Publication Oct 1, 2004 By: Melissa Heltzel Cosmetic Surgery Times

He has assembled a protocol that effectively reduces the amount of swelling, bruising and discomfort from the surgery. He hopes this will encourage people whose career, familial or social obligations might otherwise keep them from considering facelift surgery.

The preoperative period, he says, is a rigorous preparation in relaxation and education for the patient. He took his cue from more than 200 articles in anesthesia and dental journals that make a direct correlation between a patient's pre-surgical anxiety level and the degree of pain and ability to recover afterward. "If you can minimize anxiety before surgery, then I know the patients are going to require less pain medication and have less discomfort afterwards," he says.

The first building block to alleviating patient anxiety is education. Dr. Rosenberg engages patients in a 45-minute initial, forthright education session that serves both to set reasonable expectations and to put their minds at ease. He explains to patients why they can expect minimal discomfort, and that he doesn't employ the use of drains.

"Patients, I have found, find drains coming out of their skin to be extremely anxiety-producing," Dr. Rosenberg says. "By reassuring them that it's nothing like that, their blood pressure drops."

He sets up a supplement regimen for the two weeks preceding surgery that aims to keep the bruising and swelling to a minimum. He has the patient stop taking any supplements that thin the blood — such as aspirin, Vitamin E, green tea and St. John's Wort, as well as omega-3 fatty acids and fish oils. He replaces these supplements with those that aid in healing for a five-day regimen prior to surgery. It includes bromelain (500 mg, three times a day) and Arnica montana, as well as a prescription for vitamin K (Mephyton, 5 mg). He also issues a prescription for Valium (Roche Pharmaceuticals, Nutley, N.J.) to further minimize anxiety.

On the day of surgery, an anesthesiologist starts an intravenous combination of propofol and midazolam; Dr. Rosenberg follows that up by administering a long-lasting local anesthetic of lidocaine (1 percent) with epinephrine (1:100,000) equally with marcaine (0.25 percent) with epinephrine (1:200,000). The anesthesiologist administers Decadron (Merck, Rahway, N.J.) and Zofran (Glaxo-SmithKline, Research Triangle Park, N.C.), both to limit any lingering potential for nausea. The local anesthetic typically lasts through the night, barring the need for morphine or other narcotics in the recovery room, and in fact, Dr. Rosenberg finds that this combination prevents the need for anything stronger than a Tylenol (1,000 mg) later that evening.

"Hiding the scar is a must," Dr. Rosenberg explains. Thus, he says he uses post-tragal incision. "This is very meticulous and takes a few extra minutes," he says. "But when the stitches come out at seven days, you don't see a scar in front of the ear."

He then performs a deep plane facelift with minor modifications — a technique that he's found to leave less bruising and swelling than a subcutaneous or a submusclar aponeurotic system(SMAS) lift. In modifying the traditional deep plane lift, he says, "I leave the fascia and a small amount of fat on the zygomaticus major muscle. I find this approach reduces the swelling in the cheeks."

In almost every case, when dealing with the patient's neck, he performs liposuction on the neck and has found that a 2.0 mm cannulae is the least traumatic to the area, yet carries out the necessary fat removal. He then performs a submentoplasty, taking care to remain superficial to the fascia of the platysma muscle to minimize muscle injury and subsequent skin bruising. If there is noticeable capillary bleeding, he uses Tisseel (Baxter Healthcare, Deerfield, Ill.) at the time of closure, and the sealant seems to assuage further bruising and swelling. Once he completes elevation of the surgical flaps and hemostasis is achieved, then closure can begin. He separately secures the platysma muscle with running sutures to the underlying fascia, which causes less swelling in front of the ear. At last, a conforming dressing is applied to the face, putting moderate pressure on the area in front of the ear, the mastoid, the temple region and the submentum.

Following surgery, the patient is placed in the recovery area, and a cool compress is applied to reduce swelling. Dr. Rosenberg emphasizes the lack of need for opiates for the pain, thereby preventing nausea and vomiting. This saves the patient much distress and keeps unwanted pressure off the fresh sutures. After two to three hours, Dr. Rosenberg finds it greatly reduces the patient's anxiety to get out of the recovery room and into a hotel nearby the facility, accompanied by a registered nurse. The nurse will then make sure the patient is drinking fluids, and later gives the patient Tylenol (1,000 mg) every four hours and Valium (5 mg) every eight hours.

The next morning, 15 to 20 hours after the surgery, Dr. Rosenberg personally visits the patient to remove the dressing and clean the incisions. He starts the patient on a Medrol (Pharmacia Corp., Peapack, N.J.) dose pack to improve comfort and reduce swelling.

To improve the sense of well-being, the patient is encouraged to shower (with assistance) after 24 hours. Dr. Rosenberg then calls the patient every morning for the next four days to check in and answer any questions. Between days five and seven after surgery, the patient returns to his office for the removal of sutures and a consultation with a licensed aesthetician. The patient is educated in the application of LycoGel, a silica-based concealer, which can be used several days after surgery. Because, "despite the gentlest of techniques, there will always be some bruising," Dr. Rosenberg says.

In days five to seven following the surgery, Dr. Rosenberg encourages the patient to go out to lunch or dinner with friends, noting that re-entering society is key to a speedier recovery.

Some patients may be slightly behind on that curve, but nearly all are out and about, or back to work, by the tenth day following surgery.

The success of the rapid recovery facelift depends heavily on patient interaction, Dr. Rosenberg says.

"One of the greatest tools for marketing a practice is spending time with your patients to let them know you care about them. You set aside a lot of time for them because that's what people undergoing aesthetic surgery deserve," he adds.