Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery

The length of time patients spend under anesthesia during outpatient facial plastic surgery procedures does not appear to be linked to their risk of injury or death, according to a study in the January issue of Archives of Facial Plastic Surgery.

Several high-profile patient deaths in office-based plastic surgery facilities have led state regulatory agencies and medical boards to develop policies regarding the procedures performed at these locations, according to background information in the article. Some, including those in Pennsylvania and Tennessee, have mandated that any surgeries longer than four hours (240 minutes) be performed in an inpatient facility. However, there is little data on which regulatory bodies can base these types of decisions, the authors write. "Defining the risks and morbidity related to longer procedure duration, specifically in facial plastic surgery, has great significance because of the necessity to treat the aging face as a unit, thus appropriately combining multiple procedures" that will require longer surgeries, they report.

Neil A. Gordon, M.D., Yale University School of Medicine, New Haven, Conn., and Marc E. Koch, M.D., State University of New York at Stony Brook, evaluated 1,200 patients who had undergone facial plastic surgery between July 1995 and February 2005. Of those, 1,032 (86 percent) were under anesthesia for more than 240 minutes. Most of the patients in the longer anesthesia group underwent multiple facial procedures, while most in the shorter anesthesia group had only rhinoplasty (plastic surgery on the nose). All of the procedures were performed by a board-certified surgeon; 1,008 of them were performed by Dr. Gordon, accompanied by board-certified anesthesiologists.

Each participant was monitored the day after the surgery. No deaths were reported in the study and the rate of complications was similar in both groups. Three patients overall--one in the shorter anesthesia group and two in the longer--developed major complications, including respiratory failure, nervous system deficit and an adverse reaction to medication. "Contrary to reports that longer procedure duration causes a higher incidence of intractable postoperative nausea, vomiting and pain, thus necessitating higher precautionary hospitalization rates if performed in the office-based environment, we had no cases with any of these complications," the authors report. "Overall, we had no cases of major morbidity in which procedure duration was directly related to the complication or in which inpatient care would have prevented major morbidity events from occurring or being treated optimally."

"When regulatory bodies consider creating surgical guidelines, a detailed understanding of specific risks associated with different types of surgery is needed to avoid generalization and inappropriate, non–data-driven regulation," they conclude. "Although this is the largest study to date that specifically evaluates consecutive cases in which anesthesia lasted more than 240 minutes, larger series of outcomes data should be compiled to guide further evaluation of morbidity risks and ensure appropriate outcomes in office-based surgery."