General considerations

Plastic surgery may be the last remaining true general surgical specialty. All areas of the body remain within the remit of the plastic surgeon, from hand and limb surgery, body surface surgery, breast and head and neck oncology and reconstruction, to body cavity surgery, harvesting jejunum or intra-abdominal omentum as part of a reconstructive procedure, or using body wall tissue to obliterate intrathoracic cavities. This makes the life of the plastic surgery anaesthetist varied and testing.

Plastic surgery anaesthesia similarly encompasses the full range of anaesthetic challenges, including the extremes of age, significant patient co-morbidities and the obstructed, difficult and shared airway. In addition the anaesthetist may be required to manipulate the cardiovascular parameters to minimise bleeding or ensure adequate blood flow to a flap reconstruction. Both general and regional anaesthesia skills are essential, along with a finesse to ensure smooth emergence from anaesthesia and minimal post-operative pain, nausea and vomiting.

In addition to procedure-specific anaesthetic concerns, plastic surgical procedures present some general challenges.

Multiple-team involvement

Many plastic surgical procedures are performed in conjunction with other surgical teams. Breast, maxillofacial, ear nose and throat or other surgical teams may resect a tumour, for which the plastic surgeon is required to provide a reconstructive solution, while the orthopaedic surgeon may require plastic surgical involvement while reconstructing a severely damaged limb. This requires meticulous pre-operative planning, which must include the anaesthetist. It is essential that the anaesthetist is aware of what procedures are to be performed, what position the patient is required to be in, whether any position changes are required intra-operatively and what sides and sites can or cannot be used for vascular access and invasive monitoring. Particularly with regards to resection of head and neck tumours, a plan of airway management both intra- and post-operatively is required including whether a tracheostomy is planned. Such planning needs to be made well in advance and should be re-confirmed at the surgical (WHO) team brief in theatre.