Pearls in Facelif tManagement

Marc S. Zimbler, MDa,*, Grigoriy Mashkevich, MDb

KEYWORDS� Facelift � Facelift pearls � Rapid recovery facelift� Preoperative � Management

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PREOPERATIVE PEARLS

The preoperative management of a facelift patientsets the stage for a streamlined surgery coupledwith a speedy postoperative recovery. Variousrecommendations are started well before thesurgical procedure begins to ensure the bestpossible results and experience for the patient.Althoughthesurgical result isclearly themost impor-tant gauge by which rhytidectomy surgery ismeasured, one must not underestimate the patient’sperspective regarding the surgical experience. Thisperspective includes anxiety about surgery, postop-erative discomfort, and ease of recovery with returnto normal daily activities. In many cases, theseconcerns are some of the most important consider-ations that prevent patients from undergoingcosmetic surgery. If a patient recovers quickly withminimal bruising, this experience will lead to a highlevel of satisfaction and in many cases can evolveinto the best marketing technique for a surgeon’spractice. A surgeon’s patients form the strongestpractice-building tools, and quick and uneventfulrecovery from surgery will undoubtedly facilitatepatients in encouraging others to come undera particular surgeon’s care.

Theauthors takeseveralstepstoensureasmoothrecovery period with outstanding results. Suchsteps are important in the wound-healing processand also are critical in enabling patients to feel thatthey are contributing to their own recovery.

The Facelift Consultation

The initial cosmeticconsultation with the patient setsthe stage for everything that comes thereafter.

a Facial Plastic & Reconstructive Surgery, Department oMedical Center, 10 Union Square East, Suite 4J, New Yorb Facial Plastic & Reconstructive Surgery, Department ofEye & Ear Infirmary, 310 East 14 Street, 6th floor, New Y* Corresponding author.E-mail address: mzimbler@chpnet.org (M.S. Zimbler).

Facial Plast Surg Clin N Am 17 (2009) 625–632doi:10.1016/j.fsc.2009.06.0111064-7406/09/$ – see front matter ª 2009 Elsevier Inc. All

Although many physicians believe the consultationbegins when they first walk into the room to examinethe patient, this is hardly the case. The consultationactually begins well before the physician ever seteyes on the patient and includes the physician’sreputation as a surgeon, the physician’s relationshipwith colleagues (other physicians or nurses),bedside manner, Web site, and even the press heor she has received. All these items are measuresby which the physician will be evaluated before thepatient ever sets foot in the office.

The next critical measure before the actualoffice consultation is the patient’s first interactionwith the office, which occurs over the telephone.When the patient calls to schedule, is making theappointment a pleasurable experience? Is it diffi-cult to get through on the phone? Is the patientplaced on hold for an extended period of time? Ifthe patient must leave a message, is the callreturned promptly? Most importantly, is the staffinformative and courteous? Are they able toanswer detailed questions about the practice,the physician’s medical background and boardcertification, frequency of performing surgery,and hospital affiliations? All these points, whichmay seem inconsequential to the average physi-cian, are paramount in the patient’s mind whenchoosing a plastic surgeon.

The next and most critical test is the actual officevisit. Again, it is the staff that makes the firstimpression. When the patient arrives, is the stafffriendly an engaging? Is the office well appointedand tastefully decorated (Fig. 1)? Is the environ-ment warm and receptive to the patient or coldand sterile like a hospital clinic?

f Otolaryngology-Head & Neck Surgery, Beth Israelk, NY 10003, USAOtolaryngology-Head & Neck Surgery, The New Yorkork, NY 10003, USA

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Fig.1. (A) Reception desk and (B) hallway in surgeon’s office.

Fig. 2. Obagi skin care products (Obagi MedicalProducts, Long Beach, California).

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In the authors’ practices, after the consultationis completed and the patient has decided tomove forward with scheduling surgery, thesurgical coordinator takes over. The patient isgiven a medical clearance form to be completedby the primary care physician and detailed preop-erative instructions, which the patient takes hometo review. Finally, a preoperative visit is set up thatoccurs 2 weeks before surgery.

Approximately 6 weeks before surgery, theauthors like to have many patients start a formalskin care routine, which complements any facialskin tightening surgery. The authors prefer theObagi Condition & Enhance system (ObagiMedical Products, Long Beach, California)(Fig. 2) for surgical procedures with a 0.05%tretinoin regimen. This system is convenient forpatients because it is an all-inclusive regimenthat is professionally packaged, has a respectedbrand name, and provides predictable results.The system comes in two forms; the authorsprefer the system designated for surgical proce-dures, which is a milder version of the prior Nu-derm regimen. The authors provide the patient,free of charge, an Obagi travel-pack size. Thiscourtesy helps prepare the skin for surgery andgives patients great results with glowing skin; italso introduces patients to a product that theycan continue to use for years after the procedureis completed. Having this constant return ofpatient flow after surgery will encourage patientsto stay in touch with the office and keep abreast

of all of the latest technological advances andtrends.

Two Weeks Before Surgery

The 2-week window before surgery is a criticalperiod in preparing the patient for a rapid andsmooth surgical recovery. This process beginsduring the ever-important presurgical visit. Duringthis extensive office visit the patient is educatedabout the mechanics of surgery and the recoveryperiod. During this consultation, all remainingpatient questions are answered, and patients areprepared for the upcoming surgical procedure.

Box1Commonly prescribedmedications andhomeopathic remedies known to prolongbleeding time

Patients are asked to stop using thesesubstances 3 weeks before surgery (with appro-priate clearance for prescribed medications).

Blood thinners and anti-inflammatory agents

Coumadin

Plavix

Aspirin

Aspirin-containing products

Salicylates

Nonsteroidal anti-inflammatory drugs (Motrin,Advil, Aleve, Ibuprofen, Celebrex, Vioxx, andothers)

Over-the-counter pain medications (exceptTylenol)

Arthritis medications

Vitamins and dietary supplements

Multivitamins

Vitamin E

Fish oils

Pearls in Facelift Management 627

Discussion about the surgical process andrecovery is a critical step in alleviating much ofpatients’ anxiety. A forthright session serves toset reasonable expectations for patients whileputting their minds at ease. Postoperative compli-cations are discussed at length. The authors find ithelpful to have patients sign a preprinted compli-cation sheet to ensure that no questions are leftunanswered. Many of these preprinted surgery-specific forms can be obtained from colleaguesor purchased from medical societies and thencustomized to one’s own practice.

Next, the authors recommend discontinuing theuse of any products (whether prescription, over-the-counter, or homeopathic) that may interferewith blood clotting (Box 1), as long as their discon-tinuance is approved by the primary physician.Particular attention must be paid to patients whohave chronic conditions such as arthritis, migraineheadaches, and low back pain and those who areon long-term medical regimens. For most patientsthis list includes baby aspirin, various nonsteroidalanti-inflammatory drugs, and/or narcotic combi-nation drugs. Also, many herbal and homeopathicremedies such as green tea or St. John’swort have blood-thinning properties. The use ofvitamin E also is discontinued, along withomega-3 fatty acids and fish oils.

Omega-3 fatty acids

St. John’s wort

Ginkgo biloba

Garlic

Ginger

Papaya

Chamomile

Ginseng

Green tea

Two Days Before Surgery

The authors recommend that patients have all oftheir prescriptions filled at least 2 days beforesurgery to prevent any last-minute rush. Typicalpatient prescriptions include an antibiotic, a pain-killer, and some form of anxiolytic (which doublesas a sleeping aid). Patients are given a prescriptionfor Valium in case they become particularlyanxious the day before surgery. This prescriptionalso can be used during the postoperative periodand in many cases decreases the amount of post-operative narcotic requirements.

All patients are started on a combination ofArnica Montana1 (SINECCH, Alpine Pharm-aceuticals) and bromelain2,3 (500 mg, three timesper day) 2 days before surgery to diminish postop-erative bruising and swelling. Some physicians alsoprescribe vitamin K (mephyton, 5 mg), but theauthors have not found this to be beneficial.

For patients who color their hair, the authorssuggest this be done before surgery becausehair chemicals are not permitted for at least1 month after facelift surgery. It is also recommen-ded that all alcohol use be discontinued at thispoint before surgery.

The Day Before Surgery

Several things happen the day before surgery toalleviate any presurgical jitters the patient mighthave and to instill comfort and confidence in thesurgical team. First, the authors’ staff always callsthe patient to review their preoperative instructionsand answer any last-minute questions. During thisconversation the oral intake status, preoperativemedications, and postoperative private-dutynursing arrangements are reviewed. It is amazinghow many little details are caught during thissimple telephone conversation that potentiallycould cause a delay in surgery. Finally, the authorsalways speak personally with the patient the

Zimbler & Mashkevich628

evening before surgery to let the patient know howenthused they are about the procedure and toreassure them that every precaution will be takento ensure their safety and comfort. These tele-phone calls require minimal effort from the physi-cian and staff; however, they go a long way insolidifying patient confidence and comfort.

INTRAOPERATIVE PEARLSHolding-Area Basics

Theauthorsmakesure theyarrivewell before surgeryto allow adequate time with the patient, nursing, andanesthesia. On the morning of surgery, they alsospend a few solitary moments in a unhurried mannerreviewing the patient’s chart and focusing on themedical history, requested surgical procedure,photographs, and personal preferences. It is veryimportant not to appear rushed, short tempered, ordisorganized before surgery.

The surgeon should personally and legiblycomplete the consent form to avoid any confusionin the operating room. Some physicians prefer touse preprinted consent forms specific for eachsurgical procedure, thereby documenting all perti-nent issues in advance of surgery. Many of theseforms can be quite lengthy and detailed. Theauthors believe it is best to review them in thephysician’s office before surgery, rather than inthe holding area where patients may feel rushedand unable to ask all their questions.

The authors ensure the availability of all suppliesrequired for marking the patient before surgery.These items include the correct marking pen, cali-pers, rulers, hair clips, and other devices. Somesurgical facilities may not have the exact supplies;therefore, inquiring in advance may prevent

Fig. 3. (A and B) Preoperative facial markings with patien

unnecessary aggravation and delays. The authorsprefer to perform partial markings while the patientis sitting upright in the holding area (actual preaur-icular markings are made in the operating room).They find it particularly helpful to mark out severalspecific areas, including the malar high point,jowls, nasolabial folds, cervicomental angle, pla-tysmal bands, mandibular angle, and submentalcrease (Fig. 3). In many instances, when thepatient is supine on the surgical table, these land-marks can become obscured. Some surgeonsalso like to prepare the hair in the holding area,but the authors find this step to be time consumingand uncomfortable for the patient. It is muchsimpler and quicker to prepare the hair after thepatient is sedated on the operating table.

Induction and Patient Positioning

Effective communication with the anesthesiologistbegins with a discussion regarding the level ofanesthesia required for the procedure. The typeand depth of anesthesia depends on numerousfactors, including preferences of the surgeon andanesthesiologist, operative setting, length ofprocedure, and patient’s comfort level. If generalendotracheal anesthesia is selected, the type andplacement of the endotracheal tube should be clar-ified with the anesthesiologist. This communicationcontributes significantly to optimal and safe airwaymanagement for the duration of the procedure. Theauthors prefer an oral RAE endotracheal tube,placed and fixed in the midline to the upper incisorswith surgical sutures. The tube is not taped,because taping would restrict the tube’s mobilityand the surgeon’s access to submental region,particularly during liposuction or if an open

t in upright position.

Pearls in Facelift Management 629

platysmal tightening procedure is planned. A 2-0 silktie is wrapped and tied around each of the twocentral incisors and then around the endotrachealtube. If teeth are missing, a 2-0 silk suture is placedin the gingivo-buccal sulcus through the perios-teum and tied to the endotracheal tube. To preventexcessive pulling on the tube with head turningduring surgery, a rubber ‘‘accordion’’ extension isplaced at the end of the endotracheal tube. Thisextension provides additional slack for the circuitand enables easier and safer head repositioningduring the procedure. When prepping the patientand the endotracheal tube, the authors prefer tokeep the tube exposed throughout the case, sono untoward events occur during changes in headpositioning. This exposure is accomplished byprepping the proximal segment of the tube with Be-tadine and wrapping the distal segment with sterileblue towels. Some surgeons prefer to use clearsticky drapes on the tube, but the authors havefound this method to be complex and unnecessary;in some cases sticky drapes interfere with adjust-ments of the endotracheal tube during the surgery.Next, the patient’s body is pulled up to the top ofthe headrest. Such positioning is essential for es-tablishing easier access to submental structures.All pressure points (elbows, knees, and heels) arereviewed with a circulating nurse and are paddedadequately with egg crate foam (elbows and heels)and pillows (knees).

Instrumentation

Whether operating at a hospital, an outpatientsurgery center, or in one’s private office, it is criticalto select personally the instruments for the rhyti-dectomy tray. The authors have found that surgicalsets from high-volume operating rooms often

Fig. 4. (A) Kaye-Freeman facelift scissor (Accurate ScientificYork). (B) Standard facelift scissors (Accurate Scientific anYork).

contain blunt instruments, making precise and deli-cate surgical maneuvers more difficult than needbe. When operating at a hospital, the authors bringthe critical instruments with them to help preventinterruptions to the flow of surgery.

The authors have found several instruments to beparticularly useful during facelift surgery. Faceliftscissors come in all shapes and sizes, and thesurgeon must be comfortable and familiar with thisinstrument. The authors have found supercut scis-sors manufacturedbyAccurate Surgical & ScientificInstruments (Westbury, New York) to be particularlyhelpful. The supercut blades are extremely sharpand cut skin much like a scalpel. They are availablein a large variety of shapes and sizes, are extremelydurable, are not particularly costly, and have excel-lent customer service support. The particularmodels the authors prefer are the Kaye-Freeman18-cm curved with spread shanks, tapered tips,and serrated blades (Fig. 4A). They are ergonomi-cally designed, extremely sharp, and easy to usein flap undermining and dissection. Other scissormodels from this vendor include the 14-cm curvedJoseph and 17-cm curved Matarasso (Fig. 4B).Instruments useful in flap retraction include the Mill-ard thimble hook, 1-inch-wide double-prong skinhooks, Freeman rake, Anderson bear claw, andthe Converse nasal retractor. For open platysmalprocedures, a fiberoptic lighted submental retractoris particularly helpful and frees the surgeon fromwearing a cumbersome headlight.

Incisions

Before incisions are designed, a proper markingpen is required. Many markers are too thick orcoarse, whereas very fine-tipped pens with deli-cate tips (which are good for eyelid surgery

and Surgical Instruments Corporation, New York, Newd Surgical Instruments Corporation, New York, New

Fig. 6. Facelift incisions. See text for detailed descrip-tion. Curved red line indicates a sideburn incision,used to control the extent of temporal hairlineelevation.

Zimbler & Mashkevich630

markings) are too fine for facial procedures andcan run out of ink too quickly. The authors prefera marking pen manufactured by Aspen Surgical(Caledonia, Michigan) that has the benefits ofboth a fine and a thicker tip (Fig. 5).

A facelift incision is marked around the auricle.Several important concepts guide the placementof the periauricular incision, which forms the initialmeasure for avoiding several dreaded complica-tions of face lifting, such as temporal wasting,tragal eversion, pixie ear deformity, and posteriorhairline step-offs.

In patients who have a high temporal tuft orexces-sive temporal laxity, the authors modify the temporalportion of the incision with a sideburn extension(Fig. 6). This modification creates a superiorly basedtemporal advancement-rotation flap that preservestemporal hair and keeps the temporal hairlinedown. Incision marking in front of the auricle followsthe curvature of the helical root, passes over thetragal top in women (in front of the tragus in men),and curves around the lobule into the postauricularcrease. In short-scar facelifts this incision stopsjust at the level of the external auditory canal, butin more traditional procedures the postauricularcomponent of the incision connects to the hairlineat the auricular–hairline junction and darts posteri-orly at the level of the tragus.

After the markings, the hair is parted witha comb along incision lines and is bound with smallrubber bands. Wetting hair with a lubricating oint-ment, such as Surgilube or Bacitracin, greatlyassists in this process. The face then is preppedwith Betadine and is draped with full face andneck exposure.

Within hair-bearing regions (temporal andposterior), incisions are appropriately beveled to

Fig. 5. Typical surgical marking pens. From left toright: regular tip, very fine tip, combination tip(Aspen Surgical, Caledonia, Michigan).

preserve hair follicles and avoid postoperativealopecia. The angulation of hair shafts at thesesites can be especially acute, forming a 10� to20� angle with respect to the plane of the scalp.The surgeon should avoid making a full-thicknessincision in one move and instead should performseveral strokes while visualizing and followinghair shafts at all times. This technique allowsmaximal preservation of hair follicles at incisionsites. In addition, monopolar and bipolar electro-cautery should be used judiciously aroundbleeding scalp edges, because it may inducethermal injury to hair follicles. Persistently oozyskin edges can be controlled effectively by a localanesthetic injection with 1% lidocaine and1:100,000 units of epinephrine.

Dissection

After initial incisions are made with a fresh #15blade, a skin flap is elevated under direct visualiza-tion in the subcutaneous plane. The surgeon candevelop this dissection easily and quickly withthe assistance of a thimble hook retractor. Over-head lights are positioned directly over the face,transilluminating the skin flap and aiding in main-taining a uniform surgical plane Once this planeis further developed anteriorly, the straight end ofa Converse retractor can be used easily to movefreely under the flap. In the authors’ experience,bleeding on the undersurface of the skin flap iscontrolled best with unipolar cautery, whichcauses far fewer skin burns than a bipolar instru-ment. In contrast, deeper bleeding tissues are

Pearls in Facelift Management 631

coagulated more effectively and safely with bipolarcautery. The extent of subcutaneous dissectiondepends in large part on the surgical techniqueand clinical presentation of the patient. Innonsmokers with heavy jowls, a long skin flapelevated anteriorly over the jowl is especiallyuseful in providing access for direct trimming ofthe jowl. For those undergoing a deep-plane face-lift, a shorter subcutaneous dissection is per-formed. In standard lateral superficial muscularaponeurotic system (SMAS) techniques, the sub-SMAS dissection begins by identifying the pre-parotid plane anterior to the auricle. A J-shapedsegment of SMAS can be excised safely with face-lift scissors at this location. Anteriorly, proper iden-tification of a sub-SMAS plane can be assisted byhydrodissecting with several cubic centimeters ofsaline solution. In most instances, release ofparotid-cutaneous and masseteric-cutaneousretaining ligaments provides the necessary mobili-zation of the deep facial plane.

Closure

Only two relative tension points are created duringskin closure, with both affixed to deep fascia toensure long-term stabilization of the skin flap. Inthe temporal region, immediately superior to theauricle, the skin flap is placed on gentle stretchin the postero-superior direction. Care is taken toavoid overpulling (creating a wind-blown appear-ance and temporal wasting) or extreme superiorpull (creating temporal bunching). A half-mattresssuture is placed through the skin edges as wellas deep temporal fascia to achieve fixation atthis anatomic location. Posterior to the auricle,the direction of pull is essentially superior,ensuring proper alignment of the occipital hairlineand avoiding step-offs. A half-mattress suture isplaced similarly in this location, incorporating themastoid periosteum.

The remainder of skin closure is performedtension-free to avoid developing tell-tale signs offacelifting, such as anteriorly pulled tragus andsatyr ear. To achieve this closure, facial flap skinis trimmed precisely around the periphery of theauricle so that no tension is required duringclosure. The pretragal sulcus is recreated by thin-ning pretragal skin to the level of the dermis andplacing a 4-0 Vicryl suture from dermis to the peri-chondrium of the medial tragus. Skin at the earlobule is closed while incorporating the lobularligament. All incisions in the occipital and temporalhair-bearing regions are closed with staples. Theremainder of skin is closed with a simple running6-0 nylon suture. After skin closure, all incisionsare washed with saline and half-strength peroxide.

Drains and Dressings

The single most important measure to prevent post-operative hematoma is meticulous intraoperativehemostasis. When drains are used, flat size #10Jackson-Pratt (JP) drains are placed on each sideand are passed through separate stab incisionswithin hair-bearing scalp. No sutures are usedbecause the drains are held firmly in place by theneck of JP and are removed on the first postopera-tive day. Bacitracin ointment is applied liberallyover incision sites, and Telfa pads are placed aroundthe ears. A light pressure dressing consisting of fluffsanda3-inch Kling flexible dressing (Johnson&John-son, Langhorne, Pennsylvania) is applied around theneck and face. Fishnet stockinet material is quickand easy to use and keeps the dressing in place.Simply stretch the stockinet over the entire headand tear a whole for the face while tying a knot inthe top to prevent slippage. Alternately, a 3-inchCoban dressing (3M Healthcare, St. Paul, Minneso-ta) can be used. With Coban, one can regulate theamount of compression support while providing anaesthetically acceptable, skin-colored dressingthat prevents slippage.

POSTOPERATIVE PEARLSPostoperative Day #1

On the first postoperative day, the surgicaldressing is removed, and the face and neck areinspected for bruising, ischemia, and collections.Because this visit may occur in a hospital, anovernight facility, or even the patient’s home, allthe supplies required for this dressing changeare brought along. Small collections can bedrained easily with a medium-bore (21-gauge to25-gauge) needle. Local anesthetic is not requiredfor this percutaneous drainage, because the skinis sufficiently anesthetized from the faceliftdissection. Large or recurrent collections can betreated by inserting an Angiocath (14 gauge or16 gauge) and leaving it in place with a pressuredressing for a couple of days. Placement of anAngiocath allows continuing drainage andhastens the adherence of skin to the underlyingtissues.

Patients are instructed to ice for the first 48 to72 hours, to sleep on several pillows, and toavoid strenuous activity. They may advance theirdiet as tolerated and begin taking their usualmedications. They should not drive or makeimportant decisions while taking narcotics orsedatives in the immediate postoperative period.Patients are given a facial compression garmentand are instructed to wear it around the clockfor the first week. This frequency changes tonightly use after 1 week. Patients should be

Fig. 7. Auriderm postoperative gel. (Photograph cour-tesy of Biopelle, Ferndale, Michigan; with permission.)

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taking their regimen of Arnica Montana, brome-lain, and antibiotics.

Postoperative Day #3

Patients may begin showering and gently sham-pooing their hair. They are instructed to massagetheir scalp gently, rinse with tepid water, and avoidhair-coloring products for several weeks. Thiswound-care regimen is important in keeping inci-sions clear of crusting, which greatly assists withsuture removal. Ecchymosis is diminished furtherwith twice-daily application of Auriderm postoper-ative gel (Biopelle, Ferndale, Michigan) withvitamin K oxide (Fig. 7).

Patients may gradually increase their routinedaily activities at this point while avoiding bending,lifting, and other strenuous activity. Light exercise

may commence after 3 weeks, depending on indi-vidual progress and recovery.

Postoperative Day #7

All sutures and staples are removed at this point,and wounds are inspected. Areas of significantbruising or palpable firmness can be treated withseveral sessions of ultrasound shock-wavetherapy (RICH-MAR 510, Byron Medical, Tucson,Arizona). Patients are instructed to massage gentlyany areas of firmness and to use heat pads asnecessary.

Postoperative Weeks #1 to 4

Hypertrophic and erythematous surgical scarsrespond well to topical silicone gel therapy. Theauthors prefer Scarguard gel (Scarguard Labs,Great Neck, New York), which comes with itsown application brush, making it easily to applyaround facelift incisions. More extreme measuresinclude pulsed dye laser therapy,4 which can begiven several times a few weeks apart. For thick-ened scars, conservative steroid injections (Kena-log 10, Bristol-Myers, Princeton, New Jersey) canbe initiated for any subcutaneous irregularities. Aroutine follow-up sequence consists of officevisits at 3, 6, and 12 months and annuallythereafter.

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and medical use. Cell Mol Life Sci 2001;58(9):1234–45.

4. Nouri K, Jimenez GP, Harrison-Balestra C, et al.

585-nm pulsed dye laser in the treatment of surgical

scars starting on the suture removal day. Dermatol

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