#Plastic Surgery Beirut | Explore Tumblr posts and blogs

mint-moon25 · 11 months ago

Text

DEAR - KOREAN - GIRLS,

HIROSHIMA - AND - NAGASAKI

WORLD's - FIRST - ATOMIC YES

BOMBING - HAPPENED - TRUE

4 A - REASON - DEAR - KOREA,

TOKYO - JAPANESE - BOYS

AND - GIRLS - DURING HER

NIGHT - OFF - AS - PINAY

EXOTIC - DANCER - KICKED

HER - BOXED - HER - THESE

BOYS - AND - GIRLS - ORGY

ALL - THE - TIME - HEROINE

COCAINE - BEAT - HER - YES

BOYS - STABBED - STABBED

AFTER - AND - GIRLS - SAID

CAN - WE - JOIN - STABBED

HER - CORONARY - JOINED

THEM - 'CORONARY - HEART

FAILURE' - AS - JAPAN - GOT

CHEAPEST - STORAGE SENT

PHILIPPINES - 2 - THEY CALL

GARBAGE - INSULIN - TRASH

UGLY - GIRLS - WHY - HEART

GOES - 2 - TOKYO - ORGY

TOKYO - GARBAGE - GOODS

TOKYO - WHISKEY - TRASH

TOKYO - SAID - PHILIPPINES

MUST - DO - MAKE UP - IN

RESTROOM - FULL - OF

JAPANESE - URINE - AND

POOP - MIAMI - ORGY AND

HEROINE - COCAINE - AS

TOTAL - STRANGERS - DO

IT - STANDING - UP - BLKS

WANTED - VAGINA - LOOKING

FR - TENT - BEHIND - ME - AS

BLK - MALE - THERE - WANTED

2 - HUG - ME - PUT - HIS - PEE

PEE - ON - MY - THIGHS - HUG

WHO - HAS - FIANCE

USA - DUMPS - WITH URINE

AND - POOP - RESTROOMS

PUT - YOUR - MAKE UP - DO

CUT - YOUR - NAILS - IN USA

TOKYO - RESTROOMS FULL

OF - JAPANESE - URINE AND

POOP - LESBIANS - KISSING

EACH - OTHER - RAPING

DEAR - KOREAN - GIRLS,

TOKYO - JAPAN - SAID - KR

KOREAN - GIRLS - UGLIER

THAN - RAMEN - MARUCHAN

NOODLES - UGLIER - THAN

THEIR - TOILETS

KOREAN - GIRLS,

WE - WILL - BUY - YOUR

SHISEIDO - COSMETICS

EACH - ONE - 500 BILLION WON

TAX - PAID - SHISEIDO - THE

OLDEST - COSMETICS

CAPITAL - IN THE - WORLD

DEAR - WORLD,

WE - WILL - BUY - YOUR

SHISEIDO - COSMETICS

PINAYS - SELL - US - YOURS

THEY - SAID - YOUR - BIG SUSU

WHY - U - WIN - BEAUTY - YES

CONTESTS - TRUE

DEAR - PINAYS,

MY - TOKYO - JAPAN - MALE

SCIENTISTS - SURGEONS

OPERATING - PLASTIC

SURGERY - IN -

HONG KONG - ISLAND

TAX - FREE

SEOUL - SOUTH - KOREA

TOKYO - GIRLS - TOKYO

FEMALE - POLICE - TOKYO

BOYS - CALL - PREGNANT

FEMALES - FAT - PIGS

FAT - TUB - UGLY - FAT

BIG - HUGE - UGLY BOOBS

DEAR - KOREA - & - PINAYS,

JAPAN - 4 FT - TALL - 5 FT

TALL - LACK - OF - HEIGHT

UGLIEST - ADULT - JAPANESE

IMMOROAL - GIRLS - WHEN

WAS - LAST - TIME - THEY

WON - MISS EARTH

MISS UNIVERSE - EXTREMELY

UGLY - JAPANESE - GIRLS ARE

REAL - UGLY

TOKYO - MEN - SAYING

UGLY - WOMEN - PUT YOUR

MAKE UP - IN - RESTROOMS

FULL - OF - JAPANESE - POOP

AND - URINE

DEAR - KOREA,

JAPAN - HATES - CHINA

BEIJING - AND - SHANGHAI

KOREA - TOKYO - HAS - THE

CHEAPEST - HOTELS - IN THE

WORLD - DEAR - CHINA - AND

KOREA - LET's - BEAT - TOKYO

HDG - INNS

$0.25 - PER - DAY - TAX - FEES

INCLUDED - BEIJING - AND YES

SHANGHAI - LET's - MAKE

CHINA - AND - KOREA

INDIA - THEY - SAID - YOUR

WOMEN - ARE - UGLIER THAN

BROWN - SANDWICH - BAGS

TOKYO - STABS - 2 - DEATH

TOKYO - FEMALES - WEARING

JEWELRY

DEAR - INDIA,

SELL - US - YOUR - GARBAGE

SHISEIDO - COSMETICS

500 BILLION - WON

INDIA - WOMEN - JAPAN SAYS

U - HAVE - SAGGING - BREASTS

JEWELRY - YOUR - ONLY - YES

ATTRACTION

DEAR - INDIA,

ME - AND - MY - CHINESE

ACTOR - MARRYING - IN

PARIS - FRANCE

BEIRUT - WEDDINGS

WE'RE - MARRYING - IN

BEAUTIFUL - VINEYARDS

WE'RE - NOT - MARRYING

IN - GARBAGE - TOKYO

FEMALES - PUT - YOUR

MAKE UP - WHERE - TOKYO

FEMALES - URINE AND POOP

INDIA - HOTELS

HDG - INNS - COMING

$0.25 - PER - NIGHT - YES

CHECK IN - 24/7 - HOLIDAYS

INDIA - TONGUES

500 BILLION

SING - TONGUES - 500 BILLION

DEAR - INDIA,

CHANGE - YOUR - LAWS

I - WILL - GLADLY - B - YOUR

2ND - PRIME - MINISTER

ME - SECRETLY

SERENE - PRINCESS - KATARINA

KRISTIANA - MARIE CONSTANCE

BAILEY - DIRECTLY - FR - THE

QUEEN - MARY - OF - SCOTTS

SCOTLAND - LOOK - ALIKES

WERE - BEHEADED - PRISONED

FRANCE - I'M - DIRECTLY - FRM

KING LOUIS - LAST - OF FRANCE

DIRECT - DESCENDANT - OF

SIR PATRICK HENRY - USA

RELATIVES - 2 - PRODUCE

JULIUS CAESAR

KING - ALEXANDER - OF

ANCIENT - GREECE

IF - U - WANT - I - CAN - B

1 YEAR - ONLY

2ND - FEMALE - PRIME

MINISTER - OF - FRANCE

3RD - IVANKA TRUMP

WILL - U - ALLOW - US - BUT

NO - RESIDENCY

SPECIFIC - JOBS

JESUS - IS - LORD - INDIA

1 note · View note

vomitnest · 1 year ago

Text

0 notes

karimsarhane · 2 years ago

Photo

Dr. Karim Sarhane is an MD MSc graduate from the American University of Beirut. Following graduation, he completed a research fellowship at Johns Hopkins University (Maryland, USA) in peripheral nerve surgery. He then completed a residency in general surgery at the University of Toledo (Ohio, USA), followed by a year of additional training in plastic surgery. He then joined Burjeel Royal Hospital in September 2022 (after spending a total of 10 years in the USA). He is a Diplomate of the American Board of Surgery. Dr. Sarhane is a Surgeon-Scientist who combines clinical care with scientific research to deliver the best possible outcomes to his patients. He is published in top-ranked bioengineering, neuroscience, and surgery journals. He holds a patent for a novel Nanofiber Nerve Wrap that he developed with his colleagues at the Johns Hopkins Institute for NanoBioTechnology and the Johns Hopkins Department of Neuroscience (US Patent # 10500305, December 2019). He is the recipient of many research grants and research awards, including the best basic science paper at the Johns Hopkins Surgery Research Symposium, the basic science research grant prize from the American Foundation for Surgery of the Hand, the Research Pilot Grant Prize from the Plastic Surgery Foundation, and a Scholarship Award from the American College of Surgeons. He has authored to date 49 peer-reviewed articles, 11 book chapters, and 48 peer-reviewed abstracts, and has 29 national presentations. Dr. Sarhane is recognized by colleagues for his commitment to medicine, his superior surgical skills, his compassionate care, and his innovative mindset. He strives to advance surgical care through excellence in research, education, clinical care, and service. He is proud to offer the patients of the UAE the entire gamut of general and laparoscopic/robotic surgery. He is also one of the pioneer surgeons to perform migraine surgery (a new and highly effective therapeutic modality for patients suffering from intractable migraines). His areas of expertise include,

#karimsarhane #karimsarhanemd #karimahmadsarhane #drkarim_surgery

0 notes

cosmeticsurgerybeirut-blog · 6 years ago

Text

Kinds of Cosmetic Procedures you never knew!

The main focus of cosmetic surgery is to enhance the patient’s appearance. Cosmetic surgery is entirely elected by the patient and not recommended by healthcare professionals or surgeons. Think thoroughly before opting for any kind of cosmetic procedure. These surgeries would help you enhance your looks, boost your confidence and help you in re-building your identity. There are different types of cosmetic procedures which will enhance your body. Some of them are listed below:

1. Facial procedures are undertaken mostly to enhance the face. Some popular facial procedures that are performed to rejuvenate or refine your face are as follows: Facelift, Eyelid lift, Rhinoplasty, Neck contouring, Brow lift, Chin implants, Lip enhancement, etc.

2. Cosmetic breast surgery will help you get the best breast shape and size. Some of the popular breast procedures are breast augmentation, breast lift, breast reduction, etc. This is especially beneficial for breast cancer survivors too.

3. Body cosmetic surgery, Lebanon will help you refine your proportions, improve your body shape, and experience the benefits of having a perfect body that you are proud to show off. Some popular body procedures are as follows: liposuction, tummy tuck, mommy makeover, male chest reduction, skin removal surgery, feminine rejuvenation, and Brazilian butt lift.

4. There are also a wide range of nonsurgical procedures like injectables, laser treatment, and professional skin care treatments to choose from. These procedures are mainly done to improve the appearance of the skin, reduce wrinkles, and clear away any visible signs of aging. Some popular nonsurgical procedures include Botox-type injectables, injectable fillers, skin resurfacing, nonsurgical fat reduction, skin tightening, and cellulite reduction.

Whether it is a cosmetic surgery or a Plastic surgery in Lebanon, going under the knife is extremely risky and scary. You cannot take a chance by trying out various procedures as you’d be putting your looks and appearances on stake. Ensure that you learn about it thoroughly, consult various experts, and get it done from the experienced professionals for the desired outcome. Although there are numerous surgeons out there, select a famous and the most experienced one for your plastic surgery in Beirut.

#Plastic surgery Lebanon #plastic surgery Beirut

1 note · View note

architectuul · 6 years ago

Text

A Feminist Approach To Critical Spatial Practice

At the Woman’s Day we honor women architects who have been obscured and ripped off any recognition for their contribution in the architectural practice.

Poster celebrating the Women’s Day in Germany was banned in 1914.

Today we celebrate women architects whose practice is largely contributing to the discussion of the relationship of gender and space and whose references to feminism are made clear and bold through their work. Five contemporary practices and initiatives that are promoting a feminist approach to critical spatial practice and pioneering in different forms of feminist activism in architecture industry and discourse will be presented.

The establishment of practices emphasises the urgency of representation of woman in architecture, the rebellion towards sexism and the strive for diversity. Their approaches do not only unfold into theoretical discussions inside the academia but as well suggest different forms of actions in practice. Nevertheless they put forward issues such as oppression, marginalization and labor exploitation.

F-architecture is a research enterprise co-founded by Gabrielle Printz, Virginia Black and Rosana Elkhatib in Brooklyn, New York. | Photo by © Casey Carter

Feminist Architecture Collaborative is a three-woman research enterprise aimed at disentangling the contemporary spatial politics of bodies, intimately and globally. Their projects traverse theoretical and activist registers to locate new forms of architectural work through critical relationships with collaborators across continents and an expanding definition of Designer.

One of the most recent exploration of f-architecture took the shape of Cosmo-Clinical Interiors of Beirut at VI PER Gallery in Prague. | Photo by © Peter Fabo

Cosmo-Clinical Interiors of Beirut examines the constructed space, interior finishes, and designed protocols of the plastic surgery clinic to make perceptible its role in shaping subjects, virginity culture and an ideal body. The exhibition is probing the medical-cosmetic industry where cultural ideas of virginity are hacked and commodified through hymenoplasty and prosthetic hymens. The architecture is understood as the confluence of the technological, social, and economic—not a built fact, but an organizing force in a constellation of produced and productive objects.

Black Females in Architecture (BFA) encourages diversity in architecture via organized workshops and sharing advice on WhatsApp. | Photo via Dezeen

Black Females in Architecture (BFA) is a network for black women in the built environment to gain access and support structures to develop and enhance their potential in the varying disciplines. The aim is to improve the statistics of black women in the fields of architecture, landscape architecture, planning, urbanism, engineering, sustainability etc. This is initiated through regular meet-ups, workshops, mentorship programmes and design projects.

It is founded by Selasi Setufe, Neba Sere, Alisha Fisher and Akua Danso, who met at an architecture event in London. Taken by surprise by the rarely encounter of other black women in such events in architecture, that afterwards they decided to found a network, which has now over 150 members that share their concern and suggestions through organised events and through their practice they are raising awareness of diversity in architecture.

Lori Brown was the only woman in some of her design studios when she was studying at the Georgia Institute of Technology. | Photo by © Connor Martin

Architexx is a non-profit organization for gender equity in architecture transforming the profession by bridging the academy and practice.The group was founded by Nina Freedman and Lori Brown. They created a cross-generational group of academics and practitioners dedicated to the advancement of all women-identified, non-binary, gender non-conforming, and allied individuals.

They encourage and promote the leadership and retention of women in the discipline with the redefinition what contemporary success is, how value is understood and compensated. With the increase of diversity they facilitate and support open dialogue, content, conversations, that will inspire a new generation of design professionals to see themselves as agents of change by looking at the past to see new ways forward.

“Now What?!” curators Andrea J. Merrett, Roberta Washington, Sarah Rafson, Lori A. Brown with Michele Gorman, Pratt Institute Liaison and exhibition designer. | Photo by © Sally Rafson.

Now What?! is the first exhibition to examine the little-known history of architects and designers working to further the causes of the civil rights, women’s, and LGBTQ movements of the past fifty years. The exhibition content, conversations, and stories will inspire a new generation of design professionals to see themselves as agents of change by looking at the past to see new ways forward.

Parlour was initiated as part of the Australian Research Council-funded research project Equity and Diversity in the Australian Architecture Profession; Women, Work, and Leadership. It brings together research, informed opinion and resources on women, equity and architecture in Australia. It seeks to expand the spaces and opportunities available to women while also revealing many women who already contribute in diverse ways. As activists and advocates they aim to generate debate and discussion. As researchers and scholars they provide serious analysis and a firm evidence base for change. As women active in Australian architecture they seek to open up opportunities and broaden definitions of what architectural activity might be.

Parlour Guides to Equitable Practice is an initiative for an equitable practice. The guide outlines the key issues facing women in architecture and provide positive, productive strategies for change.

Women and Spatial Practice an event at University of North London, Nov 2001.

Taking place is a group of 7 women artists and architects (Sue Ridge, Julia Dwyer, Doina Petrescu, Jane Rendell, Katie Lloyd Thomas, Jos Boys, Brigid McLeer, Helen Stratford, Miche Fabre Lewin, Angie Pascoe, Teresa Hoskyns). It is an ongoing space of discussion, investigation and exchange in which to explore new practices, and to imagine and speculate on new directions and strategies for change.

Three day Feminist School of Architecture at Sheffield University. | Photo via Talking Place

Talking Place began out of a shared interest in questions of gender and spatial practice. Through various private workshops and public events they have developed a collaborative way of working together, which explores and alters institutional space through temporary and participatory interventions and through spatial installations. Their working method is process based and open-ended and depends on site research and exchange with users.

---

Pioneer Architects XIII by Klodiana Millona

#pioneer architects #women in architecture #pioneerarchitects

42 notes · View notes

veneersbeirut · 6 years ago

Photo

حصريا Exclusive Look 10 Years Younger. ‎احصل على وجه اصغر ب١٠ سنوات with Smile Lift ® Exclusively WorldWide developed by Dr.Habib Zarifeh Combining: - Plastic Surgery. - Cosmetic Dentistry Hollywood Smile. - Digital Dentistry. - TMJ Specialist. Few sessions in Few Days. Call Us Now: +96170567444 Http://www.SmileLift.com ‎احصل على وجه اصغر ب١٠ سنوات ‎حصريا في عيادات "سمايل إنفنتي" تقنية "سمايل ليفت" بالتعاون بين أطباء تجميل الاسنان وأطباء التجميل. ‏Now In #Bahrain #Tunisia #Jeddah #Dubai #Beirut #Erbil #Senegal #Michigan #Morocco #Algeria #Hollywoodsmile #veneers #dentist #dentalclinic #smilelift #fashion #fashionblogger #Models #modeling #Smile #russia #russian #البحرين - #تونس - #جدة - #دبي #بيروت (at Smile Infinity Dubai) https://www.instagram.com/p/BvRG7IaghDE/?utm_source=ig_tumblr_share&igshid=n52ypb2385c2

1 note · View note

drcharbelmedawarplasticsurgery · 7 months ago

Text

#drcharbelmedawar #beirut #blepharoplasty #google #lip fillers #rhinoplasty #browlift #plasticsurgery #marketing #lebanon #cosmetics

0 notes

ourhaileydavies · 4 years ago

Text

Juniper Publishers-Open Access Journal of Head Neck & Spine Surgery

Conscious Sedation in Plastic Surgery: Patient Safety and Cost Reduction Midazolam/Meperidine Conscious Sedation

Authored by Joseph El Khoury

Abstract

Background: Conscious sedation is an anesthetic modality used in different procedures, among which are plastic surgeries. This study evaluated the efficacy and safety of the IV Midazolam - IM Meperidine conscious sedation protocol.

Methods: Adult patients undergoing elective cosmetic surgeries were enrolled. Patients were excluded if they had a history of cardiac or respiratory disease or in case of pregnancy. Patient anxiety, nausea, and pain were evaluated during and after surgery. Physician satisfaction and reported intraoperative level of sedation were also assessed. Operative time, midazolam dose, and the lowest hemoglobin saturation level in oxygen were noted. The primary outcome was postoperative recovery time while cost reduction and post operative complications were considered as secondary outcome measures.

Results: 173 patients were recruited. 61.8% under went rhinoplasty procedures and 13.8% under went blepharoplasty. Mean recovery time was 196 minutes. Age was the most significant predictor of recovery time. Older patients recovered faster (p=0.019), were less anxious preoperatively (p=0.003) and had less postoperative pain (p=0.007) and nausea (p<0.0001). Higher dose of Midazolam were associated with more intraoperative anxiety (p=0.02) and an increased postoperative nausea (p=0.047) and emesis (p=0.032). We also can note that High (7-14 glasses/week) alcohol intake was associated with slower discharge (p=0.022).

Conclusions: The IM Meperidine-IV Midazolam conscious sedation protocol in plastic surgery operations in the one-day-surgery setting seems to be safe reproductible and cost effective.

Introduction

Conscious sedation or "Procedural Sedation and Analgesia (PSAA)” is the modality in which sedative agents are administered (with or without analgesics) to induce a minimally depressed level of consciousness sufficient to perform certain procedures. The strict definition requires that the patient be responsive to verbal command at all times and maintain airway patency and protective reflexes. It has been used across numerous specialties to perform invasive surgical, endoscopic, and intravascular procedures of limited durations; these include orthopedic, oral, plastic, neuroendovascular, cardiac, gastric, and radiological procedures [1-8]. The technique has been widely employed in plastic surgery thanks to the advantages it has over other anesthetic modalities, namely lower costs, faster recovery, better patient and surgeon satisfaction, and lower morbidity [9]. The surgical use of conscious sedation requires the concomitant administration of local anesthetic agents in order to achieve appropriate analgesia in the intraoperativeas well as the postoperative setting. Conscious sedation technique aims at attaining three main objectives when employed in plastic surgery: to reduce or eliminate the pain associated with injection of local anesthetic, to reduce or eliminate patient apprehension, and to reduce or eliminate recall of the operation [10]. This study aims to describe and evaluate the safety and efficacy of an IV Midazolam-IM Meperidine (Pethidine) conscious sedation protocol that has been in use for three decades over thousands of patients at our institution in patients under going elective cosmetic surgeries.

Patients and Methods

Ethics statement

Institutional Review Board approval was obtained. Patients aged eighteen years or older undergoing elective surgical procedures under conscious sedation provided their written informed consent to participate in the study.

Study design and patient selection

This prospective study recruited patients at the Department of Plastic Surgery in major tertiary University Hospital in Beirut from November 2013 to December 2014. Patients aged eighteen years or older undergoing elective cosmetic surgical procedures, in which the Midazolam/Meperidine conscious sedation protocol is usually used, were approached and the study objectives were explained to each patient.. Patients were excluded if they had a history of cardiac or respiratory disease or in case of pregnancy.

Surgical techniques and conscious sedation protocol

Premedication was administered at the day care unit around thirty minutes before surgery as an intramuscular injection of Meperidine 75mg, Haloperidol 2.5mg, and Atropine 0.25mg. Surgical procedures were conducted in a specially conceived operating room where the primary surgeon and his assistant - a resident - operate in the presence of one circulating nurse. Anesthesiologists were located nearby, readily available for intervention upon request.

In blepharoplasty procedures, oxybuprocaine eye drops (Cebesine 0.4%) were used in the immediate preoperative period while in rhinoplasty procedures, a lidocaine-based gel was applied intranasally before in filtration by the local anesthetic solution (Lidocaine 1% with 1/200,000 epinephrine).

After positioning and proper draping, a direct intravenous Midazolam dose (1 to 3 mg) was administered seconds before the infiltration by the local anesthetic solution. Sedation level could be readily verified through mild non-verbal stimulation by gently touching the patient's eyelashes and looking for a reflex response. Infiltration was then undergone, and in rhinoplasty, the nose was packed with gauze soaked in Lidocaine-based gel. Oxygen saturation level was monitored throughout the procedure and the levels of sedation and anxiety were constantly evaluated. If the patient became or remained conscious and/or anxious, the surgeon called for additional midazolam as needed. On the other hand, if the patient's respiratory rate and/or oxygen saturation decreased, the patient was verbally instructed to breathe deeply. In case the patient was not responsive to verbal stimulation, a brief jaw-thrust maneuver was applied, or, very rarely, a Guedel cannula could be inserted for airway patency or reverse medication could be administered.

The postoperative period consisted of a minimum of three hours of rest during which the patient wasn't allowed nothing per orem. After this recovery period, when the patient could autonomously walk and eat, he/she were considered ready for discharge.

Patient and surgeon questionnaires

Patient anxiety was evaluated before and after premedication (auto-evaluation and evaluation by the physician). Physician satisfaction was noted on a scale from zero to ten, as well as intraoperativelevel of sedation (Modified Observer's Assessment of Alertness/Sedation Scale) [11] at four different timepoints during surgery: 1- at infiltration of the local anesthetic, 2- fifteen minutes after the infiltration, 3- during lateral osteotomy (only in rhinoplasty procedures), and 4- during cast placement (only in rhinoplasty) (Table 1). Intraoperative nausea or emesis was also assessed. Operative time, midazolam dose, and the lowest hemoglobin saturation level in oxygen were noted. Postoperative anxiety, nausea/emesis, and pain were evaluated using a questionnaire employed in a study by Hasen et al. [12]. The designated primary outcome was recovery time which corresponded to the time needed to regain orthostatic autonomy after the end of the operation. Discharge time - time from the end of the operation until discharge - depended less on the autonomy of the patient than on administrative and logistic issues, which meant that it was less related to the recovery from sedation than recovery time. Cost reduction, unintended admissions, pain, anxiety, nausea, emesis, and patient recall were considered the secondary outcome measures.

Statistical analysis

Statistical analyses were done using Stata. Kolmogorov- Smirnov test was undergone to test for the normality of the distribution of independent variables. Statistical relationships were studied between dependent variables and independent variables.

Results

A total of 173 patients were recruited of which 144 were females (83.2%). Mean age was 35.2 years (95% confidence interval [32.8; 37.6] years) (Table 2). 107 patients (61.8%) underwent rhinoplasty procedures, 24 patients (13.8%) underwent blepharoplasty procedures and 42 patients (24.3%) under went other procedures (liposuction/fat grafting, otoplasty, and other procedures). Mean operative time was 59.5 minutes (95% confidence interval (CI) 56.3-62.8 minutes). Mean recovery time was 196 minutes (95% CI 181-212). None of the patients required intraoperative anesthesiologist intervention or an unintended admission. 90% of patients recalled some events from the operation while only 10% recalled an intraoperative bad experience. 10.5% of patients reported postoperative nausea. However, when asked to rate their nausea from 0 to 10, only 15.4% of 155 patients reported a score of more than 5. Postoperative emesis was reported in 14% of patients. One patient presented to the emergency department 4 hours after discharge for extrapyramidal symptoms (trismus). She was successfully treated with a 50mg intramuscular dose of promethazine (Phenergan®). Other results are summarized in Tables 2-4.

*CI: Confidence Interval.

Primary and secondary outcomes

In univariate analyses, age was the most significant predictor of recovery time. Older patients recovered faster (p=0.019), and were discharged faster (p=0.009). They were less anxious preoperatively (before (p=0.003) and after premedication (p=0.092), had less postoperative pain (p=0.007), nausea (p<0.0001), and emesis (p=0.006), and showed deeper sedation at the end of the rhinoplasty operations during cast placement (p=0.008). There was a trend towards better satisfaction with sedation in older patients (p=0.092).

Male patients were less anxious preoperatively both before (p=0.0027) and after (p=0.069) premedication, and intraoperatively (with significant patient recall of intraoperative anxiety). In rhinoplasty procedures, they were more sedated during osteotomy (p=0.0004) and during cast placement (p=0.035). They also had less vomiting episodes postoperatively (p=0.021). An average of 90.1% minimal oxygen saturation (95% confidence interval, 87.8-92.5) was noticed in all patients.

Midazolam dose was increased when intraoperative patient anxiety was reported to be high by the surgeon (p=0.011), and it was higher in patients with less deep sedation at cast placement in rhinoplasty procedures (p=0.046). Patients who had received a higher dose of Midazolam reported more intraoperative anxiety (p=0.02) and less recall of entering the operating room (p=0.0024). Higher midazolam dose was associated with increased postoperative nausea (p=0.047) and emesis (p=0.032).

Analgesic intake in the past two weeks tended to be associated with recall of events from the operation (Chi-2 test; p=0.05). 29 of 55 patients who had taken analgesics did not recall events from the operation (53%) versus 36 of 99 patients who had taken analgesics (36%).

High (7-14 glasses/week) alcohol intake was associated with slower discharge (p=0.022). In our establishment the fixed hospital cost In a conscious sedation protocol for blepharoplasty and rhinoplasty is around 700$ where it is 1700$ in a general anesthesia setting. This means a 59% cost reduction.

Discussion

Conscious sedation is an anesthetic technique where the patient's consciousness level is diminished while maintaining response to verbal command. Airway protection reflexes, muscle contraction and thermal regulatory mechanisms are still present thus preventing aspiration, deep vein thrombosis (DVT), and hypothermia [3].

None of our patients required intraoperative anesthesiologist intervention or an unintended admission. Marcus et al. [1] reported 15 unintended admissions (out of 300 patients) in their study using the fentanyl/midazolam conscious sedation protocol, 73% of which was due to nausea and vomiting. Gart et al. [3] suggested that although the rate of unintended readmission was low in conscious sedation patients, high doses of preoperative diazepam decreased intraoperative midazolam and fentanyl use and reduced the incidence of postoperative nausea/vomiting. This strategy was found to decrease the rate on unintended admissions due to nausea and vomiting from around 1% to 0%.

In our study, the mean recovery time was 196 minutes (95% CI 181-212). This result is similar to that observed in a study comparing bolus to continuous midazolam administration (A). The recovery time for procedures of 120-180 minutes duration was 90-240 minutes. However, in other studies, intraoperative IV fentanyl rather than meperidine yielded shorter recovery times (63 minutes) but requiring an anesthesiologist [6].

90% of patients recalled some events from the operation while only 10% recalled an intraoperative bad experience. 10.5% of patients in our study reported postoperative nausea and 14% reported postoperative emesis. In a study comparing conscious to deep sedation, Hasen et al. [12] reported a 17% rate of recall of unpleasant intraoperative events in the conscious sedation group (vs. only 3% in the deep sedation group). However, both groups had low recall of intraoperative pain, anxiety, and nausea, and the deep sedation group experienced significantly more nausea in the recovery room (p = 0.002), at the time of discharge (p = 0.009), and the evening after the operation (p = 0.013). Amnesia of intraoperative events confers conscious sedation a similar patient experience to that of general anesthesia. Absence of inhalational anesthetics and the low dose of narcotics decrease postoperative nausea and vomiting (PONV) [14]. PONV is often referred to by patients as the most unpleasing issue in the entire operative experience. It is closely associated with propofol and with high intraoperative opioid use which favors conscious sedation over general anesthesia - where propofol and high opioid doses are employed - and propofol-based deep sedation [3,13]. PONV incidence in benzodiazepine/opioid-based conscious sedation is reportedly higher amongst women and in the 6-16 years age group (34-51%), with decreasing incidence with age (14-40%) [14]. Our results fall into these limits with 15.4% of patients reporting a nausea score of 6 or more on a scale from 0 to 10, with female sex predisposition, and decreased PONV with advancing age.

In their study on fentanyl/midazolam conscious sedation, Marcus et al. [1] reported a negative correlation between recovery time and advancing (p <0.001). Similar results were obtained in our study where older patients recovered faster (p=0.019), and were discharged faster (p=0.009).

While general anesthesia remains the corner stone for most surgeries, it has a 1 to 50,000 fatality rate mainly due to thromboembolic events [14]. It also presents a risk of malignant hyperthermia and a 30% rate of post-operative nausea and vomiting despite proper anti-emetic measures, not to mention increased costs, hospital admissions, preoperative evaluation time, post-operative recovery time, and complications from oro-tracheal intubation (sore throat, tooth injury, atelectasis) [1,10,13,14]. On the other hand, conscious sedation decreases the risk of thromboembolic events without DVT prophylaxis [9,15], decreases hospital stay, unintended admissions, and costs, and eliminates the need for a tracheal tube [1,10,15,16].

Many protocols have been described for conscious sedation in plastic surgery; benzodiazepines are the most commonly used while propofol, ketamine and barbiturates are fairly found in some regimens [17-26]. Agents with a short duration of activity/ half-life are preferred and they are used in small incremental doses while constantly monitoring patient's alertness, respiratory rate and room air oxygen saturation. Multiple agents - propofol, ketamine, and midazolam - possess this property. However, the advantages that midazolam has include amnestic properties and reversibility, with increased patient satisfaction and safety, respectively Propofol and Ketamine lack reversibility and their use by non-anesthesiologists remains controversial [15]. Midazolam is a short-acting benzodiazepine that provides sedation, anxiolysis, and antegrade amnesia and these effects are potentiated by opioid agents. The increased hypnotic effect of midazolam with age and in females is well documented in the literature [4,5,27] and is clearly reflected in the results of this study. It should be noted that the need for sedation is not uniform throughout the procedure. An initial loading dose is required prior to the infiltration of the local anesthetic [10]. Once pain suppression is established, the depth of sedation needed becomes less important. The patient is hence allowed to gradually regain consciousness during the operation. Another bolus dose is usually added towards the end of rhinoplasty procedures prior to the lateral osteotomy to alleviate anxiety secondary to the sounds and vibrations generated by percussion. This explains why only 10% of our patients recalled peroperative bad experience while 67% recalled events from the operation. As for side effects, Midazolam-induced respiratory depression is primarily manifested by a decrease in respiratory rate while decreased oxygen saturation only comes next. Therefore, monitoring of the patient's oxygen saturation at room air but also of the respiratory rate must take place concurrently [28]. Our technique proved to be safe with an average of 90.1% minimal oxygen saturation (95% confidence interval, 87.8-92.5).

More we can notice in Figure 1 that the septoplasty added to rhinoplasty increases the risk of post-operative nausea by 2.5 folds (Figure 1). We can also add that rhinoplasty in conscious sedation setting or general anesthesia if not associated with septoplasty present with similar post operative emesis and nausea. Finally a key factor to consider is a reduction of 60% of the patient hospital cost with no increase in complications and a earlier recovery than general anesthesia.

Conclusion

This study provides further evidence on the safety and effectiveness of the IM Meperidine - IV Midazolam conscious sedation protocol in plastic surgery operations in the one-day- surgery setting. It has been used at our institution for more than twenty years over thousands of patients with no major complications occurring. Further studies are needed to compare the fentanyl/midazolam regimen with this meperidine/ midazolam protocol with or without dexmedetomidine in terms of safety, efficacy, and cost-effectiveness.

For more articles in Open access Journal of Head Neck & Spine Surgery | Juniper Publishers please click on: https://juniperpublishers.com/jhnss/index.php

#Head and neck surgery #Conscious Sedation #plastic surgery #Midazolam #Meperidine - IV #rhinoplasty

0 notes