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BackTable / ENT / Article
In-Office Facelift: Optimizing Patient Care Before, During & After
Julia Casazza • Jun 26, 2024 • 37 hits
Techniques for performing facelifts have evolved greatly since the procedure was first performed over a century ago. Optimal outcomes rely on appropriate counseling, expert surgical technique, and meticulous post-operative care. Facial plastic surgeon Dr. Dmitiri Arnatouakis recently sat down with BackTable ENT to share his insight on the procedure and how he successfully performs it in the office.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• The decision to undergo an in-office facelift should be considered within the context of the patient’s overall health, lifestyle, and aesthetic goals.
• Including tranexamic acid (TXA) in the tumescence mixture during surgery can limit bleeding associated with facelifts and related cosmetic procedures.
• The best defense against facial nerve injury is operating within the correct surgical plane.
• Adjunctive treatments, including hyperbaric oxygen and lymphatic massage, ease swelling and speed post-surgical recovery.
• Bruising and swelling are common post-facelift. Less common complications include hematoma, great auricular nerve injury, and facial nerve injury.
Table of Contents
(1) The Pre-Operative Visit
(2) Facelift Procedure Technique
(3) Post-Operative Care of the Facelift Patient
The Pre-Operative Visit
A combination of patient education, medications, and supplements prepare patients for a successful in-office facelift. During the pre-operative visit, Dr. Arnaoutakis’ nurse reviews the procedure, dosing of pre-operative medications, and supplements designed to optimize surgical outcomes. Dr. Arnaoutakis uses arnica and bromelain supplements to assist with healing post-surgery. Arnica, derived from dried flowers, has anti-inflammatory properties that are anecdotally noted to reduce bruising. Bromelain is an enzyme preparation from pineapples that accelerates surgical healing [1]. If the patient requires a drain for the procedure, drain care is also covered at the pre-operative visit.
[Dr. Gopi Shah]
Okay. Before we get to the day of surgery, what's actually going on? What are your pre-op instructions? Do you have them do things like arnica or do you have anything that they do to prep them for surgery?
[Dr. Demetri Arnaoutakis]
Oh, yes. We actually have them come in about three weeks before their surgery or their procedure and they meet with my main nurse, Kat, and she sits with each of them for probably an hour and goes over our entire pre-operative sheet. She'll review their medications when to take the antibiotics, the pain pills. We provide them all with arnica and bromelain pills if it's a facelift. We have a custom skincare line that we give to them and she explains that to them as well. Then she'll go through just everything, what to expect if they have drains.
A lot of times, I'll actually leave JP drains for 24 or 48 hours in these patients. She'll teach them how to care for them, how to record the output, and how to take care of their sutures how to clean them all that stuff. Then we just review with them their appointments. I probably see these people three to four times in the first 10 days. We really have them come back to the office often to make sure everything's healing as well as possible.
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Facelift Procedure Technique
Dr. Arnaoutakis’ built his expertise in facelift by learning from preeminent plastic surgeons and caring for patients in his own practice. He includes tranexamic acid (TXA) in his tumescence to limit bleeding. However, there is no substitute for operating the right surgical plane. Doing so controls bleeding and minimizes the chance of facial nerve injury.
After incising with a 15-blade (10-blade in the occipital hairline area), he uses three different pairs of facelift scissors to elevate the flap, contour the flap, and perform vertical spreads. He places his anchoring sutures in the fixed SMAS (Superficial Muscle Aponeurotic System) in front of the tragus and the mastoid fascia behind the ear. He establishes a sharp cervico-mental angle by taking inverting bites in the platysma just left and right of the hyoid fascia.
When closing, he prefers two layers of sutures: deep dermal with 5-0 Vicryl, then running locking sutures with 5-0 Proline. He advises against the use of skin glue when closing, as it can leave unappealing scars.
[Dr. Gopi Shah]
Then in terms of hemostasis, do you have any bipolar tricks? Pledgets and Afrin? What do you do for that?
[Dr. Demetri Arnaoutakis]
Honestly, it's just Bovie and bipolar. It's funny when you transition from the big hospitals where you have every gadget out of the sun it's I've forgotten about half of them all the surgical and the Fibrillar and the whatever else, you don't understand it, you don't really appreciate this stuff when you're a resident, but they're really expensive. I think the best form of hemostasis is just being a safe surgeon and being in the right plane. If you're on the right plane, a lot of times you really shouldn't have any bleeding. I think for me, bipolar is just the number one thing I use for coagulation.
[Dr. Gopi Shah]
In terms of tricks to raising your flaps, anything that you do differently now or any advice you would give to somebody that's coming out?
[Dr. Demetri Arnaoutakis]
Yes. I'll start my incisions with a 15-blade, a 15-blade, and then a 10-blade in the occipital hairline area. Then it's really getting the right instruments. In the beginning, I was operating at this one surgery center, and I was just using what they had, and it was frustrating. Then I reached back out to my mentor and a couple other surgeons I respect, and I was like, what instruments are you using? They told me, and then I bought those, and it was like a night and day difference. I have, like I said, three different facelift scissors, and one I use for elevating the skin flap, one I use for contouring the flap, and the other one for vertical spreads. The three of them really helped me be efficient in getting that safe plane.
[Dr. Gopi Shah]
Then any tricks or pearls to make sure you don't injure any of the facial nerve? I think it's probably staying in the right planes.
[Dr. Demetri Arnaoutakis]
Yes, staying in the right plane, and that's 15 years of training to help you escape, right? That's why we have, that's why residency is so long, that's why you do a fellowship, that's why you watch videos in your free time. honestly, when I was a resident, that was another thing. There was QMP, where a couple of very well-known facial plastic surgeons will post their videos of this is how I do it.
I've watched Dr. Andrew Giaccono from New York City, who's world-renowned now, and Dr. Mike Nayak, who's also a facial plastic surgeon in St. Louis. They each have their own video series, and they're professionally done, like this here, a back table with all the fancy microphones and all the stuff that I got to go get caught up on.
I've watched those videos from the back when I was starting out, or in fellowship and residency, and that really helps you learn how to do these surgeries safely. Unfortunately, you just eventually got to go do it yourself, and you learn from experience. It's just, the same goes for you, or Dr. Terrelson doing head and neck cancer who's done a gazillion parotidectomies, I'm sure he's a lot better now than when he started out day one, so there's really no substitute for experience.
[Dr. Gopi Shah]
Yes. In terms of securing the flaps, what sutures do you use? What do you find are your pearls there?
[Dr. Demetri Arnaoutakis]
Yes, I basically incise the SMAS from the lateral canthus, if I can imagine an imaginary line from the lateral canthus to the angle of the mandible, and then I actually extend it. I'm technically doing an extended D-plane because I'm releasing the cervical retaining ligaments, which are the ligaments between the SEM and the platysma.
I have a long flap that's going all the way, again, basically from the lateral canthus past the angle of the mandible, and then into the neck, I'm elevating the platysma about five or six centimeters down into the neck. Then I create a little backcut into the SMAS along the mandible. I'm using two OPDs, I use about four of them in the face, and I'm getting a nice purchase of the SMAS, and I'm tacking it back to the sticks. Where I cut into the SMAS, we refer to as the mobile SMAS, and the fixed SMAS is right in front of the tragus.
That's where I'm putting in my deep sutures, and so I know that's going to be a good sturdy bite, the sutures aren't going to let go or break or anything like that. That's when you can really see a tremendous lift in the jowls and the nasolabial folds. Then I'm taking the platysma, I'm slinging that back into the mastoid fascia behind the ear, and that helps create a really sharp, defined jawline.
In the neck, when I'm underneath the chin in the platysma, I use a 2-0 Vicryl. I first actually get a deep bite, I start at the hyoid, at the level of the hyoid, and I work superiorly. I get a bite of the hyoid fascia, and then I do inverting bites from the left and the right edges of the platysma, and then I stitch it down. I do at least four or five there all the way up to my incision line. That is what really helps create that sharp cervicomental angle.
[Dr. Gopi Shah]
How do know you've tacked it up enough? Is that just, again, through experience and doing enough of these?
[Dr. Demetri Arnaoutakis]
Yes, I think that's just where the art of this comes into play. It's your eye, your eye for aesthetics, and so, does it look good to you? I don't really foresee myself ever doing measurements in this area. It's really mostly like, okay, if this was your mom or your sister or your aunt, would you be okay with this or how she looks? That's just like caring and honestly having a little bit of a creative mind and making sure it looks good.
Post-Operative Care of the Facelift Patient
Close monitoring of the healing process post-facelift increases patient satisfaction and facilitates early resolution of problems. Dr. Arnaoutakis’ patients are seen in-office three or four times in the ten days following their procedure. Supplements, including oral arnica, oral bromelain, and scar cream may accelerate healing. Adjunctive treatments include hyperbaric oxygen on post-op day 1 and lymphatic massage on post-op day three and four. Complications of facelift include swelling / bruising (very common), hematoma, great auricular nerve injury, and facial nerve injury (very rare).
[Dr. Gopi Shah]
In terms of your post-op instructions, what is part of their post-op routine? Anything special? Anything that you have them do?
[Dr. Demetri Arnaoutakis]
Yes. As I mentioned earlier, they all get arnica and bromelain for bruising and swelling. We give them a scar cream to start applying once the stitches come out. We have them undergo hyperbaric oxygen. We have them undergo lymphatic massages. That's actually a big component as well, which I think really helps, their circulation and gets some of the drainage out. We have them keep, the ones who listen, really keep the suture line clean.
That's really important and just easy on us, honestly, too, when they come back to have them removed. Then just avoiding any heavy straining or exertion. Some of these patients just like they're affluent or successful business people, businessmen, and women, and they want to get back to their lives. Some of them are workout junkies. It's like, hey, just take it, like let your body heal, take it easy. Obviously, you'll get back to that before it, but I don't want you to stress yourself too soon.
[Dr. Gopi Shah]
Yes. In terms of the HBO or the lymphatic massage, when do you start that post-op?
[Dr. Demetri Arnaoutakis]
Usually post-op day one, they go for hyperbaric oxygen. You really want to find a facility that can at least, get up to two APMs. I think, if you're at 1.4, 1.5, it's almost like, not really doing anything. Ideally, you can get up to two. Then the lymphatic massage is usually like post-op day three or four. They'll love that. We have an esthetician here in my office. She's excellent, Ari. She actually also co-exists as my social media manager. She's now a trained esthetician and she's great. They'll usually get a package with her after the first one that we include for them. They'll usually end up doing like three more or so.
[Dr. Gopi Shah]
Okay. Then in terms of complications, how do you counsel patients and what have you seen in practice?
[Dr. Demetri Arnaoutakis]
Of course, we have, it's in our consent forms and the usual, the traditional with most of our skin soft tissue surgeries. Hematoma, it's fortunately very rare, maybe one in a hundred. We talk about sensory issues. It's more likely if anything nerve-related, it's going to be perhaps you cauterized or bovied close to the great auric. And now, they're a little bit numb behind their ear.
Facial paralysis is actually very rare. In fact, the rate of complication from that is the same if you're doing a deep plane versus a SMAS surgery. Any surgeon who's going to tell you that it's safer to do that, that's not actually technically true based on research. Now scarring, bruising, swelling of course is expected. I think those are the main complications.
Podcast Contributors
Dr. Demetri Arnaoutakis
Dr. Demetri Arnaoutakis is a facial plastic surgeon in Tampa Bay, Florida and Beverly Hills, California.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, September 5). Ep. 127 – In-Office Facelifts [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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