The study included retrospective and prospective analysis of patients treated from July 1995 to February 2005, most of them (1,008) by the same board-certified facial plastic surgeon.
In 86 percent of cases (1,032), general anesthesia lasted more than 240 minutes. Patients in this group generally underwent combined procedures such as rhytidectomies, blepharoplasties, browlifts and laser resurfacing.While no deaths or myocardial infarctions occurred in either group, researchers observed two major morbidity events (one cerebral hemorrhage and one case of aspiration pneumonia secondary to an obstruction event on extubation) in the more-than-240 group compared to one major morbidity (an anaphylactic reaction to medication) in the other group.
"Case duration in and of itself is not an indicator of potential morbidity or mortality in facial plastic surgery," says Neil A. Gordon, M.D., the study's lead author and clinical instructor of surgery and resident coordinator of facial plastic and reconstructive surgery at Yale University School of Medicine.
Rather, he says, "We look at facial plastic surgery very much like flying a plane. Whether one flies to Boston or Los Angeles, one's general risks are similar because they're really occurring during takeoff and landing," or the process of anesthetizing and reviving patients.
"It's an excellent study that accentuates the fact that what we had all been hoping was, in fact, the case," says James A. Yates, M.D., president of the American Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF) and a plastic surgeon based in Camp Hill, Pa.
Dr. Yates says he has been lobbying Pennsylvania regulators for several years to increase the outpatient surgical time limit to six hours, and trying to prove with data from the American Society of Plastic Surgeons (ASPS) and the American Society for Aesthetic Plastic Surgery that outpatient surgeries lasting more than four hours do not cause problems with increased morbidity or mortality.
"They're still not listening," he says, "but this (study) helps our argument."
As a consecutive case review, the study's main strength is that "The author isn't cherry-picking the good from the bad," says Ronald E. Iverson, M.D., chairman of the ASPS patient safety task force, former ASPS president and adjunct clinical professor of plastic surgery, Stanford University Medical Center.
As for weaknesses, Dr. Gordon notes that because the study included only 1,200 cases, it summarizes mainly one practice's experience. Therefore, he says, "This should be the nidus for looking at the same objective through a multicenter study that would encompass many more cases."