Perioperative Care
FACIAL PLASTIC SURGERY
Facial plastic surgery is conceptually divided into aesthetic and reconstructive disciplines. Indications for aesthetic plastic surgery include the sequelae of facial aging; rhytidosis, facial and cervical skin laxity and redundancy, brow ptosis, dermatochalasis and generalized periorbital aging, soft tissue atrophy and cervical fat excess. Additional indications include the desire for nasal refinement and correction of malformed ears, a weak or prominent chin and cheekbone or lip enhancement.
Reconstructive procedures are indicated for correction of nasal airway obstruction, and reconstruction following facial trauma, cancer therapy and birth defects. The operations vary in complexity and duration based on the indications and goals of the surgical procedure. Regardless of the indication, facial plastic surgery is most often an elective procedure done to improve the patient's quality of life. Blood loss from facial plastic and reconstructive procedures is usually minimal and cases requiring transfusions are the rare exception. Medications with anti-platelet activity such as salicylates and non-steroidal anti-inflammatory agents, vitamin E and herbal products known to increase bleeding such as ginkgo, ginseng, and supplements of ginger and garlic, must be avoided in the peri-operative setting. Long-term, facial surgery should punctuate the need to make sun protection a life-long habit.
The choice of anesthetic techniques for these procedures is evenly divided between general anesthesia and a combination of local anesthesia with intravenous sedation. Patient's preference, surgical expertise and expected duration of the procedure are all considerations in anesthetic decisions.
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USUAL POST-OPERATIVE COURSE
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Expected postoperative hospital stay: Most patients undergo operations on an outpatient basis. The remainder of patients can usually be discharged from the hospital after an overnight admission.
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Operative mortality: The operative mortality rate is under 1 percent. Most of these procedures are performed in an elective setting on patients with few coexisting medical conditions. In cases of complex reconstructive procedures on patients with multiple medical problems, the mortality rates rise proportionally.
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Special monitoring required: No special monitoring is necessary.
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Patient activity and positioning: Patients are permitted to ambulate on the evening of their procedure. They are advised to avoid straining, bending over, heavy lifting or vigorous nose blowing when nasal procedures are performed. When in bed, patients are recommended to have their head elevated 30? and ice placed on the affected areas. Ice should be maintained for 48 hours intermittently while awake to reduce post-operative ecchymosis and edema.
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Alimentation: A regular diet is permitted as tolerated.
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Antibiotic coverage: Perioperative prophylactic antibiotics are routinely used. The antibiotics selected should have good gram positive coverage for most routine facial plastic surgery procedures as well as anaerobic coverage when operating inside the mouth. Selection is further determined by the patient's allergy profile.
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POST-OPERATIVE COMPLICATIONS
Nasal Surgery:
Following nasal surgery, nasal discharge and bleeding may persist for several days. Most bleeding is mucosal in origin and is self-limited. Profuse arterial bleeding can arise from the anterior or posterior ethmoid or sphenopalatine arteries. Significant bleeding usually responds to nasal packing with expandable Merocel sponges or topical hemostatic agents. Occasionally, surgical intervention is indicated. Infection is a rare occurrence with a reported incidence of 0.8 to 1.6 percent. Following osteotomies, some facial and periorbital ecchymosis is expected. Periostitis with its associated tenderness can persist along the bone incision sites, however, this problem will resolve without therapy. Injury to the lacrimal duct can also occur but is rare. Excessive scar tissue resulting in contour deformities can often be addressed with the judicious use of subcutaneous steroid injections. Undesirable cosmetic results requiring surgical correction occur with an incidence of 5-10 percent depending on whether the nasal surgery is a primary or secondary procedure. If concomitant septoplasty is performed, septal hematoma and perforation are complications that must be identified and addressed.
Finally, nasal airway obstruction and an altered sense of smell is an expected short-term consequence of any nasal procedure; however, long-term problems may persist. Permanent changes in airflow, particularly following significant dorsal hump reduction, must be corrected surgically.
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Eyelid surgery:
Of particular importance is the risk of bleeding following periorbital fat removal. If the patient complains of deep eye pain, visual changes or observes acute swelling and bruising of one eye relative to the other, this should be taken extremely seriously and acted upon expeditiously. Should bleeding occur in the soft tissues surrounding the globe, and a hematoma develop, its extent and time of presentation will guide management. Hematomas that are large, present early and are expanding with evidence of symptomatic retrobulbar extension (decrease in visual acuity, proptosis, ocular pain, ophthalmoplegia, progressive chemosis) demand immediate exploration and hemostatic control. Urgent ophthalmologic consultation and orbital decompression are the mainstays of treatment. Untreated, retrobulbar hemorrhage can lead to the most feared potential complication of blepharoplasty, blindness. This occurs with an incidence of approximately 0.04 percent typically presenting itself within the first 24 hours after surgery and is often associated with orbital fat removal.
Infection can occur but is rare. Lid malposition, asymmetries and contour irregularities may occur and can be treated by a secondary procedure. Lagophthalmos, or difficulty fully closing the upper lid, is often transitory and responds to massage. Temporary treatment with artificial tears and lacrilube often suffices. Long-term difficulty due to overzealous upper lid skin excision can lead to persistent dry eye problems including epiphora and requires correction. Apparent ptosis is often due to upper lid edema, which is self-limiting. True ptosis, from injury to the levator apparatus, can occur and requires surgical correction. Ocular injury, including corneal abrasion, globe puncture and extraocular muscle imbalance can occur and should be evaluated by an ophthalmologist. Wound dehiscence, suture line milia and hypertrophic scarring can complicate normal wound healing. Vertical contracture forces of the lateral lid can lead to scleral show and ectropian of the lower lid and lateral hooding of the upper lid. Proper treatment should be aimed at reorienting the contracting vectors.
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Facial Flap Surgery:
Bleeding is a potential complication after any surgical procedure in the face, given the robust blood supply to this area. In the male face, the rich vascular supply associated with facial hair growth makes hematoma formation more common, with a reported incidence of 7 percent versus 0.7 percent in women following rhytidectomy. Monitoring for hematoma formation should be routine following surgery that involves flap elevation. Increasing unilateral facial pain following bilateral procedures or increasing pain of any unilateral flap associated with increasing swelling, ecchymosis, drainage and a feeling of pressure should be evaluated. If a dressing is in place, it should be removed and facial proportions and the incision site evaluated.
Depending on severity, the hematoma may be treated with local drainage or may require a return to the operating room. Untreated, hematomas can lead to devitalization of skin and cartilage. Skin necrosis and sloughing can also occur secondary to excess tension at the closure site and a compromised flap vascular supply. Infection is uncommon but can manifest on the third or fourth post-operative day and is identified as a dissecting, often fluctuant pocket with overlyng skin erythema and tenderness. Treatment should include opening the flap, draining and culturing the wound and treating with the appropriate antibiotics. Injury to either motor or sensory nerves can occur and may improve with time. Surgical correction, if required, is often less than satisfactory in reconstituting the pre-injury state. Following any flap procedure, facial asymmetries and contour irregularities may occur but can often be corrected with additional surgery. When implants are used, malpostion, asymmetry and either under or over correction are possible and may necessitate a corrective procedure. Flaps that involve hair-bearing tissues can result in transient alopecia. Finally, hypertrophic or keloid scarring can occur. Treatment includes serial steroid injection and scar revision.
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Skin Resurfacing:
Regardless of the technique used, laser, dermabrasion and chemical peeling can all result in similar complications following facial skin resurfacing. Expected sequelae are skin erythema and sun sensitivity often lasting several months following the procedure. Bacterial infection and herpes simplex outbreaks can occur within several days following resurfacing and should be aggressively treated with standard antiobiotics and antiviral medications. Undesirable hyperpigmentation can be reduced with skin lighteners, steroid creams and sun avoidance. Permanent hypopigmentaion may require micro-pigmentation for correction.
Hypertrophic scarring is a disastrous complication, but should not occur with properly performed resurfacing. Its occurrence indicates too great a depth of injury. Telangectasias may persist and can be treated with a variety of techniques. Of particular note are the cardiotoxic complications of phenol chemical peeling, which are further exacerbated by liver or kidney dysfunction. Skin resurfacing should not routinely be performed on darker skinned individuals. The significantly higher incidence of dyschromia precludes predictable recovery.
Seth A. Yellin, M.D.
Chief, Facial Plastic Surgery,
Emory Healthcare
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