The same compulsive medical history that is indicated before any surgical procedure is obtained when evaluating a patient for aesthetic surgery of the face. Specific inquiry is made regarding medications, allergies, medical problems, previous surgery, and smoking and drinking habits. The most common complication of facelifting is a hematoma and therefore the history focuses on factors that predispose to postoperative bleeding, specifically hypertension and medications that affect clotting. Surgery is not performed until the patient has been off of aspirin for 2 weeks. Facelifting is probably contraindicated in patients on warfarin (Coumadin) or clopidogrel (Plavix), even if they are allowed by their physicians to stop these medications. At the very least, facelifting on such patients is performed with extreme conservatism and only after every possible means of eliminating the effects of these medications has been pursued. Hypertension is probably the single factor that most closely correlates with postoperative hematomas, thus blood pressure must be under strict control.
FIGURE 49.1. Aging changes in the face. 1. Forehead and glabella creases. 2. Ptosis of the lateral brow. 3. Redundant upper eyelid skin. 4. Hollowing of the upper orbit. 5. Lower eyelid laxity and wrinkles. 6. Lower eyelid bags. 7. Deepening of the nasojugal groove. 8. Ptosis of the malar tissues. 9. Generalized skin laxity. 10. Deepening of nasolabial folds. 11. Perioral wrinkles. 12. Downturn of oral commissures. 13. Deepening of labiomental crease 14. Jowls. 15. Loss of neck definition and excess fat in neck. 16. Platysmal bands.
Smoking increases the risk of skin slough, the second most common complication after facelifting (1). Patients are encouraged to quit smoking permanently. Cigarette smoking, with all its deleterious effects on health, and having a facelift to feel better about oneself, are fundamentally contradictory. At the very least, patients should cease smoking 2 weeks prior to surgery. It is important that smokers know that they will never become “nonsmokers;” that is, the effects of smoking never totally disappear, and are certainly not gone in 2 weeks.
Because aesthetic surgery is elective, whenever there is a question about a preoperative medical condition, the procedure is postponed until appropriate consultations are obtained and all issues settled.
Photographs are essential for at least four reasons: (a) assistance in preoperative planning; (b) communication with patients preoperatively and postoperatively; (c) intraoperative decision making; and (d) medicolegal documentation.
One of the most difficult challenges for the plastic surgeon is deciding which patients are not candidates, on an emotional or psychological basis, for elective aesthetic surgery. Studies suggest that patients frequently harbor secret or unconscious motivations for undergoing the procedure. A patient may state that he/she wants to feel better about him- or herself when the real motivation is to recapture a straying mate (unlikely to succeed).
Patients who have difficulty delineating the anatomic alterations desired or in whom the degree of the deformity does not correlate with the degree of personal misfortune ascribed to that deformity, are not candidates for aesthetic surgery. The tough, 50-year-old lawyer who states that she does not like her jowls is a far better candidate than the seemingly docile patient who cannot articulate what bothers her and defers to “whatever you think doctor.” The surgeon will regret proceeding with an operation when his or her instincts indicate that the patient is an inappropriate candidate.
At the time of the preoperative consultation the patient is given written information concerning the planned procedure that reinforces the verbal information provided.
In addition to describing to the patient the anticipated results of the procedure, it is necessary to point out the areas where little or no benefit is expected. As described above, the nasolabial folds that may be softened slightly by a facelift but will reappear when the swelling disappears. Ptotic submandibular glands preclude a totally clean appearance to the neck. Fine wrinkles around the mouth will require a resurfacing procedure.
Patients are instructed to shower and wash their hair on the night before surgery. On the morning of surgery another shower and shampoo are desirable. At a minimum the face is thoroughly washed. Although patients are not allowed to eat anything after midnight, they are instructed to brush their teeth and rinse their mouths with mouthwash.
Given that the single most important step in avoiding a hematoma is control of the blood pressure, patients with any tendency to high blood pressure are given clonidine 0.1 mg by mouth preoperatively. Some surgeons administer the drug routinely to all patients. Clonidine is long-acting, however, and may lead to hypotension in healthy patients. Consequently, I prefer to use it selectively.
The subjects of anesthesia and which technique is the safest are poorly understood by patients. A facelift can be safely performed under local anesthesia with sedation provided by the surgeon, or by intravenous sedation or general anesthesia provided by an anesthesiologist. If the surgeon is to perform the procedure without an anesthesiologist, the patient must be completely healthy. The patient is given diazepam (Valium) 10 mg by mouth 2 hours preoperatively and brought to the facility by an escort. Meperidine (Demerol) 75 mg and hydroxyzine pamoate (Vistaril) 75 mg are administered intramuscularly. Once the effect is demonstrable, the patient is moved to the operating room to initiate the procedure. Midazolam (Versed) is given intravenously in 1-mg increments until the patient is sufficiently sedated to tolerate the injections of local anesthetic solution. Additional midazolam (Versed) is given as needed throughout the procedure, also in 1-mg doses.
In most cases, however, facelifts are performed with the help of an anesthesiologist. If the procedure is to be longer than 3 hours because of ancillary procedures, or if the patient has medical problems, then an anesthesiologist is always present.
The anesthesiologist decides where on the spectrum from conscious sedation to general anesthesia the patient is best kept, and it may vary during a procedure. The patient may be under general anesthesia, by any definition, during the injection of the local anesthetic solution, and conscious during other phases of the procedure. In other patients, despite the efforts of the anesthesiologist to provide conscious sedation, the medication will result in loss of the airway, requiring that the anesthesiologist convert the procedure to general anesthesia.
Patients and some other physicians incorrectly believe that patients are safer with “twilight” anesthesia, whatever that is. Local anesthesia is safe and general anesthesia is usually safe, but the least safe anesthetic and the one requiring the most skill to administer is the “in between” anesthetic that patients call “twilight.” Patients who are sedated but who do not have an endotracheal tube in place to control the airway are more likely to have airway problems than a patient who is completely asleep with the ventilation controlled by the anesthesiologist. Many patients who undergo facelift procedures believe they are receiving “sedation,” but they are really receiving intravenous, general anesthesia without an endotracheal tube. There is nothing wrong with the technique in the hands of an expert, but patients should be disabused of the notion that it is safer than general anesthesia.
An ideal anesthetic for facelifting would be associated with a constant blood pressure and no need for vasoactive medications to either raise or lower it. Dips in blood pressure treated with vasoconstrictors, or spikes in blood pressure treated with vasodilators, are to be avoided if at all possible. Blood pressure is ideally kept at approximately 100 mm Hg systolic, depending on the patient’s preoperative blood pressure. Excessive hypotension may obscure bleeding vessels that are best coagulated. Hypertension may be associated with excessive bleeding. The anesthesiologist should inform the surgeon of every medication administered, and the surgeon should inform the anesthesiologist of any increased tendency for bleeding. There are no secrets in the operating room.
Regardless of the type of sedation/anesthesia chosen, the face is injected with local anesthetic solution prior to the dissection. There is some controversy and little definitive data regarding the maximal amount of local anesthetic that can be used. The package insert in the lidocaine bottle states that no more than 7.5 mg/kg of lidocaine should be administered when given in combination with epinephrine. We know, however, that when dilute solutions are used in liposuction of the body, that more than 30 mg/kg of lidocaine is safe. There is evidence that the face differs from the body and that the high lidocaine doses used in the body are not safe in the face. It is reasonable to conclude that doses higher than the 7.5 mg/kg recommended by the manufacturer are probably safe in the face, but this is unproven. Until such proof exists, plastic surgeons should limit the total dose to approximately 7.5 mg/kg. In the my practice, I dilute 500 mg lidocaine (one 50 mL vial of 1% lidocaine, which is the approximate maximum dose for a 70-kg patient) to whatever volume is necessary to perform the entire procedure, no matter how dilute that solution is.
The most common solution I use is 50 mL 1% lidocaine plus 1 mL epinephrine 1:1000 plus 250 mL normal saline for a final volume of 301 mL and a final solution concentration of 0.17% lidocaine with epinephrine 1:300,000.
Because of the dilute nature of the solution used and the fact that the total dose of lidocaine does not exceed the manufacturer’s recommendation, I inject both sides of the face at the beginning of the procedure, despite recommendations by some that only one side should be injected at a time.
If the patient is adequately anesthetized, the injection of the anesthetic solution is rarely accompanied by any change in heart rate or blood pressure. The surgeon must constantly keep the injecting needle moving, however, to avoid a large intravascular injection of the epinephrine-containing solution. If a major change in blood pressure occurs, the surgeon and anesthesiologist must assume that an intravascular injection has occurred and act quickly to limit the extent of hypertension.