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Zins, James E. M.D.; Meneghetti, S Cristina M.D.; Djohan, Risal M.D.; Morgan, Mark M. M.D.; Fritz, Janet C.R.N.A.; Borkowski, Raymond G. M.D.

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Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 431-432
doi: 10.1097/PRS.0b013e31817c6ba2
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We agree that the best way to avoid operating room fires related to supplemental oxygen is to avoid the use of oxygen entirely. Dr. Pollock apparently has been able to provide conscious sedation without supplemental oxygen whatsoever. We dare say, however, that his technique is the exception rather than the rule at our institution, in our region, and, we suspect, nationally. Let us put this into perspective.

We initially became interested in this project because it was clear to us that many anesthesiologists and nurse anesthetists with whom we worked were not aware of the dangers of fire with the use of supplemental oxygen during facial surgery. This was further evidenced by two serious operating room fires, one at our institution and a second at a nearby university hospital. A third fire occurred in our locale after acceptance of our article but before publication. Further, in our review of the plastic surgery literature, guidelines for minimizing the risk of fires during facial surgery are sometimes contradictory or ill advised.1,2 For example, one author suggested the use of oxygen delivered by nasal cannuli with no mention at all regarding oxygen flow while the electrocautery is used. A second author suggested that oxygen be turned off for 1 minute before the use of the bovie. In the first case, this was the scenario that resulted in the two fires noted above. The second case is fraught with risk should the surgeon fail just once to notify the anesthesiologist to discontinue the oxygen before bovie use. These real-life events were the stimulus to the development of our technique. This and a second study we performed but have not yet published document to our satisfaction that with appropriate flows, our red-rubber nasopharyngeal tube technique will result in oxygen concentrations only minimally higher than those in room air. This is quite different from the high oxygen levels that we found around the face when a nasal cannula was used with similar oxygen flows.

In deference to Dr. Pollock's statement, we should perhaps amend the conclusions in our article. Indeed he is correct that the surest way to prevent oxygen-related fires during facial surgical procedures under conscious sedation is to avoid oxygen in its entirety. However, for those of who do use supplemental oxygen, if the nasal cannula technique is replaced with our red-rubber pharyngeal tube technique, operating room–related fires will be minimized.

Finally, should a surgeon use our technique, he or she will need to keep the patients deep. Otherwise, patients will be annoyed by the tube in their nose and the surgeon will be annoyed with us.

James E. Zins, M.D.

S. Cristina Meneghetti, M.D.

Risal Djohan, M.D.

Mark M. Morgan, M.D.

Janet Fritz, C.R.N.A.

Raymond G. Borkowski, M.D.

Department of Plastic Surgery

The Cleveland Clinic Foundation

Cleveland, Ohio


1. Greco RJ, Gonzalez R, Johnson P, et al. Potential dangers of oxygen supplementation during facial surgery. Plast Reconstr Surg. 1995;95:978–984.
2. Reyes RJ, Smith AA, Mascaro JR, et al. Supplemental oxygen: Ensuring its safe delivery during facial surgery. Plast Reconstr Surg. 1995;95:924–928.

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