Dr. Kenneth Dickie from Royal Centre of Plastic Surgery in Barrie, Ontario explained the refining experience for Ambulatory Surgery. If you have any questions, please contact Dr. Kenneth Dickie at http://royalcentreofplasticsurgery.com/

1. AMBULATORY SURGERY
REFINING THE EXPERIENCE
Dr. Kenneth Dickie
Royal Centre of Plastic Surgery

2. Measurement of Outcomes of Elective
Surgery
• Health Related Quality of Life (HRQOL)
• Patients self reported HRQOL for specific
elective surgical procedures is a more valid
outcome measure than a surgeons own
impression of outcome
• Objective assessments must incorporate the
patient’s view of the impact of the procedure
on their HRQOL

3. Emotional and Physical Reactions from
Plastic Surgery
• Physical Reactions
– Patients must be aware of nature’s “healing
curve”
– Timetable for swelling, bruising, tightness, and
numbness must be re-enforced
– 4 weeks to “looking good”
– 3 months to “healed”

4. OUTPATIENT SURGERY
• Plastic Surgery procedures
• 80% are performed as day surgery
procedures
• Majority are ASA class I and II
• Can we refine the patient experience?

5. Pre-Operative Preparation
• Patient information and informed consent
– General information
– Specific information
– Smoking and increased surgical risks
– Thrombosis risk factor assessment
– Emotional & Physical reactions from Plastic Surgery

6. Smoking and Increased Surgical Risk
• Nicotine –vasoconstriction may compromise
circulation to tissue
– Facelift
– Breast Reduction
– Abdominoplasty
– Free tissue transfers and skin flaps

7. Stop Smoking
• One month prior to surgery
• Two weeks after surgery
• Patient must sign “Smoking and Increased
Surgical Risks” form
• Cancel surgery if still smoking

8. Thrombosis Risk Factor Assessment
• Low risk—T.E.D. stockings + early ambulation
• Moderate risk- T.E.D. stockings +Sequential
Compression Device or Anticoagulant
• High risk- T.E.D. stockings + SCD +
Anticoagulant

10. Sequential Compression Device
• Surgery over 1 hour and patient over 40
places patient in moderate risk category for
DVT
• Routine use of SCD in Plastic Surgery
procedures

11. Oral Contraceptives and DVT
• Increased risk with oral contraceptives and
hormone replacement therapy
• Stop BCP/HRT therapy (if possible) 1 cycle pre-
op and 1 cycle post op
• Informed consent regarding DVT and
Pulmonary Embolism

12. Emotional and Physical Reactions from
Plastic Surgery
• Emotional Roller Coaster
– Low point day 3 to 4
– Support person crashes end of first week
– Feeling good by end of 2nd
week
– Office staff must not “abandon” patient

13. Postoperative Recovery
• Hypothermia (core temp < 36 C.)
– Over 70% of post op patients are hypothermic (depressed
thermoregulation, exposure, IV fluids, skin preps)
– Results in:
• ^ Oxygen consumption post op (shivering)
• ^ Cardiac output, hypertension, PVC’s, and arrhythmias
• ^ Patient discomfort = ^ Narcotic requirement
• LONGER STAYS IN THE RECOVERY ROOM

14. Hypothermia
• Patient Warming System
– Surrounds the patient with warm air at desired
temperature:
• Low 30-34 degrees
• Medium 36-40 degrees
• High 42-46 degrees

15. Patient Warming System
• Use intra-operatively for procedures longer than 2
hours
• Use postoperatively for procedures longer than 1
hour
• In ALL cases, there is a dramatic reduction in narcotic
requirement, post operative nausea and vomiting.
• In ALL cases, there is an enhanced speed of post
operative stabilization of the patient.

16. Patient Warming System

17. Postoperative Recovery
• ZOFRAN (Ondansetron HCl)
– 4mg I.V. q4hr. Prn
– Marked reduction in post operative nausea and
vomiting
– Increased comfort for the patient
– More rapid discharge following Day Surgery

18. Postoperative Recovery
• Nerve Blocks
– Peripheral nerve blocks with long acting
anaesthetics (Marcaine) provide enhanced patient
comfort and facilitate earlier discharge
– Reduced requirements for narcotics
postoperatively
– May be performed by the anesthesiologist or
surgeon while the patient is still under
anaesthesia

19. Prophylactic Vasodilators
• Healing complications are one of the leading causes
of litigation in Plastic Surgery
• “High Risk” zones benefit from proactive
management with topical vasodilators
• Breast Reduction (nipple ischemia), Abdominoplasty
(skin flap ischemia), Facelift (skin flap ischemia), any
tissue with impaired blood supply.

20. Prophylactic Vasodilators
• Nitro-Dur patch: 0.4 or 0.6 mgm patch
• Patients initial reaction to medication must be
monitored in the recovery room
• Patches are applied at completion of surgery
and may be easily removed if BP
problems develop (unusual)
• Patients may apply patch every 12 hours if
ischemia persists

21. Prophylactic Antibiotics in Elective Plastic
Surgery
• Any surgery greater than 2 hours in length
• Any surgery where circulation to tissue is
compromised as a result of the surgical procedure
– Breast Reduction
– Abdominoplasty
– Facelift
– Selected Reconstructive Procedures
– (any situation where prophylaxis is indicated for medical
reasons)

22. If you have any questions, feel free to contact Dr. Kenneth Dickie
at royalcentreofplasticsurgery.com
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