The duration of anesthesia does not correlate with morbidity or mortality in facial plastic surgery performed in an office-based facility, reported Dr. Neil A. Gordon of Yale University, New Haven, and Dr. Marc E. Koch of the State University of New York at Stony Brook.
The investigators conducted what they described as the first study to quantify morbidity and mortality in in-office procedures lasting longer than 4 hours, because no study to date has presented specific outcomes data on such surgery. Despite this lack of data, "state medical boards and government agencies have rushed to regulate office-based surgery" in response to reports of six patient deaths in Florida, they said (Arch. Facial Plast. Surg. 2006;8:4753).
Their study included a retrospective analysis of 492 cases of facial plastic surgery performed at a single private-practice surgical facility from July 1995 through March 2000 and a prospective analysis of 708 cases performed from April 2000 through February 2005. The cases were divided into those lasting less than 4 hours (168 cases) and those lasting longer (1,032 cases).
Most of the latter group underwent combined procedures for facial rejuvenation, such as rhytidectomies, blepharoplasties, brow lifts, and laser surgery to resurface the skin. The procedures required an average of 306 minutes. Combined procedures that take a relatively long time often are necessary "to appropriately treat the aging face as a unit, thereby preventing the disharmonious appearance produced when portions of the aging face are treated and portions are left untreated," the investigators said.
The shorter procedures were mostly isolated rhinoplasties. The average patient age was 55.7 years. Just over half the patients were older than 51 years, and almost 12% were older than 65.
There were no deaths, no myocardial infarctions, no cardiac arrhythmias, and no pulmonary embolisms.
Three cases of major morbidity occurred (a 0.25% rate), none of which were directly related to procedure duration. A 59-year-old man developed aspiration pneumonia secondary to an obstruction event on extubation, a 53-year-old woman had a cerebral hemorrhage for unknown reasons, and a 52-year-old woman had an anaphylactic reaction to cephalosporin.
"We had no cases … in which inpatient care would have prevented these major morbidity events from occurring or being treated optimally," the researchers said. In fact, it can be argued that receiving intubation for general anesthesia rather than local anesthesia in the office setting actually helped the latter two patients. Because they had secure airways at the time of the events, the surgical team was able to immediately and continuously oxygenate these patients while resuscitating and treating them. "This directly maximized their outcomes and prevented further morbidity, if not mortality," Dr. Gordon and Dr. Koch noted.
"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," they said.
According to the researchers, guidelines including "arbitrary" 4-hour cutoffs for in-office surgery durationwhich have been adopted in Pennsylvania and Tennesseeare imposing "inappropriate, non-data-driven regulation" on office-based plastic surgeons.