There are three ways to perform spinal anaesthesia; single injection, combined spinal-epidural, and continuous subarachnoid anaesthesia with small gauge spinal catheters. Single injection. Is the most widely used since it is easy to perform, safe, predictable, has low incidence of side effects, and low cost. The addition of adjuvants drugs to LAs provides sufficient time for more prolonged plastic surgical procedures, and therefore is the ideal technique in these patients.[3] Combined spinal/epidural. Combines the benefits of epidural and subarachnoid anaesthesia, lessening some of the disadvantages of both procedures. This technique allow us to titrate the upper sensory level, to reduce total dose of epidural LAs, and to continue anaesthesia as long as needed.[8,9] It is recommend for long plastic surgeries involving chest, abdomen and extremities in the same patient. Sometimes it is difficult to keep the epidural catheter in place, and it can also migrate outside the epidural space.[10,11] Continuous spinal anaesthesia. Described by Dean in 1907 [12] was reintroduced by Lemmon in 1940 [13]. The technique had several modifications until Hurley and Lambert [14] introduced the use of thin spinal microcatheters 32-gauge. Nowadays this procedure is underutilized due to several cases of cauda equina syndrome and the FDA recommendation to withdraw the technique. The main advantages of continuous spinal anaesthesia is to allow redosing of small amount of LA to prolong duration of anaesthesia/analgesia and provide better hemodynamic stability.[15] In the field of plastic surgery outpatient and short-stay cases it may be limited for older patients with prolonged procedures below Th8 dermatomes. Spinal anesthesia is done following anatomical landmarks. The introduction of ultrasound in regional anesthesia is an advanced technique that is now used in difficult cases where anatomy Spinal Epidural Spinal-epidural Anaesthetic Adjuvant Anaesthetic Adjuvant Anaesthetic

Anesthetic complications in the perioperative period in plastic surgery are extremely rare, although they can be catastrophic and sometimes fatal. The proper selection and correct preoperative assessment of patients are the key to stay away from unwanted events. Preanesthesia evaluation is mandatory in each patient and must include clinical history, complete physical examination, and routine and special laboratory tests in patients with associated pathologies. Anesthetic management is based on these results, type of surgery, experience of the anesthesiologist, and the operating environment. The anesthetic technique can be local, regional, or general with standard noninvasive monitoring. It is recommended that an anesthesiologist be present in all plastic surgery procedures. Complications are usually the result of moving away from the guidelines already established for an excellent practice or the result of sentinel events rather than human errors. Pulmonary embolism is probably the most feared complication, with soft tissue infections being the most frequent complication in plastic surgery. Less common complications include arrhythmias, overhydration, allergies, bleeding, skin necrosis, dehiscence of wounds, brain damage, and dead. Anesthesiologists, surgeons, nurses, and all personnel involved in the care of these patients must work as a team of highly qualified and updated professionals.