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.