Part IV Preoperative Part IV Preoperative Consultation Melvin A. Shiffman C  16 16.1 History The patient must have a sufficient history taken to es- tablish the problem of which the patient complains. Past history, review of systems, and family history should include all information that may impact on the proposed surgical procedure and its outcome such as prior abdominal surgeries. There must be an attempt to rule out cardiac or pulmonary problems, allergies, bleeding problems, diabetes mellitus, and other serious medical disorders. Information should be obtained about any medications being taken such as aspirin, ibuprophen, herbals, antihypertensives, anticoagulants, and estrogens. It is important to elicit prior thrombophlebitis or pulmonary embolus. Fam- ily history should include questions about bleeding tendencies or thromboembolism. 16.2 Physical Examination The physical examination should not be cursory. The systems examined should include the heart and lungs as well as the area(s) of the body involved in the pa- tient’s complaint(s). There should be a careful evalu- ation for possible abdominal wall or umbilical her- nias if abdominal liposuction is to be performed. The medical record should contain all of the appropriate information for another physician, who may examine the record, to come to the same conclusions and to make the same decisions. Preoperative and postop- erative photographs are essential. 16.3 Medical Record The content of the medical record should be suffi- cient to show that an informed consent has been given through explanation of the proposed procedure, pos- sible viable alternatives, and the risks and complica- tions. This does not mean only forms signed by the patient containing the information. The physician should state in the record that the discussion took place on the day of the discussion. The patient must make a knowledgeable decision about the proposed procedure and the physician must take an active part in making sure this is achieved even if some other health care provider has explained the procedure and risks. The physical examination must be recorded with enough pertinent information that would allow an- other physician to come to the same conclusions as to the diagnosis and the treatment. This includes perti- nent negative findings. The medical record should contain the patient’s request and the physician’s recommendations and the reasons for the recommended procedure or treatment. The physician’s thinking is an important aspect of the medical record and will substantiate any proposed or advised therapy. Preoperative and postoperative photographs should be taken. 16.4 Consent To obtain consent for a surgical procedure all that is necessary is for the patient to sign a consent form stat- ing what the procedure is in lay terms. To obtain a le- gally valid informed consent requires much more. The patient should not only know the name of the proce- dure in lay terms but also what is being done in the procedure in simple language. The material risks and complications must be explained to the patient as well as any viable alternatives of treatment and their mate- rial risks and complications. The patient must make a knowledgeable decision concerning the surgery. 16.5 Preoperative Instructions Preoperative instructions should not only be explained to the patient but should also be given in writing to 98 16 Preoperative Consultation 16.6 Postoperative Instructions The patient may be given postoperative instructions before surgery or after surgery (Table 16.5). These instructions should be explained to the patient and given to the patient in writing. the patient (Tables 16.1–16.3). Also risks and compli - cations should be oral and in writing (Table 16.4). Liposuction (suction lipectomy, liposculpture, lipoplasty, lipostructure, lipexeresis) is a method of contouring body shape by removal of excess fat using suction cannulas through small incisions. It is rarely a procedure for weight loss. The area of the body and the amount of tissue to be suctioned determines whether local tumescent anesthesia or general anesthesia will be necessary. INFORMATION ON LIPOSUCTION A. Transfusions are almost never required B. Preoperative chest X-ray, EKG and blood tests may be necessary C. If varicose veins are present, these may have to be stripped 3 months before liposuction of the legs D. Stretch marks cannot be removed E. Absolutely do not gain weight before surgery 1. If you have any doubt about the surgery, do not have it done 2.If you have had problems with drug or alcohol abuse at any time, notify the surgeon prior to scheduling the surgery 3. Absolutely no smoking for at least 2 weeks before and 2 weeks after surgery 4. Report to the physician any history of excessive bleeding or bruising 5. Report all prior mental disorders or psychological problems to your surgeon 6. If you have high blood pressure, report this to your surgeon 7. If anticoagulants (blood thinning) medication is being taken, this must be stopped at least 5 days prior to surgery and blood tests must be taken before surgery 8. No aspirin or any products containing aspirin (salicylic acid) are to be taken for at least 2 weeks prior to surgery and for at least 1 week following surgery. This includes: Aspirin, Empirin, Alka Seltzer, Anacin, Bufferin, Ecotrin, Bayer, Motrin, Darvon Compound, Excedrin, Midol, Advil, Nuprin, Ibuprin, Medipren 9. Do not take any vitamins, especially vitamins C and E for 2 weeks prior to surgery AND for 1 week after surgery 10. Discontinue all hormones (check with your physician first) 3 weeks prior to surgery and for 2 weeks after surgery 11. Try not to schedule surgery on a day close to your menstrual period. It is preferable not to do surgery the first 5 days of menstrual bleeding 12.Take a shower daily with Phisohex or Hibiclens for 3 days prior to surgery and also in the morning on the day of surgery Table 16.1. Liposuction preoperative instructions ALL SMOKING MUST BE STOPPED ATLEASTTWO(2)WEEKSPRIORTOAND TWO(2)WEEKSAFTERSURGERY OR THE SURGERY WILL BE CANCELED Table 16.2. Smoking must be stopped ALL ESTROGENS (BIRTH CONTROL PILLS AND REPLACEMENTTHERAPY)MUSTBE DISCONTINUEDATLEASTTHREE(3)WEEKS BEFORESURGERYANDFORATLEAST TWO(2) WEEKS AFTER SURGERY Table 16.3. Estrogens must be discontinued 99 Table 16.4. Risks and complications of liposuction Unsatisfactoryresultsoccurin20%ofpatients 1. Asymmetry 2.Waviness, pitting, cobblestoning, rippling, sagging, bulges, depressions 3. Thick scar: hypertrophic, keloid. The scar may not be covered by a bathing suit 4. Insufficient fat removal 5. Excessive fat removal Postoperative problems 1. Nerve damage, decrease or loss of sensation; parasthesias 2.Seroma (fluid collection in wound, lymphorrhea) 3. Hematoma, bruising 4. Scar: hypertrophic, keloid 5. Pain. May persist for months 6.Itching, burning 7. Infection, sepsis or septicemia (germs in the blood stream), cellulitis, toxic shock syndrome 8. Excess or decrease pigmentation of overlying skin 9. Skin necrosis (necrotizing fasciitis), skin slough 10. Prolonged wound drainage 11. Venous thrombosis, superficial or deep 12.Hypotension (drop in blood pressure) 13. Pulmonary (lung) emboli, fat emboli, pulmonary in farction 14.Bleeding: need for blood transfusions 15. Persistent edema (swelling). May be permanent. Labial and scrotal edema is common but temporary 16. Blisters 17. Lidocaine toxicity, drug reaction 18.Allergic contact dermatitis 19. Nausea and vomiting 20. Need for further surgery to correct postoperative problems 21. Psychological disorders 22.Perforation of the abdominal wall and underlying bowel, bladder, and/or vessels. This may require surgical repair and possibly including a temporary colostomy 23. Dissatisfaction with the results 24.Death Table 16.5. Postoperative instructions The patient or caretaker should call the doctor if there is bright red bleeding through the dressings, drainage of pus, increasing pain, or other unusual symptoms (shortness of breath, abdominal pain, chest pain, mental confusion, etc.). Some pink drainage, not bright red drainage, is to be expected and may be quite profuse the first night Prescriptions for pain medication and an antibiotic will be given to the patient. Make sure there is no allergy to either drug. Usually, the dressings are changed the first postoper- ative day by the physician. The patient should be instructed in diet and limitations of activities 1. You should rest at home for 2 days. Ambulate to the bathroom only with help. Resume normal activity after 2–3 days 2. Some pink drainage from the wound is expected for 1–3 days. Dressings should be changed as needed. If bleeding appears to be very excessive call the doctor 3. Showers may be started after the 3rd day following surgery 4. The garment may be removed and washed at any time 5. You will be immobilized in a garment for 3 weeks or tape for approximately 3–6 days. In some cases a gar- ment will have to be worn for 4–6 weeks 6. If the legs get swollen, especially after ambulating, spend more time daily and all night with the legs elevated 7. Edema in the areas liposuctioned may last for several months 8. There will be discomfort for a couple of weeks. If any area becomes more painful notify your surgeon right away 9. If fainting or collapse occurs notify your surgeon immediately 10. You will have fatigue for several weeks 11. Emotional depression after surgery is common 12. Lumps in the areas of liposuction may persist for months. Gentle but firm massage may be helpful 13. If necessary, physical therapy with massage and ultra- sound may help persistent edema and lumps 14. You will be off work several days to 2 weeks depending upon the extent of liposuction 15. Take all medications as prescribed and instructed 16. Weight gain will replace all the fat that has been re- moved 17. Satisfaction with the results of liposuction may not oc- cur for 3 months 18. Any further revision, repair, resculpturing can be done only after at least 3 months 16.6 Postoperative Instructions Drugs to Limit Use of or Avoid when Performing Liposuction Melvin A. Shiffman C  17 17.1 Introduction Liposuction is ordinarily a safe procedure when per- formed properly and with certain cautions. Excessive removal of fat with multiple other cosmetic proce- dures is prone to increase the incidence of complica- tions. Certain drugs should be avoided prior to and after liposuction because of the problems of bleeding, clotting, or toxicity. Even using lidocaine should be avoided or reduced when using general anesthesia. 17.2 Estrogen and Thromboembolic Problems 17.2.1 Introduction Oral contraceptives (estrogens) have been associated with a significant risk of thromboembolic disease. In fact, the Physicians’ Desk Reference (PDR) warns physicians and patients about this risk when taking estrogenic hormones [1]. Risk of developing blood clots: Blood clots and blockage of blood vessels are the most serious side effects of taking oral contraceptives and can be fatal. In particular, a clot in the legs can cause thrombophlebitis and a clot that travels to the lungs can cause a sudden blockage of the vessel carrying blood to the lungs If you take oral con- traceptives and need elective surgery, need to stay in bed for a prolonged illness you may be at risk of developing blood clots. You should consult your doctor about stopping oral contraceptives three to four weeks before surgery and not taking oral con- traceptives for two weeks after surgery or during bed rest. Despite this warning, many cosmetic surgeons continue to ignore the requirement that oral contra- ceptives and replacement estrogenic hormones should be stopped before and after elective cosmetic surgery. If thrombophlebitis and/or pulmonary embolus oc- cur after any cosmetic surgery in a patient who has not been forewarned to cease taking the hormones, then the surgeon exposes himself to medical mal- practice litigation. If the failure to require the patient to stop taking hormones results in an injury, then if this failure to stop taking the hormones was more- likely-than-not (probable, more than 50%) to have caused the complication or even a substantial factor, the physician may be held liable for negligence. This may be true even if the surgeon warned the patient about the possibility of thrombophlebitis, pulmonary embolus, and death and took precautions to prevent thrombophlebitis [2]. Cosmetic surgeons forget that surgery over 1 h and patients over age 40 are already moderate risks for thromboembolism [2]. Consider- ation should be given to graduated stockings or better yet intermittent compression garments during sur- gery in moderate-risk patients. 17.2.2 Discussion Venous thromboembolism afflicts 500,000– 600,000 persons annually in the general population [3, 4].The risk increases with a history of prior venous thromboembolism [5], recent surgical procedures [6 ,7], immobilization, fracture of lower extremity, and cancer [6, 8, 9], and with inherited coagulation disorders [10, 11]. Oral contraceptives pills are well known to be associated with an increased risk for ve- nous thromboembolism [3, 4] owing to the estrogen and this risk is, also, dose-related [6, 7]. In the past, there have been reports that low-dose estrogens do not cause thromboembolism [12], but more recently, there has been evidence that low-dose estrogen thera- py (postmenopausal replacement therapy) is associat- ed with increased risk for venous thromboembolism [7–10]. Postmenopausal hormone therapy has been found to cause a twofold to fourfold increase in risk for idiopathic deep venous thrombosis and pulmo- nary embolism [11, 13–16]. The Heart and Estrogen/ Progestin Replacement Study (HERS), a randomized, prospective, blinded study, found that postmeno- pausal therapy with estrogen and progestin increased 101 the risk for venous thromboembolism in women with coronary artery disease with no prior venous throm- boembolism [17–19]. What effort does it take to require that a patient cease taking estrogenic hormones at least 3 weeks be - fore surgery and 2 weeks after surgery? If the patient refuses to stop taking the hormones or cannot stop taking the hormones because of the severity of post- menopausal symptoms, then it is up to the surgeon to decide whether or not to take the risk of possible litigation by performing the elective surgery. If the decision is to perform the surgery despite the refusal to stop taking hormones, there may be a serious ques- tion brought up at litigation as to why the surgery was performed at all since the patient did not have a medi- cal need for the surgery. Of course, the mercenary as- pects of performing the surgery may be insinuated. All of the information discussed with the patient con- cerning stopping taking hormones and the refusal to stop taking hormones should be well documented in the medical record. It is without doubt that the writ- ten record is the best defense. There may be a role for 3-hydroxy-3-methylgluta- ryl coenzyme A reductase inhibitors (statin therapy) in the prevention of thromboembolism. Statins have a beneficial effect by modifying endothelial function, inflammatory responses, plaque stability, and throm- bus formation [20]. There is a suggestion that statins foster stability through reduction in macrophages and cholesterol ester content and increase the volume of collagen and smooth muscle cells. The thrombotic sequelae caused by plaque disruption are mitigated by statins through inhibition of platelet aggregation and maintenance of a favorable balance between pro- thrombotic and fibrinolytic mechanisms. 17.3 Cytochrome P450 (CYP3A4) Inhibitors Cytochrome P450 inhibitors compete with enzymes that breakdown lidocaine. The use of these inhibitors may result in lidocaine toxicity at a lower total dose than ordinarily used in tumescent anesthesia for li- posuction. These drugs (Table 17.1) should be avoided for a period time (3–10 days) before liposuction sur - gery. Some of the drugs have such a short half-life that there is no need to avoid them (i.e., Versed and Diprivan). 17.4 Dangers of Herbals in Surgery Herbals as medications have been in use for thousands of years. It has only recently come to the attention of the medical community that herbals may be danger- ous if taken just prior to surgery. The US government allows herbals to be sold as food supplements, not as drugs, and there is no federal regulation for herbal dosages or drug interactions. “Scientists need to challenge the popular belief that anything natural is safe” [21]. Allergies are known to occur and herb–drug interactions have been reported [22, 23]. Herbal medications can also affect the heart [24]. There is now a Physicians’ Desk Reference for Herbal Medications [25] with a description of each of the herbals, actions and pharmacology, indications and use, contraindications, precautions and adverse reactions, dosage, and literature. Mixing herbal med- ications and surgery can prove fatal from bleeding, arrhythmias, stroke, thromboembolism, and interac- tions with anesthetic agents [26]. St. John’s wort (Hypericum perforatum, Hypercalm, Centrum Herbals) has been reported to intensify or prolong effects of general anesthetics and, therefore, should be avoided for 2–3 weeks before surgery. This will decrease the risk of adverse reaction. St. John’s wort may inhibit monoamine oxidase (MAO). The use of agents which are MAO inhibitors (MAOIs), such as tranylcypromine and phenelzine, or have MAOI-like activity, such as dextroamphet- amine, furazolidone, procarbazine, or selegiline, concurrently with St. John’s wort can result in severe hyperpyrexia or hypertensive crisis, convulsions, or death. One agent should be discontinued at least 2 weeks before initiation of therapy with the other. Table 17.1. Cytochrome P450 (CYP3A4) inhibitors and their plasma half-lives. Avoid use for 3–10 days preoperatively (de- pending on the drug half-life) and for 24 h postoperatively Drug Plasma half-life Carbamazepine (Tegretol, Atretol) 25–65 h Cimetidine (Tagamet) – Clarithromycin (Biaxin) 5–7 h Dexamethasone (Decadron) – Diltiazam (Cardizem) 3–4.5 h Erythromycin – Flurazepam (Dalmane) 47–100 h Medrol – Metoprolol (Lopressor) 4–7 h Metronidazole (Flagyl) – Midazolam (Versed) 15 min Procardia 2 h (extended release 8 h) Propanolol (Inderal) 4 h Propofol (Diprivan) 10 min Setraline (Zoloft) 26 h Tetracycline – Thyroxine – 17.4 Dangers of Herbals in Surgery 102 17 Drugs to Limit Use of or Avoid when Performing Liposuction Serotonin is deaminated by MAO type A and, therefore, administration of drugs that inhibit this enzyme used concurrently with St. John’s wort should be avoided. The combination of one of these drugs and the herbal can lead to the “serotonin syndrome” which results in confusion, nausea, sweating, agita- tion, hypertension, and unresponsiveness. This type of reaction has been seen with the use of paroxetine and St. John’s wort. Concurrent use of St. John’s wort and tramadol or nefazodone can result in decreased uptake of serotonin and may increase the risk of the “serotonin syndrome.” St. John’s wort should be used cautiously with sym- pathomimetics such as phenylephrine, phenylpro- polamine, and pseudoephedrine as well as psycho- stimulants, isometheptene, dextromethorphan (one case of fatal drug reaction reported), and meperidine because of the ability of some plant components to inhibit MAO (in vitro). Of unknown clinical signifi- cance are the effects of ingestion of tyramine-con- taining foods and beverages such as red wine, yeast, cheese, and pickled herring with the concomitant use of the potential inhibition of MAO by St. John’s wort. Dopamine and levodopa should be used cautiously in patients using St. John’s wort. Herbs, like licorice or Ma huang, can alter blood sugar levels and may be a critical problem in diabet- ics. Any herbals that are associated with bleeding risk should never be taken with anticoagulants such as coumadin, aspirin, and Ticlid. Valerian can com- pound the sedative effects of Valium, Xanax, Elavil, Benadryl, or Vistaril. Ginseng may cause irritability if mixed with caffeine. Ma huang may elevate blood pressure and accelerate the heart rate and should not be taken with blood pressure medications, Lanoxin, or MAOIs (Nardil, Parnate). The American Society of Anesthesiologists recom- mend that patients stop taking herbal supplements 2–3 weeks before surgery since herbs may cause pro - longed anesthesia effects, increased bleeding, delay in waking, and dangerous fluctuations in blood pressure [27]. Notice that some of these herbs are everyday spices and foods! The list of herbs, with the foods and spices in bold letters, can be given to each preopera- tive patient so that they understand the seriousness of taking these herbs prior to surgery (Table 17.2). It is important for all surgeons to be aware of the possible detrimental effects of herbs and to prudently advise all patients to avoid the intake of any herb at least 2 weeks prior to any surgical procedure. 17.5 Toradol for Postoperative Analgesia Toradol (ketorolac) is an effective means of obtain- ing better pain relief or enhancing postoperative an- algesics [28–34]. Because of the possibility of bleeding and hematoma following the use of Toradol [35], this drug has been discontinued as a means of analgesia in cosmetic surgery patients. There have been some physicians who claim that a single injection of Tora- dol does not result in bleeding and that all the reports show that multiple doses may result in bleeding. In reviewing the patient records at Emory Univer- sity Hospital, Garcha and Bostwick [35] noted that the use of at least 30 mg of ketorolac resulted in he - matomas. Conrad et al. [36] reported that 30mg of ketorolac intramuscularly resulted in prolongation of the mean bleeding time from 4.9 to 7.8 min. Since a single dose of ketorolac consists of 30–60 mg, there is sufficient evidence to be wary of even a single injec- tion of ketorolac. Toradol has been shown to be 37 times more po - tent than aspirin in inhibiting platelet aggragation [37]. The elderly patient, patients with diabetes mel- litus, postoperative septic patients, and individuals with chronic renal disease or decreased cardiac out- put may be susceptible to renal failure since ketorolac blocks prostoglandin synthesis and prostoglandin preserves renal function [38]. Cosmetic surgery, with skin flaps and the critical need for good hemostasis, cannot afford to be associ- ated with a bleeding problem, which would definitely compromise the results of the surgery. At this time, it would not be within the standard of care to use To- radol for postoperative analgesia in cosmetic surgery patients unless there is more evidence that bleeding is unlikely to occur. 17.6 Droperidol in Cosmetic Surgery 17.6.1 Introduction Droperidol is a commonly used drug for tranquiliza- tion and prevention of postoperative nausea and vom- iting (PONV) following cosmetic surgery. Although it has been available for many years, the cosmetic sur- geon is unaware of the potential problems that may arise with the use of the drug. The anesthesiologist or anesthetist is usually the one who makes the decision as to whether and when it is to be administered, and how much is to be administered but it is important for the surgeon to be aware of potential dangers in the practice of medicine and especially in the practice of cosmetic surgery. 103 Table 17.2. Herbs, foods, and spices to be avoided for at least 2 weeks prior to any surgery. Everyday foods and spices are listed in bold Agrimony (Agrimonia eupatoria, agromonia, cocklebur): Coagulant effect from vitamin K constituent Alfalfa (Medicago sativa, lucerne, purple medick): Antico- agulant effect from coumarin constituents and coagu- lant effect from vitamin K Angelica (Angelica archangelica, root of the Holy Ghost): Anticoagulant and antiplatelet effect from coumarin constituents Anise (Pimpinella anisum, aniseed, sweet cumin): Anti- coagulant effect from excessive doses from coumarin constituents Arnica (Arnica montana, leopard’s bane, wolf’s bane, mountain tobacco): Anticoagulant effect from couma- rin constituents Asafoetida (Ferula assa-foetida, assant, fum, giant fennel, devil’s dung): Anticoagulant effect from coumarin constituents. Aspen (Populi cortex, Populi folium): Antiplatelet effect from salicin constituent Black cohosh (Cimicifuga racemosa, bugwort, black snake- root, baneberry): Antiplatelet effect from salicylate constituent Bogbean (Menyanthes trifoliata, water shamrock, buck- bean, marsh trefoil): Bleeding risk from unknown con- stituent Boldo (Peumus boldus, boldine): Anticoagulant effect from coumarin constituents Borage seed oil (Borago officinalis, starflower, burage): An- ticoagulant effect from γ-linolenic acid and antiplatelet effect Bromelain (Ananas comosus, bromelin): Anticoagulant ef- fect from enzyme constituent Capsicum (Capsicum frutescen, African pepper, cayenne, chili pepper): Antiplatelet effect from capsaicinoid constituents Celery (Apium graveolens, smallage, Apii fructus): Anti- platelet effect from apiogenin (coumarin) constituent Clove (Syzygium aromaticum, caryophyllus): Antiplatelet effect from eugenol constituent Danshen (Salvia miltiorrhiza, red sage, salvia root): Anti- coagulant effect from protocatechualdehyde 3,4-dihy- droxyphenyl-lactic acid constituent Dong Quai (Angelica sinensis, Danggui, Chinese angelica): Anticoagulant and antiplatelet effect from coumarin constituents European mistletoe (Viscum album, devil’s fuge, druden- fuss, all-heal): Coagulant effect from lectin constituent Fenugreek (Trigonella foenum-graecum, bird’s foot, Greek hay): Anticoagulant effect from coumarin constituents Feverfew (Tanacetum parthenium, bachelor’s button, feath- erfew, midsummer daisy): Antiplatelet effect from the crude extracts Fish oils (omega-3 fatty acids): Antiplatelet effect with prostacyclin synthesis, vasodilatation, reduced platelets and adhesiveness, and prolonged bleeding time Fucus (Fucus vesiculosis, kelp, black tang, bladder wrack, cutweed): Anticoagulant effect which can increase the risk of bleeding Garlic (Allium sativum, nectar of the gods, stinking rose): Inhibition of platelet aggregation and possible increase risk of bleeding in excessive doses Ginger (Zingiber officinale): Anticoagulant effect with in- creased risk of bleeding Ginkgo (Ginkgo biloba, maidenhair): Inhibits platelet ag- gregation and decreases blood viscosity Ginseng (Panax ginseng, Asian ginseng, Korean red, jint- sam): Anticoagulant and antiplatelet effects Goldenseal (Hydrastis canadensis, eye balm, yellow puc- coon): Coagulant effect from berberine constituent Horse chestnut (Aesculus hippocastanum, escine, veno- stat): Anticoagulant effect from aesculin (coumarin) constituent Horseradish (Armoracia rusticana, pepperroot, mountain radish): Anticoagulant effect from coumarin constitu- ents Licorice (Glycyrrhiza glabra, sweet root): Antiplatelet effect from coumarin constituent Meadowseet (Filipendula ulmaria, bridewort, dropwort): Anticoagulant effect from salicylate constituents Northern prickly ash (Xanthoxylum americanum, pepper wood, toothache bark): Anticoagulant effect from cou- marin constituents Onion (Allium cepa): Antiplatelet effect from unknown constituent Papain (Carica papaya): Bleeding risk from unknown con- stituent Passionflower (Passiflora incarnata, apricot vine, Maypop): Anticoagulant effect from coumarin constituents Pau D’Arco (Tabebuia impetiginosa, ipes, taheebo tea, lapa- cho): Anticoagulant effect from lapachol constituent Plantain (Plantago major, common plantain, greater plan- tain): Coagulant effect from vitamin K constituent Poplar (Populus tacamahacca, balm of Gilead): Antiplatelet effect from salicin constituent Quassia (Quassia amara, bitterwood): Anticoagulant effect from coumarin constituents Red clover (Trifolium praetense, trefoil, cow clover, bee- bread): Anticoagulant effect from coumarin constitu- ents Roman chamomile (Chamaemelum nobile, English chamo- mile, whig plant, garden chamomile): Anticoagulant effect from coumarin constituents Safflower (Carthamus tinctorium, saffron, zaffer): Antico- agulant effect from safflower yellow constituent Southernprickly ash (Zanthoxylum clava-herculis, sea ash, yellow wood): Anticoagulant effect from coumarin constituents Stinging nettle (Urtica dioica, nettle): Coagulant effect from vitamin K constituent Sweet clover (Melilotus officinalis, hay flower, common melilot, sweet lucerne): Anticoagulant effect from di- cumarol constituent Sweet vernal grass (Anthoxanthum odoratum, spring grass): Anticoagulant effect from coumarin constituent Tonka bean (Dipterux odorata, coumarouna, torquin bean): Anticoagulant effect from coumarin constituent 17.6 Droperidol Cosmetic Surgery 104 17 Drugs to Limit Use of or Avoid when Performing Liposuction The Food and Drug Administration (FDA) has is- sued a warning concerning droperidol because of re- ports of death associated with QT prolongation and torsades de pointes even within the approved dosage range. 17.6.2 Droperidol in the Physician’s Desk Reference In 1997, the listing under droperidol in the PDR in- cluded Inapsine (Akorn, Abita Springs, LA, USA) as droperidol [39]. By 1998, droperidol was listed as Droperidol (SoloPak Pharmaceuticals, Boca Raton, FL, USA), Droperidol (Astra Merck, Wayne, PA, USA), and as the combination fentanyl citrate and droperidol (Astra, Wayne, PA, USA) [40]. In 2000, the only listing was a combination of fentanyl citrate and droperidol (Astra Zeneca, Wilmington, DE, USA) [41]. The 2001 (55th edition) and 2002 (56th edition) editions of the PDR no longer included droperidol in their listings; however, droperidol was still available through Abbott Laboratories, North Chicago, IL, USA. 17.6.3 Droperidol 17.6. 3.1 Effects (Pharmacology) Droperidol produces marked tranquilization and se- dation as well as an antiemetic effect, lowering PONV [42]. The drug potentiates other central nervous system depressants and produces mild α-adrenergic blockade, peripheral vascular dilatation, and reduces the pressor effect of epinephrine. It can produce hy- potension, decreased peripheral vascular resistance, and decreased pulmonary arterial pressure. The in- cidence of epinephrine-induced arrhythmias may be reduced. The onset of action from intramuscular or intra- venous injection is 3–10 min and the peak effect is approximately up to 30 min. The duration of effect is 2–4 h, although alteration of alertness may persist as long as 12 h. 17.6. 3.2 Indications Droperidol is indicated for the production of tran- quilization and to reduce PONV [42]. It may be used for premedication, induction, and as an adjunct in the maintenance of general and regional anesthesia. Droperidol is used in combination with opioids for neuroleptanalgesia. 17.6.3.3 Precautions Patients receiving droperidol should have appropri- ate surveillance [42]. Concomitant opioids should initially be used in reduced doses. Reduced doses should be used in elderly, debilitated, and other poor- risk patients. When droperidol is used during spinal or peridural anesthesia, the anesthetist must be fa- miliar with the physiologic alterations involved with these types of anesthesia (i.e., alteration of respira- tions, peripheral vasodilatation, and hypotension). If hypotension occurs, hypovolemia should be consid- ered and appropriate fluid resuscitation be utilized. If fluid volume replacement does not work, then pressor agents, other than epinephrine, should be adminis- tered. Epinephrine may paradoxically decrease the blood pressure in patients receiving droperidol. Vital signs should be monitored routinely. Droperidol should be administered with caution to patients with liver or kidney dysfunction since these organs metabolize and excrete drugs. Other depres- sant drugs such as barbiturates, tranquilizers, and opioids may have an additive or potentiating effect with droperidol. The dose of other depressant drugs or droperidol should be reduced. 17.6. 3.4 Adverse Reactions The commonest reactions to droperidol are mild-to- moderate hypotension and tachycardia that usually subside without treatment [42]. If hypotension per- sists, parenteral fluid should be administered because of possible hypovolemia. Turmeric (Curcuma longa, Indian saffron, tumeric): Anti- platelet effect from curcumin constituent Vitamin E (α-tocopherol): Inhibits platelet aggregation and adhesion and interferes with vitamin-K-dependent clotting factor in large doses Wild carrot (Daucus carota, Queen Anne’s lace, beesnest plant): Anticoagulant effect from coumarin constitu- ents Wild lettuce (Lactuca virosa, green endive, lettuce opi- um): Anticoagulant effect from coumarin constituents Willow bark (Salix alba, white willow, silbereide): Anti- platelet effects from salicylate constituents Yarrow (Achillea millefolium, wound wort, thousand-leaf): Coagulant effect from achilleine constituent Table 17.2. Continued 105 Behavioral reactions include dysphoria, postop- erative drowsiness, restlessness, hyperactivity, and anxiety. Extrapyramidal symptoms such as dystonia, akathisia, and oculogyric crisis can be treated with anticholinergic drugs. Postoperative hallucinations, sometimes associated with mental depression, have been reported. Less commonly reported reactions are anaphylaxis, dizziness, chills, and/or shivering, laryngospasm, and bronchospasm. There have been reports of elevated blood pressure without preexisting hypertension. 17.6.3.5 Food and Drug Administration Warnings In December 2001, the FDA required a black box warning labeling change be implemented. Akorn sup- plied the following drug warning: December 4, 2001 Dear Health Care Professional, Reports of deaths associated with QT prolonga- tion and torsades de pointes in patients treated with doses of Inapsine (droperidol) above, within, and even below the approved range have prompted Akorn to revise sections of the prescribing infor- mation, specifically 1) WARNINGS (include a new Box Warning), which call attention to the potential for serious morbidity and mortality, 2) INDICA- TIONS, which reinforces the appropriate patient population for whom this product is intended, and 3) DOSAGE AND ADMINSTRATION, which clarifies the available dosing information. There have been a number of reports of patients who have been treated with droperidol and who developed suspected or established torsades de pointes, at times leading to death. There have been additional cases of symptomatic arrhythmia associated with a prolonged QT interval after droperidol administration that have been submitted via ongoing safety surveillance activi- ties. In addition, clinical investigators have reported a dose-related increase in QT% prolongation with dro- peridol and replication of cardiac changes in a patient rechallenged with droperidol. Therefore, Akorn has made important changes in the Inapsine label. The following box warning has been added: WA RN ING Cases of QT prolongation and or torsades de pointes have been reported in patients receiving INAPSINE at doses at or below recommended dos- es. Some cases have occurred in patients with no known risk factors for QT prolongation and some cases have been fatal. Due to its potential for serious proarrhythmic ef- fects and death, INAPSINE should be reserved for use in the treatment of patients who fail to show an acceptable response to other adequate treatments, either because of insufficient effectiveness or the inability to achieve and effective dose due to intol- erable adverse side effects from those drugs (see Warnings, Adverse Reactions, Contraindications, and Precautions). Cases Of QT prolongation and serious arrhyth- mias (e.g., torsades de pointes) have been reported in patients treated with INAPSINE. Based on these reports, all patients should undergo a 12-lead ECG prior to administration of INAPSINE to determine if a prolonged QT interval (i.e., QTc greater than 440 msec for males and 450 msec for females) is present. If there is a prolonged QT interval, INAP- SINE should NOT be administered. For patients in whom the potential benefit of INAPSINE treat- ment is felt to outweigh the risks of potentially serious arrhythmia, ECG monitoring should be performed prior to treatment and continued for 2–3 hours after completing treatment to monitor for arrhythmias. INAPSINE is contraindicated in patients with known or suspected QT prolongation, including patients with congenital long QT syndrome. INAPSINE should be administered with extreme caution to patients who may be at risk for develop- ment of prolonged QT syndrome (e.g., congestive heart failure, bradycardia, use of a diuretic, cardiac hypertrophy, hypokalemia, hypomagnesemia, or administration of other drugs known to increase the QT interval). Other risk factors may include age over 65 years, alcohol abuse, and use of agents such as benzodiazepines, volatile anesthetics and IV opiates. Droperidol should be initiated at a low dose and adjusted upward, with caution, as needed to achieve the desired effect. 17.6.3.5 Conclusions The potent warning supplied by Akorn requires that droperidol not be used on a routine basis but only when other medications do not work for postopera- tive nausea and vomiting. If there is a decision to use droperidol, then the medical record should contain a clear-cut explanation of the reasons for its use. Before using droperidol, a 12-lead ECG must be performed to determine if a prolonged QT interval is present. Contraindications to the use of droperidol include known or suspected prolonged QT interval, including patients with congenital long QT syndrome. Droperi- dol should be administered with extreme caution in 17.6 Droperidol Cosmetic Surgery [...]... transfer with decanting stand (by Richter) b From left: a 3- mm-gauge multihole tip infiltrator and 3- , 3. 7- and 4.6-mm-gauge CF cannulas (Tulip) c Special cannulas for difficult areas of aspiration, the two-hole flat tip and the Tiger tip (Grams Medical) d The Toledo V-tip dissector cannula (Byron) 125 126 20 Refinements in Liposculpture of the Buttocks and Thighs Final passage with a fine cannula is necessary... for liposuction Dermatol Surg 1996;22:921–7 16 Samdal F, Amland PF, Bugge JF: Plasma lidocaine levels during suction-assisted lipectomy using large doses of dilute lidocaine with epinephrine Plast Reconstr Surg 1994; 93( 6):1217– 23 131 132 20 Refinements in Liposculpture of the Buttocks and Thighs 17 Burk RW 3rd, Guzman-Stein G, Vasconez LO: Lidocaine and epinephrine levels in tumescent technique liposuction. .. cardiovascular event reduction J Amer Med Assoc 1996;279(20):16 43 1650 21 Mullins, R.: Quoted by Woznicki, A.: Herbs In Readers Digest, 2000;July;49–51 22 Fugh-Berman, A.: Herb-drug interactions Lancet 2000 ;35 5: 134 – 135 23 Windrum, P., Hull, D.R., Morris, T.C.M.: Herb-drug interactions Lancet 2000 ;35 5:1019–1020 24 Herbs and Health: Harvard Heart Lett 2000;10(7) :3 4 25 PDR for Herbal Medications, first edition Montvale,... Comparison of room temperature and warmed local anesthetic solution for tumescent liposuction A randomized double-blind study Dermatol Surg 1998;22:707–9 13 Samdal F, Amland PF, Bugge JF: Blood loss during liposuction using the tumescent technique Aesth Plast Surg 1994;18:157–60 14 Pitman GH, Aker JS, Tripp ZD: Tumescent liposuction A surgeon‘s perspective Clin Plast Surg 1996; 23: 633 –41; discussion 642–5 15... Preoperative and b postoperative photographs show the illusion of enhanced chin projection after submental and submandibular liposuction as well as enhancement of the mandibular margin with improvement of the cervicomental angle Fig 18 .3 a Preoperative and b postoperative photographs show elimination of the double chin and augmentation of the facial skeleton status after jowl, submental, and submandibular liposuction. .. new analgesic Fortschr Med 1991;109:6 43 646 31 O’Donovan, S., Ferrara, A., Larach, S., Williamson, P.: Intraoperative use of Toradol facilitates outpatient hemorrhoidectomy Dis Colon Rectum 1994 ;37 :7 93 799 32 Richman, I.M.: Use of Toradol in anorectal surgery Dis Colon Rectum 19 93; 36:295–296 33 Spindler, J.S., Mehlisch, D., Brown, C.R.: Intraoperative ketorolac and morphine in the treatment of moderate... aspirated, and a rolled cotton gauze is used to hold these fluffs in place Coban R (3M, St Paul, MN, USA) dressing is applied using light but continuous pressure (Fig 18. 13) The dressing is left undisturbed for 2 3 days and is then removed After this, an elastic dressing is used at night and when indoors and changed by the patient as 117 118 18 Facial Recontouring with Liposuction Fig 18. 13 Immediate... of Head and Neck Surgery St Louis, Mosby-Year Book 1992:791–8 03 11 Kloehn RA Commentary on ultrasound-assisted lipoplasty: task force July 1966 report to membership (letter) Plast Reconstr Surg 1997;99(4):1198–1199 12 Hudson P Recent advances in liposuction Plast Surg Prod March/April 1998:20–22 13 Mladick RA: Lipoplasty an ideal adjunctive procedure for the face lift Clin Plast Surg 1989;16 :33 3 14 Lawrence... Disease and Steroid Hormone Contraception: Venous thromboembolic disease and combined oral contraceptives: results of an international multicentre casecontrolled study Lancet 1995; 133 :1575–1582 5 Gerstman, B.B., Piper, J.M., Tomita, D.K., Ferguson, W.J., Stadel, B.V., Lundin, F.E.: Oral contraceptive estrogen dose and the risk of deep venous thromboembolic disease Am J Epidemiol 1991; 133 :32 37 6 Carr,... 2000;May 30 :1A 27 Cherken, L.: What you don’t know about herbs and drugs can hurt you Family Circle 2000;Sept 12:90 28 Baumann, T.J.: Place of ketorolac in pain management Clin Pharm 1990;9: 938 29 Cataldo, P.A., Senagore, A.J., Kilbride, M.J.: Ketorolac and patient controlled analgesia in the treatment of postoperative pain Surg Gynecol Obstet 19 93; 176: 435 – 438 30 Freie, H.M.: Treatment of moderate and severe . used for the lipectomy. A 5-mm cannula is usually used in the sub- mandibular, submental, and jowl areas and a 3- mm cannula is used for the melolabial fold. A non-aspira- tive cannula is used to. Ketorolac and patient controlled analgesia in the treatment of postopera- tive pain. Surg Gynecol Obstet 19 93; 176: 435 – 438 30 . Freie, H.M.: Treatment of moderate and severe pain. Ke- torolac–a. imbrication. 5. Ptotic submandibular glands and hypertrophy of parotid glands can mimic areas of excess adipose collection and should be appreciated and not trau- matized. 18 .3 Instrumentation The