Related Digital Media are available in the full-text ver-
sion of the article on www.PRSGlobalOpen.com.
Disclosure: Dr. Janis receives royalties from Thieme and
Springer Publishing. The other authors have no nancial
interest to declare.
From the Department of Plastic and Reconstructive Surgery, The
Ohio State University Medical Center, Columbus, Ohio.
Received for publication June 30, 2022; accepted September 8,
Copyright © 2022 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This
is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
Outpatient procedures remain a popular trend in
recent years. In 2020, 82% of cosmetic procedures and
41% of reconstructive procedures were performed in the
outpatient setting, compared with 81% and 62% in 2007,
respectively.1,2 Internationally, 56% of cosmetic proce-
dures were performed in the outpatient setting in 2020.3
Improved convenience, comfort, and costs benet both
patients and surgeons when compared with the hospital
setting.4–6 It is, therefore, reasonable to expect the preva-
lence of outpatient procedures to continue, or even rise,
into the future. Despite such momentum, regulations have
been slow to keep pace; fewer than 30 states have laws gov-
erning ofce-based surgery (OBS), and even fewer states
require accreditation.7,8 Among those that do, there is a
lack of standardization over accreditation.9
Conicting evidence exists regarding the complica-
tion rate in OBS compared with other surgical settings.10–12
Regardless, patient safety remains paramount.4 Given the
lack of safety regulations for OBS, organizations, such as
the American College of Surgeons, the American Society
of Plastic Surgeons (ASPS), the Aesthetic Society (formerly
ASAPS), and the American Association for Accreditation
of Ambulatory Surgery Facilities (AAAASF), have released
practice advisories to guide surgeons.13–16 As such, the
onus of patient safety lies on the shoulders of surgeons.
This article will summarize and consolidate contem-
porary, evidence-based practice guidelines to help plas-
tic surgeons understand topics guiding patient safety in
OBS. The principles outlined herein are not exhaustive,
nor are they hard and fast rules. They also should not be
interpreted as the legal standard of medical care. Rather,
physicians should use these guidelines to inform their own
understanding of the evidence and supplement their best
clinical judgment within individual circumstances.
PRINCIPLES GOVERNING OFFICE SAFETY
Accreditation provides validation of safe practices,
compares performance against other accredited facili-
ties, and standardizes practice guidelines.12,17 This dem-
onstrates that the practice meets a nationally accepted
standard and is committed to patient safety and qual-
ity care.17 Current accreditation organizations include
AAAASF, the Accreditation Association for Ambulatory
Health Care, and the Joint Commission.14,17,18 With
expanding medical tourism, reciprocal demand for
patient safety has increased international outreach from
these organizations.19 AAAASF has modied domestic
accreditation standards to accommodate cultural and
social differences internationally and been endorsed by
the International Society for Aesthetic Plastic Surgery.
Kevin K. Zhang, BA
Nihaal Reddy, BS
Jeffrey E. Janis, MD, FACS
Summary: Outpatient procedures are extremely prevalent in plastic surgery, with
an estimated 82% of cosmetic plastic surgery occurring in this setting. Given that
patient safety is paramount, this practical review summarizes major contemporary,
evidence-based recommendations regarding ofce-based plastic surgery. These
recommendations not only outline clinical aspects of patient safety guidelines,
but administrative, as well, which in combination will provide the reader/prac-
tice with a structure and culture that is conducive to the commitment to patient
safety. Proper protocols to address potential issues and emergencies that can arise
in ofce-based surgery, and staff familiarity with thereof, are also necessary to be
best prepared for such situations. (Plast Reconstr Surg Glob Open 2022;10:e4634; doi:
10.1097/GOX.0000000000004634; Published online 9 November 2022.)
Ofce-based Plastic Surgery—Evidence-based
Clinical and Administrative Guidelines
PRS Global Open • 2022
All accredited facilities are reevaluated yearly via self-
survey and every 3 years by an onsite inspector.19 While
each agency has their own process, they share the goal
of ensuring quality health care and patient safety.17
Membership to plastic surgery societies also demon-
strates a commitment to patient safety; ASPS and the
Aesthetic Society mandate members operate in accred-
ited outpatient facilities.20
Culture of Safety
The Institute of Medicine denes safety culture as “indi-
vidual and organizational behavior, based upon shared
beliefs and values that continuously seek to minimize
patient harm.”21 This culture is a foundational element
of outpatient surgery. Administering surveys can evaluate
perception of safety culture in the ofce.22 Physicians and
staff are responsible for maintaining and honoring the
ofce culture to ensure a collective commitment to qual-
ity improvement and patient safety.23
Personnel and Training
Physicians should maintain certication as recog-
nized by the American Board of Medical Specialties, the
American Osteopathic Association, or a state-approved
board with equivalent standards.4,14,24,25 Ofce-based phy-
sicians are generally subject to less-detailed credential
review, predisposing them to “practice drift”; that is, they
are more susceptible to providing care outside the scope
of their training.26–30 Physicians must work within the
scope of their licensing, experience level, and the facility’s
accreditation guidelines.4,14,28,29 This also applies to anes-
thesiologists, who may receive less ambulatory training in
residency, as well as nursing and support staff.18,23,31,32
Informed consent is the acknowledgement of a discus-
sion between the provider and patient about the proposed
procedure, including indications, expectations, risks, and
benets along with alternative options.25,32 This includes
a corresponding discussion with the anesthesiologist
regarding the anesthetic plan.26 Discussions should consist
of nonmedical jargon, with communication performed at
a fth-grade level and translated into the patient’s pre-
ferred language.32–35 Supplemental use of visual aids can
improve understanding and retention of information.33
Patients should demonstrate their understanding of the
discussion and proposed treatment using the teach-back
method before signing their consent.32,33 Consent should
also be thoroughly obtained for legal purposes.34
In 2021, the US Food and Drug Administration
updated informed consent protocols tying breast implant
manufacturers and plastic surgeons to a comprehensive
decision-making process with patients. These involve
a device-specic label consisting of ve components
(Table 1), including an additional checklist created by
implant manufacturers for obtaining informed consent.
This checklist aims to conrm understanding of the risks
associated with the operation and implant, and it must be
signed by both the patient and implanting plastic surgeon
after review. Implant manufacturers are prohibited from
selling breast implants to surgeons until they attest in writ-
ing their agreement to using the checklist while obtaining
ASPS encourages plastic surgeons to become famil-
iar with these new Food and Drug Administration guide-
lines.36 For this purpose, both organizations have released
examples of implant labels.38,39 These examples are not
ofcial manufacturer labels and should only be used as
reference—not for patient care.
PROTOCOLS TO ENSURE SAFETY
Organization is essential to maintaining a safe and suc-
cessful ambulatory practice. Perioperative patient safety
checklists are simple tools that promote safety culture and
have helped decrease complication rates.40–42 The World
Health Organization Surgical Safety Checklist is one
example that can be tailored to its user’s needs, such as
for outpatient plastic surgery. (See gure, Supplemental
Digital Content 1, which displays an example of a 28-ele-
ment, perioperative checklist template for use in the
ofce-based setting developed by Rosenberg et al 2012,
http://links.lww.com/PRSGO/C236.)40,43 However, emer-
gencies may arise, and equipment and established policies
should be familiar to all staff to handle both routine and
Fires in the OR involve three components: an oxidizer,
often oxygen or nitrous oxide; an ignition source, such
as cautery; and fuel, which includes sponges and alco-
hol-based solutions.45–48 Proper management of fuel and
ignition sources in the OR and perioperative areas is pri-
ority.24,45–47 It is crucial to observe proper safety technique
of potential ignition devices, allow preparation solution to
completely dry to disperse ammable fumes, keep gauze
and sponges moist, and minimize oxygen concentration
as appropriate (ideally <50% FiO2).45–48
The major factor behind re litigation is lack of discus-
sion among the surgical team regarding the risk of re.45
As such, re-safety training and teamwork are necessary.
If a re occurs, the procedure must be stopped, and re
protocols should be executed.45,47
Table 1. The Five Components of Breast Implant Manufacturer Labeling
Components of Breast Implant Manufacturer Labeling
1.A “black box” warning regarding potential short-term, long-term, and life-threatening consequences associated with implant
2.A patient decision checklist to help conrm patient understanding of the benets, aforementioned risks, and other information about the implant.
3.Updated recommendations about silicone gel-lled implant rupture-screening protocols.
4.A device description with a list of materials that compose the implant.
5.A patient device card to full medical device tracking requirements.
Zhang et al. • Outpatient Plastic Surgery Safety
EQUIPMENT AND STERILITY
Properly functioning equipment and sharps and ster-
ile technique are crucial for OR safety. For any OBS using
sedation, the America Society of Anesthesiologists (ASA)
and AAAASF recommend monitoring pulse oximetry,
electrocardiogram, blood pressure, capnography, and
temperature.4,24,25 Equipment must be frequently main-
tained, sanitized, inspected, and sterilized with an auto-
clave, as appropriate.5,24 Intraoperative events, such as
hypothermia or bleeding, increase postoperative morbid-
ity, and equipment should be ready to prevent and treat
such incidents.16,24,49–52 The CDC establishes sterility and
disinfection protocols adopted by many hospitals; ofce-
based practitioners should use such a model as well.53
Ultimately, meticulous adherence to proper sharps and
sterile technique is best for ensuring surgical safety.41,54
Despite this, sharps and needlestick injuries remain
among the most common injuries sustained by surgeons.
In the event of a sharps injury or exposure to blood-borne
infection, staff must wash the area, report the injury, obtain
patient samples for source testing, and receive proper and
punctual prophylaxis to HIV and hepatitis B or C viruses,
Documentation and Quality Improvement
For every procedure, documentation should include
indications, procedure-specic information, ndings,
specimens, complications, and patient tolerance. A pro-
cedure should be documented immediately after its com-
pletion. Inclusion of all pertinent points is important for
continuity of care, protecting patient safety and privacy,
and potential legal ramications.32 Such medical records
must be stored within the facility.24
Thorough documentation can also help with quality
improvement. Monthly audits of random cases and opera-
tive sequalae should be performed, and adverse events
must be analyzed and used to improve systems and pre-
vent reoccurrences.24,56,57 The National Surgical Quality
Improvement Program allows practices to collect and
compare patient data with other participating facilities. It
also uses data sharing to develop and update best practice
guidelines to its member practices.58 Indeed, adherence
to National Surgical Quality Improvement Program pro-
tocols has decreased the risk of surgical complications and
increased patient satisfaction ratings.59–61 More specic to
plastic surgery, the Tracking Operations and Outcomes
for Plastic Surgeons and ASPS Qualied Clinical Data
Registry help plastic surgeons identify areas for improve-
ment and compare quality improvement efforts with their
peers. All ASPS members are encouraged to participate
in the Tracking Operations and Outcomes for Plastic
Surgeons program, and AAAASF requires its member
practices to engage in quality improvement programs.57,62
Within the effort to improve patient care, many plastic
surgeons have turned to standardized risk stratication
during patient evaluations. Postoperative scoring tools
such as the LACE+ index and TIME-H objectively evalu-
ate patient characteristics and comorbidities to stratify
patients on their risk for developing complications. This
information helps providers reallocate resources and
attention to better monitor those deemed high risk and
avoid excessive care to patients who may not require
After surgery, minimizing complications should be a
priority. Postoperative nausea and vomiting (PONV) leads
to multiple morbidities, including dehydration, electro-
lyte imbalances, aspiration, wound complications, and
anorexia. Furthermore, PONV can delay discharge and is
a leading cause of unanticipated hospital admission.4,7,65
PONV may be reduced by modifying anesthesia, using
pharmacologic prophylaxis, and managing pain. Long-
term monitoring of patients at high risk for postoperative
complications should be performed.
At discharge, patients should be handed off to an
adult who can understand and adhere to postoperative
directives. The use of durable materials with basic illus-
trations is a valuable resource in assisting with this goal.67
Follow-up visits allow physicians to monitor for compli-
cations and manage wound care devices such as closed-
suction drains.41,67 The timing of follow-up is important
too; appointments within a week of discharge can reduce
readmission rates in inpatients.68 Clinic staff may help
improve adherence by emphasizing the importance of
follow-up appointments, providing resources that amelio-
rate socioeconomic barriers, and sending appointment
EMERGENCY AND TRANSFER PROTOCOLS
Detailed protocols for handling medical and situ-
ational emergencies (eg, inclement weather and re)
should be available for reference at any time.26,32,44 Facility
premises should be spacious and organized to enable
lifesaving interventions and retrieval of equipment.4,24 A
source of emergency power must be present and immedi-
ately available.24 At least one physician who is credentialed
in the resuscitative techniques advanced trauma life sup-
port, advanced cardiovascular life support, or pediatric
advanced life support must be present until the patient is
ready for transfer. Medical personnel with direct patient
contact should be trained in basic life support.14,18 For
emergent anaphylaxis, epinephrine or alternative vasoac-
tive drugs should be administered intravenously. Steroids
and antihistamines may be used as adjuncts or for mild
reactions, and glucagon should be available for rescue
treatment for epinephrine nonresponders (eg, due to
β-blocker use).71 Physicians should also have admitting
privileges or maintain an emergency transfer agreement
with a nearby hospital.4,13,14
Periodic inventory checks and simulations are recom-
mended to keep members of the clinical team familiar
and coordinated with their roles.4,32,56 These can be done
via walk-throughs, role-playing, or practice on manne-
quins. Debrief sessions provide an opportunity to discuss
strengths and areas of improvement to better prepare for
the next drill or a real situation.56
PRS Global Open • 2022
PERIPROCEDURAL SAFETY PRINCIPLES
Periprocedural evaluations, including histories and
physical examinations, are crucial for determining out-
patient surgical eligibility and identifying and plan-
ning for potential complications.24,32,51,72 Information to
elicit includes patient allergies, adverse drug reactions,
medications and drug history, nutritional status, and
comorbidities, such as obesity, cardiovascular disease, pul-
monary disease, diabetes mellitus, and obstructive sleep
apnea.4,5,25,32,41,51,72,73 Preoperative laboratory testing is not
Obesity and Procedure Characteristics
Patient BMI must be considered when planning out-
patient plastic surgery, as BMI is directly correlated with
the risk of perioperative complications.51,74–81 The British
National Health Service recommends patients undergo-
ing body contouring surgery who have a BMI less than or
equal to 28; however, no further clinical guidelines exist
for setting BMI limits or contraindicating plastic surgery
due to obesity.79,80,82 Instead, clinical judgment should
account for the combination of procedures to be per-
formed, procedure indication, and the overall health of
Procedure length is known to impact postoperative
morbidity.51 Administration of anesthesia for more than
1 hour and operations ending after 3 are signicant,
independent predictors of unanticipated admission fol-
lowing surgery.83 Although a procedure duration of less
than 6 hours was accepted as a safe cutoff, those lasting
more than 4 hours, as well as combined procedures (in
particular with abdominoplasty), are signicant risk factors
for developing venous thromboembolism (VTE).51,75,82–85
Similarly, specic to liposuction, a lipoaspirate volume less
than 5 L was considered safe.82 Two recent reviews found
an increased risk of VTE in those with a lipoaspirate more
than 3 L,85 and an increased risk of VTE and other com-
plications in those with a lipoaspirate more than 3.5 L.86
Therefore, further postoperative monitoring can be
considered for patients with a BMI more than 30 kg/m2,
liposuction volume more than 3 L, operative time more
than 4 hours, and those undergoing combined proce-
dures.51,85 Postoperative monitoring must be supervised by
a health care provider with documentation of a course of
events.24,85 Finally, longer procedures should be scheduled
earlier in the day.
The increasing popularity of alternative and homeo-
pathic medicine without regulation of product labeling
poses potential health risks for surgical patients.41,87,88
Screening for these supplements should be part of the
preprocedure evaluation.88 For homeopathic medica-
tions lacking pharmacokinetic data, ASA recommends
they be discontinued 2–3 weeks preoperatively and not
be resumed for another 1–2 weeks postoperatively.41,88,89
Ultimately, an empathetic surgeon can counsel on
homeopathic therapies while maintaining cultural
respect and patient compliance in preparation for
Preoperative evaluations are necessary to maintain
patient safety when administering sedatives, local, or
general anesthesia.24,92 The chosen anesthetic technique
should be appropriate for both the patient’s overall health
and the procedure.26 The ASA Patient Selection Physical
Status Classication System places patients into four cat-
egories of health and ability to tolerate anesthesia.14,32,51
Categories 1–3 are able to undergo OBS, whereas those in
category 4 are not.26,41,51,72
Conscious sedation, characterized by the patient’s
ability to self-maintain spontaneous respirations and air-
way protection, and local anesthesia can be considered in
the OBS setting, including for facial and breast surgery
and body contouring.92–94 These techniques offer multiple
advantages over general anesthesia, including shorter
recovery, less PONV, improved cost effectiveness, and less
equipment and personnel required for administration.
Low-dose propofol is a good sedative in OBS because of
its anxiolytic and amnestic properties and its manage-
able pharmacodynamics and side effects. Adjuvants, such
as ketamine, fentanyl, and benzodiazepines, may also be
used. Oral sedation offers some advantages over intrave-
nous administration, such as relative vital sign stability, but
it also lengthens drug onset and duration, which could
Targeted techniques and nerve blocks can also be
applied in certain operations. Inltration of anesthesia
between the internal oblique and transversus abdominis
(TAP blocks) can reduce the need for postoperative anal-
gesia in abdominal surgery.95,96 Pectoralis and intercostal
nerve blocks are a strong rst choice for local anesthesia
in breast procedures, with serratus anterior plane and
erector spinae plane blocks as reasonable alternatives or
Ropivacaine is commonly used as the local agent.96
Liposomal bupivacaine has a duration of action of approx-
imately 72 hours and can, therefore, be effective in reduc-
ing postoperative pain.99 The aforementioned blocks
are similar in efcacy and safety, so surgeons should
use whichever block they are most comfortable with.96
Surgeons should also be aware of signs of anesthetic toxic-
ity, including agitation, confusion, dizziness, drowsiness,
tinnitus, perioral numbness, metallic taste, and dysarthria.
Antidotes should be available for administration as neces-
sary, including benzodiazepines in the event of seizures or
epinephrine for cardiac arrest.100
Patients considered for conscious sedation should be
ASA 1 or 2 and emotionally stable to reduce the risk of
intraoperative agitation. Given the nature of conscious
sedation and local anesthesia, it is the surgeon’s responsi-
bility to be aware of the patient’s comfort level and be in
communication with the anesthesiologist.92
Surgical site infections are a risk ubiquitous to all set-
tings. The Surgical Care Improvement Project recommends
IV antibiotic prophylaxis between 30 and 59 minutes of inci-
sion (2 hours for vancomycin and uoroquinolones).101–103
Preoperative antibiotics should be tailored to the patient;
Zhang et al. • Outpatient Plastic Surgery Safety
cefazolin, or clindamycin in those with beta-lactam aller-
gies, is commonly used. If the surgery lasts over 4 hours,
repeat dosing is indicated.99 Antibiotics are unnecessary 24
hours postoperatively in clean cases except with placing a
foreign object or for head and neck oncologic reconstruc-
tion.41,101,103–106 Antibiotic administration and discontinu-
ation time, and incision time, should be documented.105
While no guidelines exist for antibiotic prophylaxis based
on procedural characteristics in plastic surgery, surgeons
can refer to the standards recommended by other surgical
specialties in combination with their own judgment.101
Plastic surgeons must assess for VTE risk by record-
ing predisposing conditions and lifestyle factors
(Table 2).23,51,84,107 The Caprini Score uses this informa-
tion to stratify patients into low-, moderate-, and high-risk
categories, allowing systematic administration of VTE
prophylaxis based on risk prole.16,108–112 The American
Association of Plastic Surgeons released recommenda-
tions in 2015 regarding deep vein thrombosis and pulmo-
nary embolism (DVT/PE) prevention in plastic surgery
(Table 3).110,113 However, there remains no all-encom-
passing recommendation regarding VTE chemoprophy-
laxis based on Caprini stratication, and surgeons should
use clinical judgment when evaluating patients for VTE
management.108,109,114 An exception may be noted for
abdominoplasty, which is associated with a higher risk of
developing VTE; studies have shown benet in using VTE
chemoprophylaxis in abdominoplasty patients.23,99,112,115
Hypothermia is an intraoperative event associated
with increased risks of surgical site infections, myocardial
events, and blood loss due to disruption of the coagulation
cascade24,50,116,117; a 1 °C decrease in core body temperature
increases blood loss by as much as 20%, in turn increas-
ing the likelihood of a transfusion.16,49–51 Hypothermia
can also potentiate the effects of anesthesia and prolong
the duration of postoperative recovery and the hospital
stay.50,116–118 Therefore, measures to prevent hypothermia
should be available, including but not limited to, ambi-
ent temperature optimization, forced air warming blan-
kets (bair huggers), warmed intravenous uids, and blood
products.16,24,51,117 Strict monitoring of patients’ vitals and
temperature is necessary in all practices.4
Malignant hyperthermia (MH) is a life-threatening,
anesthetic emergency that must be investigated during
the preprocedure evaluation. A query of personal and
family history of adverse anesthesia reactions, such as
intraoperative trismus, unexplained fevers, or deaths dur-
ing anesthesia, should be performed.119,120 If a patient is
deemed susceptible to hyperthermia or has history of
muscular pathology, he/she may still undergo outpa-
tient surgery with proper precautions.120,121 This includes
obtaining a baseline serum creatine kinase, potassium,
and myoglobin level.120 Nontriggering anesthetics such as
propofol and vecuronium should be used for all suscep-
tible patients, while volatile anesthetics and succinylcho-
line must be avoided.119,120,122 Early recognition of MH is
crucial, with common indicators being end-tidal hypercar-
bia, sinus tachycardia, and masseter spasm.117 In the event
of a hyperthermic crisis, dantrolene and active cooling
methods, such as ice packs and cold IV uids, should be
ready until the patient can be transferred to a hospital.51,117
Failure to monitor temperature is associated with mortal-
ity in MH, further highlighting the importance of moni-
toring vitals during and up to 2.5 hours after surgery.50,51
Multimodal Analgesia (MMA)
The use of local anesthesia and adjunctive MMA can
provide many benets pertaining to operative and post-
operative anesthesia. Improved comfort and PONV man-
agement reduce unanticipated postoperative admissions
and promote recovery with increased patient satisfac-
tion.23,51,96,97,99,123,124 Importantly, use of local anesthesia and
MMA could reduce the need for opioids and, thus, reduce
the risk of new persistent opioid use.96,97,99,124–126 Appropriate
supplementation with NSAIDs, acetaminophen, gabapen-
tinoids, and steroids is, therefore, recommended.98,123
As physicians, patient safety is the foremost priority.
In an ever-evolving landscape that favors decentraliza-
tion, this means the institution, adherence, and con-
tinual improvement of culture and protocols to secure
high-level patient care. For the plastic surgeon, it also
Table 2. Common Risk Factors for Venous Thromboembolism
Common Risk Factors for Venous Thromboembolism
Personal or family history of clotting disorders (eg, factor V Leiden)
History of more than three pregnancies
Chronic heart failure
Recent muscular trauma
Connement to a bed and/or armchair
Use of general anesthesia during surgery
Standing >6 hours per day
Performance of combined procedures
Performance of abdominoplasty
Table 3. American Association of Plastic Surgeons 2015 Recommendations for DVT/PE Prevention in Plastic Surgery
Recommendations for Prevention of Deep Vein Thrombosis and Pulmonary Embolism in Plastic Surgery
1. Use nongeneral anesthesia when appropriate.
2. All patients should have intermittent pneumatic compression.
3. All patients should have preoperative Caprini risk stratication performed.
4. Chemoprophylaxis for Caprini scores >8 should be considered on an individualized basis.
PRS Global Open • 2022
means assessing whether the patient is suitable for out-
patient surgery and knowing and preparing for adverse
events that may occur in the facility or after discharge.
This article represents a starting point for the outpatient
plastic surgeon to reference with the goal of promot-
ing consistent understanding and awareness for patient
safety. Indeed, a conscientious physician who exercises
prudent clinical judgment goes a long way in ensuring
patient safety. (See table, Supplemental Digital Content
2, which displays the main takeaways of each topic sec-
tion discussed in this article, http://links.lww.com/
Jeffrey E. Janis, MD, FACS
Department of Plastic and Reconstructive Surgery
Ohio State University Wexner Medical Center
915 Olentangy River Road, Suite 2140
Columbus, OH 43212
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