There were 2 complications. One patient who received epinephrine 1:800,000 developed a hematoma of the right neck several hours after discharge requiring surgical evacuation. Another patient experienced weakness in the left buccal branch distribution that fully resolved within 1 month. There were no systemic complications. All ultrasound scans were negative.
Blood Flow after a Face Lift Dissection
The author expected a diminution in blood flow caused by the face lift dissection. However, the data did not support this hypothesis. All 4 combined absolute and relative postoperative perfusion measurements (right, 67.3% vs 60.5%; left, 74.7% vs 70.7%) were higher after surgery than before surgery, although not significantly (Table 2). There are several possible explanations. First, the dissection was subcutaneous over the lateral neck, but largely sub-SMAS in the face (Fig. 2). Second, the author uses hydrodissection13 in creating the subcutaneous tissue plane, which may be less traumatic to the skin flap.14 Third, lidocaine10,15–17 and bupivacaine18 produce local vasodilation, thought to be caused by a local chemical sympathectomy effect,17 which would not be balanced by the vasoconstrictive effect of epinephrine in the 3 patients who did not receive epinephrine. This vasodilation is overcome by epinephrine, producing net vasoconstriction,10,15–18 caused by the α-adrenergic effect of epinephrine on the smooth muscle of arterioles.15,19 The finding of excellent post-face lift flap perfusion is consistent with the author’s clinical experience of few cases of marginal skin loss.20
In an effort to control for any possible confounders (eg, room temperature, ambient lighting, and neurohormonal factors), the perfusion of the temple was used for reference. The mean measurements representing the combined data relative to the temple showed perfusion levels decreased by almost half (Table 3). The combined perfusion measurements for the 2 epinephrine concentrations were surprisingly similar, attesting to the efficacy of the more dilute epinephrine concentration. Similarly, Dunlevy et al,10 in their study using a laser Doppler flowmeter, found that a 1:800,000 concentration of epinephrine reduced cutaneous blood flow approximately 50% in patients undergoing head and neck surgery. These investigators10 also found that a 1:400,000 concentration decreased blood flow about 60%, with no significant difference in blood flow comparing epinephrine concentrations of 1:200,000 and 1:400,000. In their study of albino rabbits, Siegel and Vistnes11 found no significant difference in hemostatic effect comparing epinephrine concentrations of 1:100,000, 1:400,000, and 1:800,000; a concentration of 1:1,600,000 was significantly less effective. Previous studies show that the reduction in blood flow reaches a plateau between 5 and 10 minutes after epinephrine injection,10,15,16,18,19 although the maximum effect requires 25 minutes.17
Today, plastic surgeons use a variety of epinephrine concentrations, from 1:160,000 to 1:4,000,00014,20–41 (Fig. 11). Because epinephrine can produce toxic local (eg, skin necrosis)10,16,18,19 and systemic side effects (eg, tachycardia, arrhythmias, and hypertension)10,15,18 from stimulation of α- and β-adrenergic receptors,10,19 the prudent surgeon will choose the most dilute solution that provides adequate vasoconstriction. The measurements in this study suggest that 1:300,000 and 1:800,000 epinephrine concentrations are both effective.
Limited information is available regarding blood loss associated with a face lift. A surprisingly heavy blood loss is calculated from hematocrits when a face lift (including endoscopic forehead lifts) is performed at the time of body contouring surgery, approximately 500 mL.9 This nontrivial blood loss attests to the highly vascular nature of the face and the scalp. Hence, the need to minimize surgical blood loss and the role for vasoconstriction.
To gauge the frequency of hematomas, the author reviewed 40 face lift studies published in the plastic surgical literature in the last 15 years,14,20–58 including fluid collections treated with needle aspiration when they were reported. The mean hematoma rate was 3.8%. This rate is more than twice the frequency of this complication in a recent review59 that did not include hematomas treated with needle aspiration or seromas when these fluid collections were reported separately. The mean frequency of hematomas reported in the 6 prospective studies20,28,31,47,48,56 was 6.7%.
Approximately 86% of hematomas develop within 24 hours of surgery.27,60 Some plastic surgeons recommend against using epinephrine.25,32 The theory is that bleeding is suppressed during surgery but occurs postoperatively after the vasoconstrictive effect of the epinephrine wears off. However, there is no significant correlation between epinephrine concentration and reported hematoma rates (Fig. 11). Most surgeons take a “second look”61 for hemostasis after the face lift repair and before skin closure. Nevertheless, hematomas occur even in patients treated by experienced plastic surgeons paying meticulous attention to hemostasis.13
Perhaps unfairly, patients may judge the extent of bruising as an indication of the degree of surgical trauma. Without epinephrine, the local vasodilatory effect of lidocaine is unopposed,10,15–18 increasing bruising and delaying patient recovery (Fig. 3). Epinephrine also serves to reduce the rate of systemic absorption of local anesthetic agents, reducing the risk of systemic toxicity.9
Many plastic surgeons advocate close control of blood pressure during surgery and postoperatively, including the use of clonidine.14,25,27,34,38,58,62 Although avoidance of hypertension is always advisable,59 the value of intraoperative hypotension is less clear.53,60 Local vasoconstriction is preferred to systemic hypotension to reduce blood loss. Moreover, intraoperative hypotension might be expected to increase the risk of rebound bleeding after surgery. Feldman41 takes the opposite approach, administering intravenous ephedrine to elevate the patient’s blood pressure during surgery, “so that the final look for hemostasis is a reliable one.” However, vasoactive medications can interfere with the reliability of pulse, blood pressure, and respiratory rate when titrating propofol and fentanyl doses. To ensure the validity of these important clinical indicators, the author prefers normotensive anesthesia. When pain and a full bladder are ruled out as causes of intra- or postoperative hypertension, antihypertensives may occasionally be administered (eg, labetalol, esmolol, and hydralazine). The incidence of postoperative nausea and vomiting, which can raise the blood pressure, may be reduced by using a propofol infusion rather than anesthetic gas9,27 and by routinely administering antiemetics.9,34,58,59
Choice of Local Anesthesia
Most plastic surgeons use lidocaine for local anesthesia, usually in a concentration of 0.5% (range, 0.25–1%).14,20–24,26,27,30,31,33,36,38–40,60 Other investigators use bupivacaine either on its own29,35,63,64 or with lidocaine.14,20,25,28,31,62 Bupivacaine has a greater potency and duration of action than lidocaine.9 Its safety has been documented when administered into the subcutaneous tissue in dilute concentrations and when combined with lidocaine.9 Postoperative analgesia is helpful in reducing the need for analgesic medication in the immediate postoperative period. Narcotic analgesics are a common cause of nausea and vomiting; their use should be minimized.21 The longer duration of action of bupivacaine makes it frequently possible to evacuate a hematoma several hours after surgery without the need for a general anesthetic or additional local anesthesia. Hematomas are less onerous when they can be treated without a return trip to the operating room and without the need for another general anesthetic.
Limitations of the Study
The sample size was small, comprising only 9 patients. It is not feasible to study a large number of patients because this sophisticated imaging technology is expensive and there is no third-party payer. The cost of each study was $1300, representing the cost of each dye kit, borne by the author. Nevertheless, in view of the higher (not lower) perfusion values after surgery, it is doubtful that a significant decrease in tissue perfusion would be detected if the sample sizes were larger. There is subjectivity in assigning measurement sites and variability of perfusion measurements, although this problem is largely mitigated by combining measurements. This study provides no information on smokers, male patients, other face lift techniques, or the duration of vasoconstriction.
Strengths of the Study
A novel imaging method provides data that were previously unavailable. Eighteen before-and-after perfusion studies were possible because the procedure is bilateral. Importantly, patients served as their own controls, avoiding confounders that can affect comparisons in different patients. The same surgeon used the same technique in this prospective study of consecutive patients with a 100% inclusion rate, avoiding selection bias and adding to the reliability of the conclusions.
A deep-plane face lift dissection does not decrease skin flap perfusion (See Video, Supplemental Digital Content 4, which demonstrates a comprehensive video showing patient interviews before and 24 hours after surgery, local anesthetic injection, face lift dissection, and SPY laser fluorescence imaging videos. This video is available in the “Related Videos” section of the full-text article at http://www.PRSGO.com or available at http://links.lww.com/PRSGO/A126). Both 1:300,000 epinephrine and 1:800,000 epinephrine concentrations are effective in producing intraoperative vasoconstriction.
The author thanks Jane Zagorski, PhD, for statistical analysis, Sarah Maxwell, RN, for data collection, and Gwendolyn Godfrey for illustrations.
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