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
POSTOPERATIVE COURSE
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.
Operative
mortality: The operative mortality rate is under 1%. 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.
Special monitoring required: No
special monitoring is necessary. 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. Alimentation: A
regular diet is permitted as tolerated. 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%. 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% 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.
Back to top 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%
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 difficultyly
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. Back
to top 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% versus 0.7% 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. Back to top 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 disastrous sequelae 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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