Aftercare61

Dimitrije E. Panfilov

At the end of facelift surgery, we make a head net bandage. Some years ago we used a head and neck garment and observed frequent ecchymosis in the neck area; now we have stopped doing this. There is no need for compressive bandages but we put some more gauze strips behind the ears as a small or big collection of residual blood can be expected there.

When I started my career as a facelift surgeon, I spend almost a third of the operating time completing meticulous haemostasis - mostly through electro-cautery. I divided sharply the tissue elements from each other and then I had bleeding. If one does not catch the whole vessel with the electrocautery forceps, it may provoke more bleeding. If we perform electro-cautery near some nerve branches, thermal damage to them could occur.

I have learned to prepare skin flaps blindly with "spreading scissors" and "grasping forceps". I start the preparation in the retroauricular region , and when I have advanced medial enough, I leave a strip of gauze there and go to the cheek. When I have finished with cheek-skin flap, I go back to the neck, pull the strip of gauze out, and mostly it does not bleed anymore. This procedure enables me to not use electrocautery except sometimes at McGregor's patch (if it cannot be divided bluntly) or at retroauricular skin edges.

We do not administrate any prophylactic antibiotics except when we insert chin implants through the lower lip. Not more than 25% of our patients ask for analgetics. It seems that positive motivation for surgery sets free endorphins, so some patients say that they had no pain. For we who are performing these operations it is hard to believe that there was no pain at all. We discharge patients on the same evening or in the late afternoon on the day when the surgery was done accompanied by relatives or friends (not alone!). Patients from afar or with accompanied surgeries are advised to stay in the clinic for one or two nights (or to stay in a hotel near the clinic), because on the first postoperative day the bandages should be removed. Usually, we do not leave drains in the wound; if we recognize a tendency for haematoma or seroma formation, we apply fibrin glue as a sealing substance instead of drainage. Four days after surgery, we allow our patients to wash their hair.

Dermafibroma Drain
Fig. 61.1. a Head net bandage for 1 day is sufficient in most cases. b A head-neck garment we do not employ anymore; it can cause cervical ecchymosis
Facelift Bandages
  1. 61.2. a Dermographic markings for facelift, autologous fat transfer, removal of three dermatofibromas on the forehead and the left root of the nose, left chin. b One day after surgery: bruising, swellings, infraocular haematomas. c One week postoperatively; visible scars after removal of dermatofibromas; otherwise she would be ready to go out. d Two weeks postoperatively; she is ready for all her activities. Patient e before. and f 5 years after surgery
  2. 61.2. a Dermographic markings for facelift, autologous fat transfer, removal of three dermatofibromas on the forehead and the left root of the nose, left chin. b One day after surgery: bruising, swellings, infraocular haematomas. c One week postoperatively; visible scars after removal of dermatofibromas; otherwise she would be ready to go out. d Two weeks postoperatively; she is ready for all her activities. Patient e before. and f 5 years after surgery
  1. 61.3. a-d The unlimited fantasy of our patients is applied to hide the traces of surgery (any woman can make from nothing a hat, a salad, and a scene, somebody said); when eyelid surgery has been done we recommend dark sunglasses. e Forehead lift with periocular ecchymoses f could benefit from large, dark sunglasses
  2. 61.3. a-d The unlimited fantasy of our patients is applied to hide the traces of surgery (any woman can make from nothing a hat, a salad, and a scene, somebody said); when eyelid surgery has been done we recommend dark sunglasses. e Forehead lift with periocular ecchymoses f could benefit from large, dark sunglasses
Fat Transfer Forehead
Fig. 61.4. a Patient before minimal-invasive, deep-intensive (MIDI) facelift and eyelid surgery. b First day postoperatively c second day. and d after 10 days, when anchorage sutures had been removed

After discharge from the clinic, follow-up appointments are arranged. The surgeon will usually want to remove the stitches personally. This is done with the patient fully conscious and makes more of an impression on the patients than the operation itself, especially if surgery was performed under general anaesthesia. On the sixth postoperative day, the intradermal sutures can be removed. At this point about 80% of our patients are ready to appear in public. Nowadays our patients decide to be operated on or not depending on the permanence of the effect of surgery, and on how quick their resocialization is expected to be. In this world of ever-increasing pace, we have to recognize such trends and try to adapt ourselves. Those times are over when a patient after facelift stayed for a week in hospital and returned to her/his activities 4-6 weeks later. "When can I start meeting people again after the operation?" This is a question we hear regularly towards the end of the consultation. On average it takes about 6-12 days before the swelling and any possible bruises resolve. Sometimes it will take a few days more or a few days less.

Fig. 61.6. That somebody looks like that on the second postoperative day is almost a bit of impudence. She is 48 years of age; 2 days after MIDI facelift we do not even see suture strips because she wears a wig

Lipodistrofia

Fig. 61.6. That somebody looks like that on the second postoperative day is almost a bit of impudence. She is 48 years of age; 2 days after MIDI facelift we do not even see suture strips because she wears a wig

After 9 or 10 days we remove the anchorage sutures and a make-up stylist can now help with the patient's appearance - even fresh scars can be treated with make-up. Until that time, cosmetic camouflage can be put only over haematomas but not over fresh scars. Our usual follow-ups are after 3 weeks, 6 weeks, 3 months, one year and any time afterwards.

There is a great difference amongst individuals as to how fast healing process is, and it depends on many factors. We advise our patients to stop smoking, not to take aspirin (and ibuprofen) and oestrogen hormones for 3 weeks before and 3 weeks after surgery, and not to drink alcohol for 1 week before and 1 week after surgery. We cannot force a person to do this; we can just recommend they do so.

Facelift Week

Fig. 61.7. a A 46-year-old patient refused to stop her oestrogen therapy preopera-tively. b First day after MIDI facelift and four blepharoplasties. c Two weeks postoperatively - still a lot of haematomas. d After 4 weeks

  • an extremely long period nowadays
  • she is free of colour marks. e Six weeks postoperatively. Her 8-year-old daughter said: "Bingo mom, it is great that you have done it!" f Another MIDI face patient, 45 years of age with her 17-year-old daughter; she is happy to be considered as the older sister of her daughter (6 weeks postoperatively)

Fig. 61.7. a A 46-year-old patient refused to stop her oestrogen therapy preopera-tively. b First day after MIDI facelift and four blepharoplasties. c Two weeks postoperatively - still a lot of haematomas. d After 4 weeks

  • an extremely long period nowadays
  • she is free of colour marks. e Six weeks postoperatively. Her 8-year-old daughter said: "Bingo mom, it is great that you have done it!" f Another MIDI face patient, 45 years of age with her 17-year-old daughter; she is happy to be considered as the older sister of her daughter (6 weeks postoperatively)
Sibling Aesthetic

Fig. 61.8. a Patient before facelift surgery. b When driving a car on the third postoperative day, she turned her head quickly to the left; a haematoma on the right side of her neck jumped up. c Evacuation has been done with a liposuctioning machine. d A 50 ml haematoma was removed, but it hurts. e It is simpler, easier, and less painful to do it with a syringe

Two thirds of all complications after facelift surgeries are haematomas. If there is intraoperative bleeding, we have to stop it. For our outpatients, we have the rule to monitor them for at least 6 h postoperatively, and to see them next morning, which is about 20 h after surgery finished. After that point all patients are advised to phone at any time after that if they notice something unusual. Sometimes from the second to the fifth postoperative day, some quick movement of the head can provoke late postoperative bleeding. Reoperation is not always necessary. Sometimes the simple evacuation of the haematoma or seroma is enough with compressive bandages afterwards.

Fig. 61.9. Greater auricular nerve indicated with the tip of closed scissors over the belly of the sternocleidomastoid; beyond the v. iugularis externa

Nerve injuries belong with skin necrosis to major complications after facelift surgery. Injury of the great auricular nerve could occur if we cut it with anaesthesia of the ear and preauricular region or neurinoma if we get it into the suture over the mastoid region. To avoid both, we make dermographic markings preop-

eratively: 6.5 cm below the external auditory canal or about 5 cm below the ear lobe.

Injuries of motor nerve branches can result in temporary or permanent mimical disorder. Thermal damages caused by electrocautery are reversible; tran-section of these branches is permanent, It is also advisable to mark the frontal, buccal, and marginal branches on the skin with dermography preopera-tively, where these branches come out superficially.

There are some complications which happen really rarely. One patient from Russia underwent in our clinic in Germany a minimal-invasive, deep-intensive (MIDI) facelift, reductive rhinoplasty, and breast and lip augmentation. She insisted on flying to Naples on the fifth postoperative day ("see Naples and die"). I entreated her and her husband: "Please do not do it. We don't have any complications yet, but four surgeries were done. And the air-pressure changes will not support the healing, just the opposite." But, they went - to be back in 3 days. A strange thing happened: any time when she was eating (especially chocolate), a bubble like a cherry jumped out on her left cheek. I made a revisionary surgery and found only clear fluid inside: it was a salivary cyst! This does not need any revision. It disappears spontaneously after 3-4 weeks.

Aesthetik Surgery
  1. 61.10. a Orbicularis oris muscle transitory paresis after elevation of lip commissures; preoperative appearance. b Two weeks, c 3 weeks, and d 4 weeks afterwards; complete restitu-
  2. Since that case we do not apply the double loop when catching the orbicularis oris muscle bundle in our "optimistic suture", but just a single one
  3. 61.10. a Orbicularis oris muscle transitory paresis after elevation of lip commissures; preoperative appearance. b Two weeks, c 3 weeks, and d 4 weeks afterwards; complete restitu-
  4. Since that case we do not apply the double loop when catching the orbicularis oris muscle bundle in our "optimistic suture", but just a single one

Another strange case was a patient who was operated on 3 weeks before had circumscribed inflammation on her right cheek! We went through the reopened wound below the ear lobe with an endoscope and found a swab of gauze there. After 6 months we added some autologous fat there and after 1 year made a mini facelift on that side to improve the appearance of her right cheek.

  1. 61.11. Salivary cyst of left cheek after MIDI facelift
  2. 61.11. Salivary cyst of left cheek after MIDI facelift
Boys And Girls Exploring Genitals

Fig. 61.12. a Localized inflammation of the right cheek, 3 weeks after initial surgery. b After removal of a forgotten swab of gauze. c Six months later the defect was filled up with 5 ml of autologous fat. d One year later a unilateral mini facelift has completed the reconstruction of her right cheek

Preauricular Cyst RemovalFacelifts Leave Scar Behind Ear
  1. 61.13. a Six months after facelift surgery a severe retroauricular scar developed; the preauricular scar was not affected. b We waited until "crescendo" - first 6 months and "decrescendo scarring" - next 6 months - were completed and this hypertrophic scar was removed with radiosurgery under peroperative administration of N-acetyl-L-hydroxyproline. c Skin was tightened. The same ear after d 1 month and e 1 year
  2. 61.13. a Six months after facelift surgery a severe retroauricular scar developed; the preauricular scar was not affected. b We waited until "crescendo" - first 6 months and "decrescendo scarring" - next 6 months - were completed and this hypertrophic scar was removed with radiosurgery under peroperative administration of N-acetyl-L-hydroxyproline. c Skin was tightened. The same ear after d 1 month and e 1 year

Hypertrophic scars or real keloids are also rare. If they occur, it is mostly in the retroauricular region. They are very resistant to therapy. We mostly apply direct injections of steroids. There is also a medication against rheumatism called N-acetyl-L-hydroxy-

proline (AHP 200 - Oxaceprol) which should be taken 3 weeks before and 3 weeks after surgical removal of a hypertrophic scar. We administrate two pills containing 200 mg oxaceprol, three times. In the case illustrated in Fig. 61.13, it seems that it was helpful.

Fig. 61.14. a Facelift stigma of "operated face" with a distorted hairline. b Distorted hairline with overdosed facelift 14 years postoperatively

Nowadays we do not often see faces with overstretched skin and a distorted hairline without mimetic expressions, like masks, like a face from a wind tunnel, often with a "stair scar" behind the ear. These were static "facelift stigmatas" of "operated faces" and negative advertising for our profession usually seen in multilifted patients until the 1970s. Also dynamic "facelift stigma" is possible if the mimetic expression has been distorted like in a uncorrected paraoral K-point.

Many things should come together so that we achieve excellent results: good candidates with developed sagging of facial structure, but good skin conditions, angles of facial structure which promise attractiveness, optimistic patients with realistic expectations. This is very important. We all love to have satisfied, happy patients at the end of our treatment.

But, if something goes wrong, if some complication occur, or if the patient is worried or discouraged, we have to help her/him. Every patient must be guaranteed to receive qualified aftercare and follow-up. It is not advisable, for example, to look in the mirror during the first 2 days after face surgery. Many a patient is seized with fear at the sight of the swellings and bruises: "How on earth do I look! Why did I have this done to me!" The surgeon must then provide comfort and reassurance until the third day after the operation, at the latest, when the mood switches as the patient is happy again about his/her operation and the rapid improvement. We just have to encourage our patients; we can say to them: "Oh, thank you for making my surgery a success." We are those who know hundreds or thousands of such situations; we have something like a "time prism" in our heads. We know how somebody will look in 3 days., 3 weeks, 3 months...

And if patients have objections they could be justified or unjustified. We have to give them the opportunity and time to tell us their complaints. If we have not done the perfect job, we should offer to improve the small irregularities, or if we have not achieved the result which we expected ourselves, we could offer another surgery at a reduced price or free of charge. But anyhow, we should have patience to listen to our patients. If the patient has unjustified objections, I show him/her pictures of before and after. Then all doubts are removed.

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Responses

  • zewdi afwerki
    What does face look like 2 weeks after facelift?
    3 years ago

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