Assessment of Duration of Facial Plastic Ambulatory Surgery and Risk of Complications

Abstract

This systematic review examines the association of the length of surgical procedures performed at ambulatory surgery centers with the risk of complications.

Surgery volume in ambulatory surgery centers (ASCs) has increased markedly in recent decades, especially for plastic and reconstructive surgical procedures. Cosmetic procedure complication rates range from 0.33% to 1.9% at ASCs.¹ State regulatory bodies have sought to limit procedure length at ASCs, citing the rationale that longer procedure duration may be associated with increased complication rates. In the United States, there are state-specific regulatory policies for ASCs. Pennsylvania limits surgery length to 4 hours, and Connecticut limits surgery length to 1.5 hours with a 4-hour recovery time. In 2009, an evidence-based safety advisory on patient selection and ambulatory surgery from the American Society of Plastic Surgery recommended a 6-hour maximum surgery length at ASCs.²

Regulation of surgical procedure length is a contentious issue. Limited data suggest a link between length of surgery and risk profile among patients undergoing body procedures (eg, abdominoplasty and body contouring with high-volume liposuction).³ This finding is consistent with known consequences of body composition, fluid administration, and postoperative recovery. The safety profile for facial plastic surgery differs from that of such body procedures because of differences in blood loss, fluid shifts, postoperative pain, mobility, and venous thromboembolic rates. We therefore conducted a systematic review to determine the association between facial plastic surgery duration and risk of complications.

Methods

A literature search using the Medical Subject Heading search terms anesthesia, analgesia, anesthetics, plastic surgery, reconstructive surgery procedures, and ambulatory surgical procedures was conducted from January 1, 1969, to May 30, 2016, to identify articles published from 1969 to 2016 in PubMed, Embase, Cochrane Central, and CINAHL. Articles on patients younger than 16 years, articles on inpatient surgery, and non-English articles were excluded. Forty-one articles were identified for full review. Independent investigators reviewed articles and collected data on standardized forms following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (eAppendix in the Supplement). Articles were assessed for risk of bias using the Downs and Black scale.

Results

Three articles^4,5,6 reported on 1983 unique patients. Gordon and Koch⁴ described 1200 cases of aging face and nasal surgery with the patient under general anesthesia or sedation. Molliex et al⁵ described 24 nasal procedures performed with the patient under regional blocks with mild sedation. Phillips et al⁶ reported 2595 plastic surgery procedures, including procedures with the patient under general anesthesia. For the article by Phillips et al,⁶ the authors were contacted, allowing data from 759 facial plastic surgery procedures to be extracted. Of these procedures, 78 of 759 patients (10.3%) also underwent body surgery.

Six major complications were reported (complication rate, 0.25%; 1 of 380 patients) (Table 1), and all patients recovered fully. No mortalities were reported. No unanticipated admissions resulted from minor complications, including nausea (Table 2). Gordon and Koch⁴ reported no urinary retention, whereas the facial plastic surgery subset in the study by Phillips et al⁶ had 2 instances of urinary retention, both after operations longer than 4 hours. Prolonged recovery did not lead to unplanned admissions in any studies. Gordon and Koch⁴ reported 1 hematoma in 1200 cases (with return to the operating room). Phillips et al⁶ reported 22 hematomas in 759 cases, with many hematomas aspirated in the clinic postoperatively; it is unclear whether any of these patients returned to the operating room. The studies rated fair to poor in quality because of retrospective design, variable follow-up length, poor description of cointerventions, lack of anesthesia details, and lack of definitions for outcome variables.

Table 1. Major Morbidities Identified in the Studies Examining Length of Surgery in Facial Plastic and Reconstructive Surgery.

Source	No. of Major Morbidities/No. of Patients (%)	Major Complications (No. of Complications)	Procedure Duration, h
Gordon and Koch,4 2006	1/400 (0.25)	Aspiration pneumonia (requiring intubation) (1)	>4
		Cerebral hemorrhage (1)	>4
		Anaphylaxis reaction during induction (1)	<4a
Molliex et al,5 1995	0/24	No major complications	NA
Phillips et al,6 2012	1/1300 (<0.001)	DVT (occurred in a patient who later tested positive for a prothrombotic familial abnormality) (1)	>4
		Pulmonary embolism (1)	<4
Facial subset	1/380 (0.26)	DVT (same as reported by Philip et al6) (1)	4
		Cardiac arrhythmia (resolved with observation) (1)	>4

Abbreviations: DVT, deep vein thrombosis; NA, not applicable.

^aInduction.

Table 2. Other Complications Identified in the Studies Examining Length of Surgery in Facial Plastic and Reconstructive Surgery.

Source	Admissions	Postoperative Nausea	Urinary Retention	Prolonged Recovery	Hematoma	Corneal Abrasion	Infection	Other
Gordon and Koch,4 2006	2 (Major complications)	0 Admissions	0	6 Total (1 of 168 <4 h vs 5 of 1032 >4 h)	1 Patient >4 h	12 Total (2 of 168 <4 h vs 10 of 1032 >4 h)	1 Patient (>4 h)	1 Patient with temporary foot drop, 1 patient with temporary ulnar praxia, 2 with coccyx, and 1 with ankle soft tissue breakdown (all >4 h)
Molliex et al,5 1995	0	NR	NR	NR	0	NR	NR	8 Patients with light bruising and swelling and 1 with temporary diplopia
Phillips et al,6 2012	5 (2 Major complications and 3 hematomas)	0 Admissions of 78 total (66 of 2371 <4 h vs 12 of 210 >4 h; OR, 2.1)	32 Total (16 of 2371 <4 h vs 16 of 210 >4 h; OR, 12.1)	NR	46 Total	NR	7 Total	7 Patients with minor pulmonary, 13 with minor hypotension, and 41 with minor cardiac (nonsignificant difference for >4 or <4 h)
Facial subset	2 (Arrhythmia and DVT)	0 Admissions of 22 total (16 of 628 <4 h vs 6 of 121 >4 h)	2 Total (0 of 628 <4 h vs 2 of 121 >4 h)	87 Total (56 of 628 <4 h vs 31 of 121 >4 h)	22 Total (10 of 628 <4 h vs 12 of 121 >4 h)	9 Total (6 of 628 <4 h and 3 of 121 >4 h)	2 Patients (<4 h)	1 ED visit for migraine (>4 h)

Abbreviations: DVT, deep vein thrombosis; ED, emergency department; NR, not reported; OR, odds ratio.

Discussion

Complications after facial plastic surgery are rare, even after procedures that last longer than 4 hours. The primary limitation of this review is that large cohort studies examining length of surgery and complications for facial plastic surgery are lacking. Furthermore, current reports are retrospective, with small sample sizes and variable reporting. These studies^4,5,6 reported low complication rates regardless of length of surgery and no mortality. Regulating length of surgery has implications for practices. Current guidelines do not consider specific surgical procedures and are not directed by substantive data.

Supplement.

eAppendix. PRISMA Flow Diagram