Optimizing Ventilation for Prone Cosmetic Surgery

Procedures such as Brazilian Butt Lifts, posterior trunk lifts, flank liposuction, and back roll resections require extended prone positioning. While this position provides optimal surgical access, it introduces challenges for anesthesia providers. Increased airway pressures, impaired venous return, and complex body support arrangements can negatively affect ventilation and hemodynamic stability. Improper ventilation strategies may prolong emergence, increase the risk of postoperative nausea and vomiting, and contribute to rare but serious complications such as increased intraocular pressure. This guide outlines best practices in ventilation, positioning, and monitoring to ensure patient safety during prone cosmetic procedures.

Pre-Positioning Safety Protocols

Prior to transitioning a patient into the prone position, anesthesia providers should follow a standardized pre-checklist. The “TOPP” mnemonic can help ensure critical elements are addressed:

• Tube secured using cloth ties and tape to reduce the risk of accidental extubation.
• Oral or tracheal bite block placed to protect the endotracheal tube pilot line.
• Padding prepared with chest rolls and head supports to prevent abdominal compression and inferior vena cava obstruction.
• Pressure lines and intravenous tubing confirmed to be free of kinks to maintain monitoring integrity and fluid administration.

Conducting a 10-second pause before repositioning can prevent extended troubleshooting later.

Positioning Best Practices

Chest Support

Use lateral chest rolls positioned at nipple level to allow abdominal contents to hang freely. This technique has been shown to reduce peak airway pressure and improve ventilation mechanics. Avoid central bolsters that may increase intra-abdominal pressure.

Facial Support and Visualization

Select low-profile foam face pillows with a mirrored base. These allow continuous visualization of the patient’s mouth and endotracheal tube for condensation or lip positioning without requiring physical manipulation.

Eye and Ear Protection

Document hourly checks for eye pressure relief. Designate a callout during the procedure to verify that the eyes remain free from compression. Gel padding should be used for knees and heels to prevent nerve injuries during prolonged procedures.

Selecting Appropriate Ventilation Modes

Ventilation strategy should be tailored to patient anatomy and surgical duration:

• Volume-Controlled Ventilation (VCV) is appropriate for short procedures in healthy patients but may result in higher peak pressures in individuals with elevated body mass index.
• Pressure-Controlled Ventilation with Volume Guarantee (PCV-VG) is preferred for patients with high airway resistance or obesity, as it delivers consistent volumes at lower pressures.
• Pressure Support Ventilation can be employed during total intravenous anesthesia weaning for a smoother emergence.

Initial settings for PCV-VG may include inspiratory pressure of 18 to 20 cm H₂O, an inspiratory to expiratory ratio of 1 to 1.5, and a positive end-expiratory pressure of 6 cm H₂O. Adjustments should maintain end-tidal carbon dioxide between 35 and 40 mm Hg.

Managing PEEP and Recruitment Maneuvers

High levels of positive end-expiratory pressure, combined with abdominal compression, can elevate central venous and intraocular pressures. To mitigate this:

• Perform a recruitment breath of 30 cm H₂O for eight seconds after prone positioning.
• Maintain PEEP between 5 and 6 cm H₂O.
• Avoid excessive Trendelenburg positioning.
• Repeat recruitment maneuvers every 60 minutes or after significant fluid shifts exceeding one liter.

Fluid and Hemodynamic Optimization

Goal-directed fluid therapy remains effective in the prone position and can be guided by stroke volume variation monitors. Targets should include:

• Stroke volume variation less than 13 percent, prompting a 250 mL lactated Ringer’s bolus if exceeded.
• Mean arterial pressure greater than 65 mm Hg, with interventions including phenylephrine 40 micrograms or ephedrine 5 milligrams.
• Urine output above 0.3 mL/kg/hour. If low, consider 100 mL of 5 percent albumin.

Use warmed irrigation solutions and inflow tubing to prevent intraoperative hypothermia.

Safe Extubation Protocols

Extubation strategy should consider patient comorbidities and procedure length:

• For healthy patients undergoing short procedures, deep extubation in the prone position is acceptable following suctioning and application of a face mask for oxygen delivery.
• For patients with obesity or sleep apnea, reposition to supine for an awake extubation with airway support.
• In cases involving facial or neck surgery, always extubate in the supine position to ensure dressing integrity and airway patency.

Always confirm the presence of a cuff leak prior to deep extubation and retain the bite block until the return of airway reflexes.

Key Performance Indicators to Monitor

Monitoring the following outcome metrics can guide quality improvement:

• Peak airway pressure trends, with a target below 30 cm H₂O.
• Incidence of oxygen saturation below 94 percent in the PACU.
• Cases of corneal abrasion and postoperative vision changes, both of which should be zero.
• Postoperative nausea and vomiting rates greater than grade 2 within 24 hours.

Monthly review of these indicators supports iterative refinement of protocols and training.

Conclusion

Effective ventilation management in prone cosmetic surgery involves careful coordination of airway pressures, positioning techniques, and hemodynamic support. Utilizing structured checklists, appropriate ventilator settings, and continuous monitoring can help maintain patient safety and enhance recovery outcomes. Practices that incorporate CRNAs trained in prone ventilation, hemodynamic optimization, and advanced positioning techniques can elevate both safety and efficiency in the cosmetic operating room.