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Fires and Burns During Plastic Surgery

Lowry, Robert K. PA-C*; Noone, R. Barrett MD*

Special Article

Many plastic surgery procedures are performed under local anethesia. When the procedure involves the head and neck, oxygen is perilously close to the surgical field. A thorough understanding of the fire triangle will allow the plastic surgeon to develop a routine that will avoid any risk of fire. The fire triangle consists of a heat source, a fuel, and an oxidizer. By removing one component of the fire triangle, the risk of fire is averted. An in-depth look at each component is needed because fire hazards involve some surprising sources.

*Lankenau Hospital, Wynnewood, PA; and Bryn Mawr Hospital, Bryn Mawr, PA.

Received May 16, 2000, and

in revised form Aug 19, 2000.

Accepted for publication Aug 19, 2000.

Address correspondence to Mr Lowry, 1 Licia Drive, Broomall, PA 19008.

Fire has always been a threat in the operating room (OR). Less combustible anesthetic agents have greatly reduced both the number and severity of fires. 1 As more plastic surgery operations, especially head and neck procedures, are performed with the patient under local anesthesia with oxygen supplementation, OR fires and patient burns loom as a potential danger. Although OR fires are rare, they are potentially catastrophic. Facial surgery is the second most common site of fire, after tonsillectomy. Fires during facial, neck, and tonsil surgery account for approximately 78% of all surgical fires (Valley Labs Fire Safety in-service). Every surgical suite should develop a comprehensive policy on fire prevention. We explain common fire hazards in the OR, and ways to reduce the risk of fires and patient burns during plastic surgery.

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The Fire Triangle

There are three basic components required for ignition of fire: heat, fuel, and an oxidizer. These three components makeup the fire triangle (Fig). 2 A fuel must be ignited by a heat source in the presence of an oxidizer to ignite a fire. In this article, we assume that oxygen is the oxidizer unless stated otherwise, but be aware that nitrous oxide mixed with oxygen is also a potent oxidizer. 3,4 Control or avoidance of any one of these three components of the fire triangle will eliminate the fire hazard.



The heat or ignition source comes from a variety of origins 2,4:

  • Electrosurgical unit (ESU)
  • Laparoscopic ESU
  • Fiberoptic light source
  • Laser
  • Burrs and drills
  • Defibrillator
  • Spark from faulty equipment

The ever-present ESU, which is used in approximately 85% of surgeries (Valley Labs Fire Safety in-service), is the most common ignition source. Lasers are rapidly becoming a much more common source of fires and direct patient burns during plastic surgery procedures. A fiberoptic light source can generate enough heat to cause a fire or burn. And sparks from burrs and drills, defibrillators, and faulty electrical equipment can ignite a fire.

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Fire Hazards in the OR

There are an abundance of fuels likely to burn in the OR 2–5:

  • I. Ointments and solutions
    • A. Prep solutions
      1. Alcohol (also in a catgut suture packet)
      2. Chlorhexidine digluconate (Hibitane)
      3. Iodophor (Duraprep)
    • B. Tinctures
      1. Benzoin
      2. Mastisol
      3. Collodion (ether, alcohol, and pyroxylin)
      4. Merthiolate (Thimerosal)
    • C. Petrolatum or petrolatum-based ointment (use K-Y jelly)
    • D. Solvents/degreasers
      1. Acetone
      2. Ether
    • E. Aerosols
    • F. Paraffin and wax
  • II. Drapes and dressings
    • A. Cloth or paper drapes/towels
    • B. Cloth or paper gowns
    • C. Sponges, laps, ray-techs
    • D. Throat/nose packing
  • III. Patient
    • A. Hair
    • B. Clothing/gown
    • C. Gastrointestinal gasses (methane)
  • IV. Equipment in field
    • A. Plastic
      1. Steri-drape
      2. Tegaderm
      3. Nasogastric tubes
      4. Endotracheal tube
      5. Oxygen line
      6. Sterile cable cover
      7. Splint
    • B. Latex/rubber
      1. Gloves
      2. Rubber shods
      3. Gaskets
    • C. Suture
    • D. Mesh

Alcohol is a very potent fuel. When using alcohol as a solvent (e.g., to remove a skin marker or adhesive) the OR team must not use the ESU until the vapors dissipate and the alcohol is rinsed away with water or saline. Alcohol should not be used as a prep solution. Preps, such as iodophor (Duraprep) and chlorhexidine digluconate (Hibitane), contain alcohol but in aqueous solution that is less flammable. Excess prep solution must be wiped away before draping to prevent flammable vapors from collecting under drapes. Water-based preps such as Betadine, Soloprep, and Pharmaseal contain no alcohol and are considered nonflammable.

Any solution labeled tincture, by definition is suspended in alcohol and is therefore extremely combustible. Benzoin, Mastisol, collodion, and merthiolate (Thimerosal) all contain alcohol. These dangerously flammable solutions should be used with the utmost caution in the OR. Surgeons should be aware that catgut suture is stored in a 10% alcohol solution in the pack. 6

Petroleum jelly (Vaseline) and petroleum-based ointments can ignite in the presence of oxygen. 7 A water-soluble lubricant (K-Y jelly) should be used instead of petrolatum on the field because it is not flammable. Caution is advised when using other materials that are flammable such as degreasers (acetone and ether), aerosols, paraffin, and wax.

Any cloth or paper drapes, towels, and gowns; or sponges, laps, packs, or ray-techs will ignite if sufficient oxygen is present. It is very important to remember that the patient’s hair, gown, or clothing will also ignite. When surgery is performed on a hair-bearing area (such as the face) under local anesthesia with oxygen supplementation, measures to prevent combustion must be instituted (see the next section).

When the ESU contacts plastic or latex supplies in the oxygen-saturated surgical field, ignition may result. The technique of using the ESU to incise the trachea for tracheotomy can cause a catastrophic fire if the ESU contacts the endotracheal tube or its balloon. 2 When a laser is used during general anesthesia, a special laser-safe endotracheal tube (that will not ignite if the laser should accidentally contact it) must be used.

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Fire Prevention Measures

Because heat, fuel, and oxygen are needed for a fire to start, prevention is aimed at making certain that at least one of these three elements is removed from the equation.

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Oxygen supplementation during head and neck surgery under local anesthesia, with or without sedation, carries the risk of fire. When a surgeon must use the ESU during a procedure and oxygen is flowing nearby, the oxygen must be curtailed or closely controlled, and fuels in the field must be minimized. The use of 100% oxygen will cause an oxygen-enriched atmosphere (OEA). An OEA is defined simply as an oxygen concentration greater than the normal atmospheric concentration of 21%. 4,5

Supplemental oxygen should be delivered via nasal prongs. There are many tricks used to minimize the oxygen concentration in the field. Many surgeons cut off the prongs and insert one or both ends of the tubing deeper into the nose or mouth. It is generally safe to place the prongs in the patient’s mouth when operating on the upper face. The tubing should be taped to direct it from harm’s way. The surgical team must exercise extreme vigilance to be sure the prongs and tubing stay in place. The tubing must never be rigged so that it blows oxygen openly over the field or you risk igniting a fire on the patient’s face.

When using oxygen prongs during facial surgery under local anesthesia, the surgeon should instruct the anesthetist to turn off the oxygen, then wait at least 60 seconds for the oxygen to dissipate before using the ESU. Although seemingly tedious, delays in surgery can be minimized if the surgeon and physician assistant anticipate the need for cautery. With experience, a smooth routine develops, leading to greater safety. At the point when the ESU is no longer needed, the oxygen can be resumed.

Regulating the oxygen at the lowest setting that keeps the patient’s oxygen saturation at a safe level is recommended. In most cases approximately 2 to 3 liters per minute is all that is needed. 8 Some institutions now use oxygen “for rescue only,” and do not routinely give oxygen supplementation. Of course, this level depends on the patient’s ASA status and the level of sedation required for the procedure. Delivering compressed air instead of 100% oxygen will also maintain a normal oxygen concentration in the operative area. 9

Drapes or towels must not be tented over the oxygen to block it from the field. Pockets of concentrated oxygen may vent into the field unpredictably and may cause an unexpected risk of fire. Because oxygen is heavier than room air it will settle in such low-lying areas as beneath drapes or in cavities. Oxygen and flammable vapors may also pool under the drapes, causing the fire to spread over a wider area. Drape fabric will also absorb oxygen, thus greatly enhancing its potential to ignite and enhancing its heat intensity after ignition. 2,4,5

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As mentioned earlier, the primary sources of heat are the ESU, laser, and fiberoptic light source. When not in use, the fiberoptic light source should be turned off. The light, if left on dry drapes over time, can cause ignition, especially near areas of high oxygen concentration.

When using the ESU, one must make sure that one of the other two components of the fire triangle is not present. Because oxygen supplementation will create an OEA during facial plastic surgery with patients under local anesthesia, one should eliminate or at least minimize the danger of any fuels in the field. All fuels listed previously must be kept away from the ESU tip and other heat sources.

When using the ESU, commonsense precautions must be taken to prevent fires or burns. 4,10 When not using the ESU, place it in the provided holster to prevent inadvertent activation of the button and firing of the ESU at an inopportune moment. To decrease electrical arcing and heat buildup, which can hasten combustion, the ESU should be set to the lowest power setting that still allows it to function efficiently. An alternative is to use bipolar cautery. A clean ESU tip must be maintained to avoid carbon accumulation, which will also tend to cause heat buildup.

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In certain situations, one must use the ESU in the presence of a fuel that cannot be completely eliminated. In these cases, oxygen—the last component of the fire triangle—must be removed. Also, precautions should be taken to limit the amount and combustibility of the fuels in the field.

For facial operations, facial hair should be coated with K-Y jelly, not petrolatum. Sponges, laps, ray-techs, and nasal/throat packs must be moistened thoroughly with water or saline to inhibit combustion, especially when oxygen supplementation is used. 2–5,9

When preps, alcohol, tinctures (which are alcohol based), and degreasers are used, steps to prevent fire should be instituted. The surgeon should wait as long as 10 minutes for the vapors to dissipate from these extremely combustible solutions. The ESU should be turned off as a reminder and to prevent accidental activation of the machine during this period. These solutions, vapors, and aerosols must not be allowed to accumulate on or under nearby drapes, gauze, or on the patient. Excess solution should be wiped away with water or saline before using the ESU.

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Long-Term Fire Prevention

A long-term fire prevention plan should be developed for the OR in addition to taking precautions during surgery. Such a program can be divided into two segments. The first is to educate personnel regarding policies and safe practices of ESU safety. The second is to develop and update safety program standards:

  • I. Education
    • A. Policy manual
    • B. Orientation program
    • C. Annual in-service with test
    • D. Principles of ESU
    • E. Fire safety certification
  • II. Safety program standards
    • A. Preventative maintenance schedule (temperature, humidity, machines, cords, plugs, outlets)
    • B. Calibration of equipment
    • C. Review and update of safety legislation
    • D. Reporting system for actual or potential electrical mishaps

Fire safety awareness is promoted by the creation of a structured orientation program plus an annual in-service update. The educational program should include a test for all personnel, including surgeons. A comprehensive policy manual on fire safety must be readily available in the OR, and should be reviewed at set intervals. The staff should be indoctrinated to the fire triangle, heat sources, and flammable materials. New legislation or policies should be emphasized during the in-service update. JCAHO standards regarding fire rescue should be reviewed. Staff members should be encouraged to report incidents involving fire or electrical mishaps and carelessness. Hospitals should consider issuing a fire safety certificate much like a cardiopulmonary resuscitation certificate.

Fire safety program standards should be developed in cooperation with the biomedical department. These standards will dictate a preventative maintenance schedule for the ESU and other electronic equipment. Equipment calibration schedules must be followed to ensure that they meet the parameters established by the manufacturer. 11 A system to report faulty electrical equipment, cords, and outlets officially must be in place. A file of these reports along with documentation of how the problem was corrected should be maintained. The staff is encouraged to identify and report potential electrical problems like worn or cracked cords.

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A fire safety education program, reporting system, and maintenance schedule will heighten the OR staff’s awareness of fire safety issues, leading to a decrease in the incidence and severity of fires in the OR. Such a program would also decrease an institution’s liability both by preventing and by documenting careful maintenance and repair of electrical equipment. The end result is a safer environment for patients and staff in the OR.

The authors have no conflict of interest with any company or product mentioned in this manuscript.

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© 2001 Lippincott Williams & Wilkins, Inc.