressing with a similar head bandage, patients can return a reasonable distance to their home with instructions to return in 4 or 5 days for removal of sutures. Most hemorrhagic problems develop in the first 6 hours after the adrenaline effect on small vessels wears off. It is not too much to perform a four-lid blepharoplasty and bilateral rhytidectomy in one ambulatory procedure. Forehead and brow corrective procedures add more to rhytidectomy and blepharoplasty than is desirable for most patients. The same precautions regarding the eyes must be exercised as when blepharoplasty alone is performed. Because rhytidectomy and blepharoplasty performed at the same time is such a long procedure, general anesthesia is particularly unsuitable for ambulatory care patients. Serious, unrecognized, retrobulbar hemorrhage and permanent loss of visual acuity can occur in a patient under general anesthesia who has had a four-lid blepharoplasty followed by bilateral rhytidectomy.
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Nasal Surgery Practically all nasal procedures can be performed efficiently in an ambulatory setting. An anesthesiologist or anesthetist is usually not needed. If proper preoperative preparations are made to be certain that patients are driven to and from the ambulatory center by a responsible person, pentobarbital, diazepam, or other such agents can be taken orally at home so that proper preanesthetic sedation is present soon after arrival in the ambulatory center. A supplement of intramuscular meperidine just before entering the operating room can provide the last additional sedation and considerable amnesia without the necessity of utilizing intravenous medication. Patients and the person who will be taking care of them after they leave the ambulatory center should have postoperative measures such as application of cold compresses to the eyes and changing of the drip pad beneath the tip of the nose demonstrated by a nurse or surgeon before the patient departs. It is important not to underestimate the mistakes untrained people make applying ice or changing a bandage when only verbal instructions are given. Hemorrhage, of course, is the complication patients fear most after nasal surgery; reassurance that hemorrhage, if it occurs, is not going to be a serious threat to life or health should be given repeatedly during preoperative counseling. Such first aid measures as staying calm, assuming a head elevated position, pressing on the upper lip, and applying a cold towel to the posterior neck should be reviewed with the patient and his or her attendants as often as necessary. Finally, patients undergoing nasal surgery should be given day and night emergency telephone numbers and instructed to make contact with the proper person any time hemorrhage lasts more than 30 minutes. Pedicle flaps to the nasal area are easily performed and taken care of under ambulatory conditions. Local forehead and cheek flaps are the best restorations for ambulatory patients to take care of, but distant flaps such as an arm flap also can be attached and detached in an ambulatory surgical setting if satisfactory postoperative care at 'bome can be arranged. If nasal packs remain longer than 24 hours, most surgeons prescribe oral antibiotics such as tetracycline to prevent maxillary or other sinus infection. Patients with nasal packs cannot take their temperature orally and may not recognize the symptoms of early sinusitis. Detailed instruction concerning care of ecchymotic and edematous eyelids can prevent an anguished cry for help in the morning after surgery when patients find it difficult to open their eyes by normal levator function. Ears All ear procedures, including complex second stage cartilage grafts, can be performed nicely in an ambulatory setting. Removal of costal cartilage for head and neck procedures is not dangerous in an ambulatory setting provided that proper precautions are taken, including careful dissection in a subperichondrial plane, particularly on the posterior surface of the cartilage. After cartilage has been removed, the wound should be filled with saline solution while the anesthetist produces forced inspiration. If air does escape and a small hole in the pleura is identified, it should be closed
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with a few silk sutures while air is aspirated and the lung is overinflated. A postoperative x-ray can be obtained to be certain that pneumothorax does not recur or is not present to a significant degree. It is possible most of the time to remove cartilage without producing a pneumothorax; the possibility that a pneumothorax might be produced is not a sufficient reason to admit patients to a hospital for cartilage grafts. Other stages in the reconstruction of an ear and cosmetic otoplasty are performed very satisfactorily in an ambulatory setting.
BREASTS Reduction mammoplasty and modified or radical mastectomy are about the only procedures that cannot be performed on the breast in an ambulatory care facility. Reconstruction of the breast after mastectomy can be carried out well in an ambulatory center if an inflatable prosthesis or expander is used; transverse abdominal or latissimus dorsi flaps require hospitalization. Open Biopsy One of the more frequently performed procedures in ambulatory centers is open biopsy of a calcified suspicious area detectable by a mammogram. Many patients are still admitted to the hospital for this procedure under the mistaken notion that hospital radiology services are needed to locate the suspicious area. Similar services can be performed on an outpatient basis if a radiology unit is reasonably nearby. Inserting a needle under fluoroscopic control before the patient is taken to the operating room is the preferred procedure. Experience reveals, however, that insertion of a needle by a radiologist seldom is necessary. Consultation with the radiologist usually makes it possible to identify the area topographically with remarkable accuracy. Because a quadrant resection or slightly less than a quadrant resection can be carried out without deforming the breast significantly, the area removed after gross topical localization almost always contains the calcified area. Thus, a surgeon who goes over the mammogram carefully with the radiologist prior to surgery will find the suspicious area in the specimen when it is looked at by x-ray examination postoperatively 95 per cent of the time without the use of a needle. The specimen can be taken to the radiologist while the wound is being closed. Only rarely does the specimen not contain the calcified area; in this event the surgeon simply has to reopen the wound and excise a little more tissue in the direction the radiologist directs. Good hemostasis is difficult through a circumareolar incision. Either a Penrose or small Jackson-Pratt suction drain is helpful in preventing large mammary hematomas. Augmentation Mammoplasty Augmentation mammoplasty is performed ideally in an ambulatory setting. General anesthesia is preferred, unless economic factors are a major consideration, as they frequently are. It is very difficult to anesthetize completely the large area on both sides of the thorax required to insert a
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prosthesis without pain. Particularly when a submuscular pocket is developed, detachment of the origin of the pectoralis major muscle from the sixth rib produces considerable discomfort. The amount of local anesthetic needed to block both sides of the thorax simultaneously approaches toxic levels. Bilateral augmentation mammoplasty can be performed in an ambulatory center under local anesthesia but considerable skill and patience are required and general anesthesia usually is better. Mastopexy Mastopexy, including simultaneous insertion of a silicone prosthesis, also can be performed in an ambulatory setting. The major disadvantage is the length of the procedure and the need for general anesthesia. It requires 2.5 to 3 hours of anesthesia to perform bilateral mastopexy and augmentation at the same time. Recovery time is prolonged, particularly if postoperative nausea and vomiting are encountered. When breast tissue 'is not removed, postoperative hemorrhage of a significant degree is not likely to occur. The same type of fitted elastic brassiere used following augmentation mammoplasty provides excellent outpatient compression and virtually eliminates postoperative hemorrhage as a significant problem. Reduction Mammoplasty The major reason reduction mammoplasty is not recommended in an outpatient ambulatory setting is the problem of operative hemorrhage and blood replacement. There is a great variation in the amount of hemorrhage encountered. Cutting through breast tissue causes intraoperative hemorrhage of a type that is not encountered during simple mastectomy or dissecting beneath the breast during augmentation procedures. Because of the length of the procedure it is advisable to have two teams when possible. Operating on both breasts simultaneously adds to the magnitude of blood loss, however, and often makes transfusion necessary. Theoretically, reduction mammoplasty can be performed in an.,outpatient ambulatory setting, provided that blood replacement can be arranged if needed. At least two units of blood are needed in some patients. The problem can be solved by bleeding patients several weeks before operation and storing the blood in a local approved blood bank or by making arrangements for delivery of whole blood or packed cells to the ambulatory care center from a licensed blood bank in the area. 1 By the time such arrangements are made and adequate protection assured and such time-consuming procedures as crossmatching and typing are carried out, it usually is not worthwhile to try to perform reduction mammoplasty in an ambulatory setting. If the problem of blood replacement can be solved, however, there is no reason why reduction mammoplasty should not be performed on outpatients. Mastectomy Simple mastectomy, including removal of the first and second line of lymph nodes in the axilla, can be performed without difficulty in an ambulatory setting. Suction drainage, when needed, does not complicate the situation for intelligent patients and their attendants. The complication most likely to occur in outpatients having major breast surgery, including
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simple mastectomy, is pulmonary atelectasis. Atelactasis is especially frequent when a tight elastic brassiere or a circular compression dressing is utilized. When compression dressings can be avoided, such as those following simple mastectomy, lumpectomy, quadrant resection, and so on, a suction drain r~ther than circular compressive dressings protect the patient against postoperative atelectasis. When compression is mandatory, for example, after augmentation mammoplasty, mastopexy, or breast reconstruction, special emphasis and warning must be given to the patient and attendant to encourage deep breathing on a regular basis. Temperature should be taken at home approximately every four hours and the physician notified if temperature becomes elevated. Such patients need to be seen the day after surgery to be certain that pulmonary complications are not developing. Reconstruction of Nipple and Areola Reconstruction of the nipple and areola should be performed in an outpatient setting. Local anesthesia suffices and postoperative care is not complicated. Full thickness pigmented grafts from the junction of the posterior thigh and buttock make superb areolar grafts and can be performed under local anesthesia without significant disability. Paper tape utilized to maintain the nipple and areolar restoration in outpatients can be left in place for 3 weeks and is not disturbed by bathing. Operative correction of inverted nipples and exploration of a bleeding duct to locate an intraductal papilloma are performed efficiently in an ambulatory setting. RECONSTRUCTIVE HAND SURGERY With the obvious exception of microvascular transfer of tissue or replantation procedures in which blood How must be monitored continuously, almost all reconstructive hand surgery can be performed in an ambulatory setting. Control of pain, monitoring the constrictive nature of circular dressings, and maintenance of elevation are the major problems of performing plastic surgery in an ambulatory setting. Pain Control Satisfactory relief of pain is the most difficult problem. Acetaminophen with codeine and virtually all non-narcotic drugs are not adequate for most patients on the first night following reconstructive hand surgery. Unless there is a specific allergy or hypersensitivity, meperidine or pentazocine is needed and should be prescribed in sufficient doses from the beginning of the postoperative period. These drugs have to be given more often than every 4 hours to relieve pain effectively in most patients. After a relatively small procedure, such as decompression for de Quervain's disease, carpal tunnel release, or tenovaginotomy, 50 mg tablets of meperidine or pentazocine every 3 hours as needed for pain usually is adequate. Occasionally a major exception is carpal tunnel release. Although the reason is not clear, some patients who have had nothing more done to them than incision of the transverse carpal ligament have what they describe as
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excruciating pain the first night after surgery. It is helpful, therefore, to write a meperidine prescription for two tablets (100 mg) every 3 hours if needed. The prescription should be given to the patient 1 or 2 days before surgery so that the drug will be available immediately, if necessary, rather than after a trip to the drugstore or waiting for someone else to perform that service after postoperative pain begins. Regardless of the operative procedure, any patient who has not obtained relief for at least 2 hours after taking 100 mg of meperidine by mouth should be seen by the surgeon. These patients may have an enlarging hematoma or a dressing complication that requires physical manipulation rather than larger does of narcotics. In summary, pain following reconstructive hand surgery is substantial. It is tolerated less gracefully in an ambulatory setting than in a hospital room and will almost always require at least 50 mg of meperidine every 3 hours to control. Extensive procedures, such as joint replacement, tendon grafts, open reduction of fractures, and treatment of crushing fingertip injuries, should be followed by 100 mg of meperidine by mouth every 3 hours if needed and, if pain is still intolerable, local adjustments of the bandage or cast are in order. There is a fine line between the minimal dose of a narcotic required for even stoical individuals with a high pain threshold after a relatively minor procedure and extremely anxious patients, with a low threshold of pain, following a major procedure. The surgeon has only about 50 mg of meperidine or pentazocine to work with over the whole range of patients having everything from minor surgery to major procedures. Because it is not good judgment to administer more than 100 mg of meperidine or pentazocine by mouth every 3 hours to a patient in an ambulatory setting, relief of pain has to be obtained in other ways in some patients. Adjustment of the bandage is the most frequently useful procedure. Dressings Whether changing a dressing in the evening after surgery actually relieves compression on tissue and thus relieves the intensity of peripheral painful stimuli, or whether the observation of merely seeing the dressing removed and knowing that the doctor has inspected what lies beneath reassures the patient and thus raises the threshold for painful stimuli, is often a moot question. The inescapable conclusion is that the dressing must be removed on the evening after ambulatory surgery if a patient does not achieve relief of postoperative pain with 100 mg of meperidine. It is mandatory, therefore, to have access to a hand dressing tray so that the second dressing will not be compromised in quality because it was performed outside of the operating room. The tray must include sterile gloves and a mask as well as all of the dressing materials needed. Circular plaster should not be applied during the first 48 hours after ambulatory hand surgery. If rigid immobilization is required, a volar or dorsal plaster splint should be utilized so that it can be removed and reapplied in a hotel room if necessary. The dressing material most often appearing too tight on the first postoperative night is Conform (Kendall Co., Boston, Massachusetts). Conform, a semielastic woven cotton roller gauze, makes a superb external dressing for plastic surgery procedures on the limbs or head. However, it
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is very easy to apply Conform too tightly as a circular dressing around the hand, and so special precautions must be taken for ambulatory patients. Fingertip injuries are some of the most painful procedures treated on an ambulatory care basis. Application of a finger to a curved metal splint may not be tolerable in an ambulatory setting. Uncontrollable extensor spasm causes the patient to try to straighten the finger in spite of the restraining dressing holding it against a metal splint. It may be necessary in such patients to allow the finger to rest in complete extension for 24 or 48 hours until anxiety and early postoperative pain subside. Joints can be placed in a more functional position several days later. Anesthesia The type of anesthetic also influences postoperative pain and the control of postoperative pain. Contrary to what might be predicted, it is not a good idea to use long-acting, local anesthetics when reconstructive hand surgery is performed in an ambulatory setting during morning hours. It actually is preferable to have the local anesthetic wear off and the patient pass through the first hour or two of most severe pain before evening hours and darkness appear. When a long-acting agent is used late in the morning, it may be 7:00 or 8:00 P.M. before the anesthetic wears off and the first severe pain occurs. Long-acting anesthetics are very useful, however, in the late afternoon or evening hours for exactly the same reason. One very helpful maneuver is to perform a metacarpal block or local infiltration of a wound with a long-lasting anesthetic such as bupivacaine when a postoperative dressing is performed early in the evening. Local anesthesia during the early evening hours or until the patient falls asleep may be exactly what is needed to help them through the first night after ambulatory plastic surgery. Disappearance of local anesthesia and appearance of the first wave of relatively severe postoperative pain during the early evening hours may set the stage for a sleepless and painful first night. Metacarpal blocks and brachial blocks are the two best methods for providing anesthesia for the patient undergoing ambulatory reconstructive hand surgery. Ulnar nerve block at the elbow or wrist and median nerve block at the wrist and digital finger blocks both seem to be less desirable as far as pain control during the first 24 to 36 hours. However, utilization of brachial block raises several questions. The most frustrating problem regarding brachial block anesthesia in an outpatient setting is determining who is going to perform the block and what should be the standard of ancillary care. In a hospital setting, the standard usually is that an anesthesiologist performs the block; patients are prepared as for a general anesthetic, including nothing by mouth, preanesthetic medication, and the usual laboratory determinations such as electrocardiograms, chest x-ray, blood and urine analysis; an anesthetist, anesthetic resident, or anesthesiologist monitors the patient during surgery; and the patient stays in the hospital overnight. The cost of such a procedure obViously is the same as for any general anesthesia. It is customary in most institutions for the department of anesthesia to make the same hospital and profeSSional charges for a brachial block as for general anesthesia. The rationale is that an untoward reaction caused by allergy, hypersensitivity,
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or intra-arterial or intravenous injection of drugs can be handled most efficiently under hospital conditions and by anesthesia personnel. If other complications, such as peripheral neuritis, hematoma, or pneumothorax occur, the medicolegal risk is minimal because maximal preventive measures were taken. In the experience of the author, brachial block anesthesia can be administered in an ambulatory care center without sacrificing Significant patient safety and at considerable reduction in cost. The dilemma this statement exposes can be expressed in the question "How much safety can patients afford?" There is some risk in any operative procedure, including the risk of an anesthetic of any kind; it is unthinkable to subject patients to irresponsible risk, but equally irresponsible in 1987 to provide all of the safety measures that money can buy to cover every theoretical or practical consequence without concern about such practical matters as burgeoning cost. The author respectfully recognizes that most anesthesiologists do not agree with the standard that is recommended in this chapter. Over 3000 brachial block anesthetics have been performed by the author, however, under conditions ranging from a university hospital setting to a tent in the jungle without a fatality or a single permanent or serious complication. Brachial block anesthesia can be performed safely and effectively by a surgeon who has been properly trained and has experience performing the procedure under supervision. If a preoperative history and physical examination are normal, it is not necessary to perform preoperative laboratory tests. Brachial block anesthesia can be performed safely on patients who have not fasted and who do not wish to have preoperative sedation. An intravenous line should be in place so that emergency drugs can be administered easily if an untoward reaction occurs. Continuous electronic monitoring or a nurse performing the same service normally is mandatory. Resuscitation equipment and sufficient ancillary help should be available for an emergency. Obviously, the surgeon must be trained and currently proficient in cardiopulmonary resuscitation. The foregoing procedure for adminisi:ering brachial block anesthesia provides a practical, responsible standard of safety and can result in over $500 in savings to the patient by eliminating laboratory tests, an anesthetist or anesthesiologist sitting with a patient through a 2 to 3 hour procedure, and the various inflated hospital charges for the use of anesthesia equipment and supplies. Many thousands of brachial block anesthetics have been administered under similar conditions; there are no data to suggest that a significant or irresponsible risk occurs when the procedure described is followed. Drainage Continuous suction drainage seldom is needed following ambulatory hand surgery. A Penrose drain placed in a palmar wound following an extensive dissection of the palmar fascia is helpful, and it can be removed by the patient if a large silk ligature is tied to the exposed portion of the drain and brought out along the skin beneath the proximal end of the dressing in the forearm. Patients can remove their own drains at an
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appointed time by pulling the suture and sliding the drain out beneath the undisturbed bandage.
LIPOSUCTION The major consideration in performing liposuction procedures in an ambulatory setting is blood loss or fluid replacement, or both. Most surgeons have arbitrarily adopted a rule that no more than 3000 ml of aspirate should be removed in an ambulatory facility. Because the aspirate has a 20 per cent hemoglobin level, this rule is conservative and usually good judgment. Fluid replacement is important and most centers anticipate fluid loss by giving a preoperative load of 1000 to 1500 ml of balanced salt solution containing 5 per cent ethyl alcohol. Addition of alcohol is theoretically useful for prevention of fat emboli; in practice the procedure is probably of more medicolegal than medical value. Patients should remain in the recovery area until total fluid replacement has been achieved. Patients usually do better if kept in a few degrees of Trendelenburg position for approximately 6 hours after major lipolysis procedures. Both hips and lateral thighs can be treated in a single procedure. Both buttocks and abdomen also can be treated by suction lipectomy as a single procedure in an ambulatory setting. Small procedures such as submental lipectomy are ideal for ambulatory centers. Massive procedures in which thighs, abdomen, and buttocks are suctioned should not be performed in an ambulatory setting. Prefitted elastic garments commercially available make ideal postoperative dressings. Suction drainage can be utilized on an outpatient basis, but it is usually not necessary unless a major vessel is inadvertently damaged or some hemorrhagic complication occurs. The same suction pump and some of the large cannulas used for suction evacuation of the uterus can be utilized satisfactorily in ambulatory centers to perform suction lipolysis. Postoperative care is exactly the same as when lipolysis is performed in a hospital environment. General anesthesia is almost always preferable when a relatively large area is treated. Postoperative pain is not severe; narcotics usually are not necessary for most patients. At most 2 or 3 days bed rest is all that is required, even for patients having both thighs or both buttocks treated.
CONCLUSION Plastic surgery is one of the most ideal surgical specialties to utilize ambulatory surgery facilities. With the exception of patients who have had complicated transfer or replantation of composite tissue and patients who might have significant hemorrhage, airway obstruction, or major vascular complications, plastic surgery can be performed safely and efficiently on an outpatient basis. The critical factor in postoperative care is whether anything more than rest, nourishment, fluids, and relief of pain will be needed. Most procedures in plastic surgery do not require postoperative care other than nourishment and relief of pair and can be performed in an outpatient
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setting less expensively and more conveniently than in the hospital. Local conditions including proximity of radiology, emergency room, and major hospital facilities influence tire decision to perform surgery in an ambulatory center. In most areas, the protection that established medical facilities offer is available, and the plastic surgeon has been able to conduct most of his or her work outside of a medical center. The major disadvantage has been the effect on the surgeon of being removed from the mainstream of medical thought and practice; patients, for the most part, respond favorably to outpatient surgery and will continue to encourage plastic surgeons to give them the opportunity to avoid hospitalization.
REFERENCES 1. Mandel MA: Autotransfusion in elective plastic surgical operations. Plast Reconstr Surg 77:767, 1986 2. Schumacher EF: Small is Beautiful: Economics as if People Mattered. New York, Harper & Row, 1973 Suite 2204 Professional Village 109 Conner Drive Chapel Hill, North Carolina 27514