INTRODUCTION
Initially, attempts to treat wrinkles were based on resections of skin bands
associated with broad tissue detachment, with short-term results and
poor-quality scars1-4. Indeed, superficial muscular aponeurotic
system (SMAS) treatments represent a wide evolution in face-lift surgery, with
more lasting and natural results than other treatments1-4.
The search for more efficient operative techniques or tactics with better
results, always associated with greater safety and lower incidence of
complications in the short and long term, continues until today1,3-5.
Despite the ongoing improvement, the most frequent complication of face-lift
surgery continues to be hematoma, which when of large proportions, may
compromise flap vascularization, for which another urgent surgical approach is
required (expansive and/or voluminous case), significantly delaying patient
recovery. It can also prolong the time of edema and ecchymoses, with risks of
developing necrosis, dyschromia, and irregularities in the skin after
healing6-9.
According to the literature, the incidence of hematomas following face-lift
procedures ranges from 0.2% to 8%, and in men, the incidence can reach
12.9%8-10 (Table 1).
Table 1 - Incidence of hematomas requiring surgical evacuation following
rhytidectomy in women and men*
Authors |
Year |
No. of cases of hematoma |
Incidence (%) |
Before 1980† |
|
|
|
|
Serson-Nesto |
1964 |
170 |
2 |
1.2 |
Galozzi et al. |
1965 |
100 |
3 |
3.0 |
Conway |
1970 |
325 |
21 |
6.6 |
McGregor and Greenberg |
1971 |
524 |
42 |
8.0 |
McDowell |
1972 |
105 |
3 |
2.9 |
Webster |
1972 |
221 |
2 |
0.9 |
Pitanguy et al. |
1972 |
1600 |
89 |
5.5 |
Rees et al. |
1973 |
806 |
23 |
2.9 |
Barker |
1974 |
163 |
2 |
1.3 |
Black |
1976 |
1804 |
48 |
2.7 |
Baker et al. |
1977 |
1500 |
46 |
3.0 |
Stark |
1977 |
500 |
13 |
2.6 |
Leist et al. |
1977 |
324 |
19 |
5.9 |
Straith et al. |
1977 |
500 |
8 |
1.6 |
Thompson and Ashley |
1978 |
922 |
44 |
5.0 |
Lemmon and Hamra |
1980 |
577 |
5 |
0.8 |
Total |
|
10141 |
370 |
3.6 |
After 1980‡ |
|
|
|
|
Matsunaga |
1981 |
427 |
1 |
0,2 |
Fodor |
1982 |
100 |
1 |
1,0 |
Owsley |
1983 |
435 |
6 |
1,4 |
Lemmon |
1983 |
1445 |
8 |
0,5 |
Shirakabe |
1988 |
738 |
9 |
1,2 |
Rees et al. |
1994 |
1236 |
23 |
1,9 |
Marchac and Sandor |
1994 |
412 |
17 |
4,2 |
Heinreichs and Kaidi |
1999 |
200 |
2 |
1,0 |
Kamer and Song |
2000 |
451 |
10 |
2,2 |
Grover et al. |
2001 |
1078 |
45 |
4,2 |
Total |
|
6522 |
122 |
1,9 |
Table 1 - Incidence of hematomas requiring surgical evacuation following
rhytidectomy in women and men*
Several measures have been taken to reduce the incidence of hematomas, such as
blood pressure (BP) control in the perioperative and postoperative periods,
dressings, drains, fibrin glue, and platelet gel7,9,10.
Nevertheless, hematoma persists as the main complication of face-lift
procedures, with the constant analysis and study of cases being essential for
better standardization of preventive measures for this significant complication
(Figures 1A and 1B).
Figure 1 - A: Significant postoperative hematoma;
B: Significant postoperative hematoma
Figure 1 - A: Significant postoperative hematoma;
B: Significant postoperative hematoma
OBJECTIVE
This study aimed to present a proposal of perioperative and postoperative
systematization for the prevention of hematoma formation after rhytidectomies by
analyzing current literatures, a series of cases, and the author’s personal
experience.
METHODS
The author has been performing face-lift procedures since 1992. Over the years,
several changes in approaches have been proposed to improve results and reduce
complications. Since 2015, the author has been using complete systematization,
which is presented below and in Chart 1.
The data of all the cases analyzed in this article were collected from medical
records of the institution, whose clinical director is the main author. The
study was conducted in accordance with the principles of the Declaration of
Helsinki.
Chart 1 - Systematization used for preventing hematomas following face-lift
procedures.
Preoperative measures |
Hospital environment |
Long-term indwelling urinary catheterization (until
hospital discharge)
|
Intraoperative measures |
General anesthesia |
Pneumatic compression of LL (for DVT
prophylaxis)
|
Infiltration of approximately 100 mL of 0.375% +
lidocaine solution in each hemiface
|
Adrenaline at 1:600,000 |
Definitive hemostasis - 20
minutes per hemiface |
Under SBP 130
mmHg (never under hypotension)
|
Reduction of dead space: eight Baroudi sutures +
use of fibrin glue
|
Postoperative measures |
Maintain the head high |
Dressing using low-compression elastic mesh |
Cold saline solution compresses + frozen gel bag
(1/1h)
|
Administration of antiemetics at fixed times |
Rigorous BP control (1 h/1 h) - Intravenous
administration of clonidine if SBP 140
mmHg
|
Pneumatic compression of the LL during the entire
hospitalization
|
LMWH - start the morning after surgery |
Do not walk in the first 24 hours (during
hospitalization)
|
Hospital discharge only in the morning following
surgery and if BP is under control
|
Outpatient reevaluation within 48 hours |
Chart 1 - Systematization used for preventing hematomas following face-lift
procedures.
All the face-lift procedures were performed in a hospital environment, with the
patient under general anesthesia and with noninvasive BP monitoring and
indwelling urinary catheterization.
Approximately 100 mL of 0.375% lidocaine solution was infiltrated by hemiface,
with adrenaline at 1:600,000. Although some authors avoid such infiltration
because of the risk of vasodilation rebound after the use of adrenaline
solution10, we believe that this
approach facilitates detachment and visualization of the appropriate surgical
plan, in addition to minimizing intraoperative bleeding and facilitating
definitive hemostasis7,8.
The surgical time for hemostasis is never <20 minutes for each hemiface and is
always performed with systolic pressure values of ≥130 mmHg. Definitive
hemostasis should never be performed in hypotension.
In all the cases, we used quilting sutures with absorbable stitches between the
detached flap and the SMAS, similar to Baroudi’s stitches in
abdominoplasties11,12.
Generally, eight stitches were distributed in each hemiface to hinder the
expansion of an eventual hematoma, besides reducing the dead space and
facilitating the adhesion of the flap (Figure 2).
Figure 2 - Quilting sutures between the detached flap and the SMAS.
Figure 2 - Quilting sutures between the detached flap and the SMAS.
We routinely used fibrin glue (Tessel®) in the detached area of the face
and neck with the intention of improving flap adhesion, enhancing hemostasis,
and preventing hematomas (Figure 3).
Figure 3 - Use of fibrin glue on facial and cervical detached
tissues.
Figure 3 - Use of fibrin glue on facial and cervical detached
tissues.
We did not use a drain, and the dressing was made with a low compressive elastic
mesh and compresses soaked in cold saline solution, which were renewed every
hour. Moreover, we placed frozen gel bags on the compresses, which were also
renewed systematically every hour. The objective was to generate
vasoconstriction in the first hours and inhibit bleeding.
All the dressing was removed the next morning at the time of discharge, and the
patients continued to use the frozen gel bags over the hemifaces (always with
the skin protected) at home, 30 minutes at a time and with intervals of 1 hour
for a total period of 48 hours (except at night to sleep).
During hospitalization, all the patients were instructed to remain with their
heads held at approximately 30°. We also prescribe medications with a fixed
schedule for the prevention of vomiting, and we maintained strict BP control
with reevaluations every hour. When the systolic BP reached 140 mmHg, we
initiated antihypertensive treatment, usually with intravenous clonidine.
As the patients were probed, they were not allowed to get up during the entire
hospitalization, not even to go to the bathroom, because we believe that
immobilization reduces the risk of bleeding. To reduce the risk of deep vein
thrombosis, all the patients wore intermittent compression boots throughout the
surgery and hospitalization. Moreover, they started using lowweight heparin the
morning after the surgery, before discharge from the hospital.
All the patients stayed overnight in the hospital, were discharged in the morning
after the surgery, and were reevaluated at the physician’s clinic 48 hours after
discharge, when lymphatic drainage by the physiotherapy team already
started.
For didactic purposes, we considered as hematomas only those cases that required
drainage for hematomas, even small ones, during, for example, suture removal or
new incisions, in a hospital environment in patients undergoing surgical
interventions. They cause significant distortions in the face, threaten the
integrity of the skin flaps due to the great distension they cause, and require
prompt emptying. The small blood collections that eventually form during the
postoperative period in a localized manner and without causing harm to the flap
were disregarded. Usually, they are benign occurrences that are drained in the
physician’s clinic with punctures, commonly after the 10th day, when
they are liquefied.
RESULTS
From January 1992 to March 2018, a period longer than 26 years, the author
performed 1,138 face-lifts procedures, a number close to that performed by
Rohrich in a 23-year analysis4,8. Since August
2013, the author has been working exclusively with facial plastic surgery.
Reliable records on the occurrence of hematomas have been available since July
2011. Therefore, all data from the medical records dated since then were
included in the analysis.
From July 2011 to December 2014, the period prior to the adoption of
systematization, 233 patients underwent face-lift procedures, of whom 8 had a
hematoma (incidence of 3.43%).
Since January 2015, we used the aforementioned systematization and had, until
March 2018, 6 cases of hematomas in 361 surgeries (incidence, 1.66%). All the
bruises occurred in the first 48 hours after surgery.
Thus, with the introduction of the new measures, we obtained a 48.4% reduction in
our hematoma rates. The Fischer exact test did not show statistical significance
for these results (p > 0.05).
The set of measures used seems to have led to this significant reduction, which
we observed to be continually occurring. In the last 19 months included in the
analysis, 177 consecutive face-lift procedures were performed, in which no
occurrence of this complication was observed.
Figure 4 shows the significant decrease in
the incidence of hematomas after the beginning of the use of systematization,
despite the progressive increase in the number of surgical cases in the same
period. The number of cases increased from 52 in 2012 to 114 cases in 2017. To
avoid distortions, the graph included only the years when data were collected
over the 12 months (Figure 4).
Figure 4 - Incidence of hematomas following face-lift procedures The orange
line represents the beginning of the use of systematization.
Figure 4 - Incidence of hematomas following face-lift procedures The orange
line represents the beginning of the use of systematization.
DISCUSSION
Several factors are associated with the formation of hematomas following
face-lift procedures, including the type of anesthesia, age, sex, surgical
technique, the combination of procedures, use of drains, and BP9. We observed that the data were not enough
to determine the specific cause responsible for the formation of hematomas
following rhytidectomy9,10. Therefore, a set of measures is
necessary for its prevention.
Adequate techniques and anesthesia care are vital components to prevent
preoperative and postoperative complications. Specifically, in the prevention of
hematomas after rhytidectomy, the control of BP, heart rate, anxiety, analgesia,
and vomiting are essential13.
In the immediate preoperative period, the patients received benzodiazepines to
reduce anxiety and enhance the effect of the sedative medication. Despite the
good results achieved by some authors with the use of local anesthesia
associated with intravenous sedation9, we
chose to always perform these surgeries under general anesthesia, as we believe
that patients remain better monitored and controlled, with airways assured
during head movements and a closed system for oxygen delivery, which allow safe
use of electrocautery8,13.
During the preparation for surgery, we infiltrated a 0.375% lidocaine solution
with adrenaline at 1:600,000 in each hemiface; some authors prefer not to
perform this procedure because of the potential risk of rebound
vasodilatation10. However, like most
surgeons, we believe that this approach optimizes the detachment and
visualization of the appropriate surgical plan, in addition to minimizing
intraoperative and postoperative bleeding, which greatly facilitates definitive
hemostasis6-13.
Of all the factors responsible for the formation of hematomas following
rhytidectomy, hypertension is certainly the main factor, a fact well documented
by several authors such as Baker, Knize, Ramanadham, and Rohrich7-13. Regardless of the perioperative approach proposed by each
author, agreement is always reached that strict control of intraoperative and
postoperative pressures is associated with the reduction of the incidence rates
of hematomas following face-lift7-13. Baker
reported in his study on hematomas in men that strict BP control reduced the
incidence from 8.7% in 1977 to 3.97% in 20059,13,14.
BP just below normal or even mild hypotension is tolerated during facial flap
detachment to minimize perioperative bleeding. However, definitive hemostasis
under hypotension should never be performed because of the risk of masking
injured perforating vessels that could bleed significantly in the postoperative
period after the expected rebound increase in BP7-16. Routinely,
we perform hemostasis after the systolic BP reaches ≥130 mmHg.
Rohrich et al. recommend the use of 0.1- to 0.2- mg transdermal clonidine
adhesive per day before entering the operating room, with maintenance for up to
7 days in the postoperative period4,7,8,13,14. Rohrich
justifies this prolonged use on the basis of the observation that hypertensive
peaks are more common in the postoperative period than in the intraoperative or
immediate postoperative period8.
In our routine, we use intravenous clonidine during hospitalization when the
systolic BP reaches 140 mmHg. We consider that the constant use of a transdermal
clonidine adhesive increases the risk of hypotension in the first postoperative
days and, consequently, increases the risk of falls and consequent trauma.
Furthermore, other factors such as anxiety, pain, urinary retention, nausea, and
vomiting are directly associated with increased BP and, consequently, the
formation of hematomas7-15. They must be adequately prevented. In
our routine practice, antiemetic medication is used at a fixed time, starting
even before the patient’s anesthetic awakening, a protocol also adopted by Baker
and Rohrich9,13,14. All the patients received indwelling urinary
catheterization during the entire hospitalization.
In all the cases, we used quilting sutures between the dermis of the detached
flap and the SMAS; we consider this step important for reducing dead space
(improving flap adhesion) and limiting the dissemination of any hematoma that
may form. These sutures are similar to Baroudi’s sutures in abdominoplasties and
have already been described in rhytidectomies by the same surgeon11,12.
In addition to these quilting sutures, we used fibrin glue (Tessel®) to
provide better adhesion to the detached and pulled flap, besides preventing the
formation of hematomas. The use of fibrin glues and other flap adhesion
mechanisms is controversial. Fibrin sealants have demonstrated good efficacy in
controlling slow and focal bleeding or diffuse bleeding9,17,18. While some
authors such as Marchac and Sándor19
reported that after the use of fibrin glue in aerosol under the detached flap,
they observed a decrease in the incidence of hematomas. Others such as Fezza et
al.20 reported only a reduction in
edema and ecchymosis, without statistically significant differences in the
incidence of hematomas. The plateletbased sealing gel is an alternative, but
further studies are needed to define its potential in the prevention of
hematomas17.
Still in the operating room, soon after surgery, the patients were positioned
with their head elevated to 30° and received cold compresses on their face,
which were systematically changed every 30 minutes, to generate
vasoconstriction. After hospital discharge, we recommended strict maintenance of
ice therapy 30 minutes for 48 to 72 hours.
According to the literature, the incidence of hematomas following face-lift is
0.2% to 8%, and in men, this incidence can reach 12.9%8-16.
Before the adoption of the systematization in 2015, we observed an incidence of
3.43%, and after implementation, the incidence became 1.66%, which represents a
decrease of approximately 48.4%. The current index is close to the lower limits
reported in the literature. With the data analyzed, we did not reach statistical
significance. However, it is important to emphasize that the incidence has been
decreasing, as the last 177 cases analyzed showed no incidence of hematomas.
CONCLUSION
After analyzing our series of cases and the data in the literature, we observed a
significant reduction in the incidence of hematomas following rhytidectomy over
the years with the use of the proposed standardization. The set of proposed
measures acts synergistically to reduce the incidence of this serious
complication. In our opinion, none of these measures alone would be able to
achieve such a reduction in hematoma index.
Although the sample size was insufficient to prove statistical significance (p
> 0.05), we are convinced that the numbers are promising. Despite that
hematoma is the most frequent complication in face-lift surgery, the number of
surgeries was relatively small, which makes the expansion of the series of cases
essential to obtain more robust data. However, it is important to emphasize that
systematization has been progressively consolidated in our service, and
consistency must be maintained in the application of the protocol, and the
adequate data must be collected, always with the aim of obtaining the best
possible outcome for the patient.
COLLABORATIONS
TCTC
|
Analysis and/or data interpretation, conception and design study,
conceptualization, data curation, final manuscript approval,
investigation, methodology, project administration, realization of
operations and/ or trials, resources, supervision, visualization,
writing - original draft preparation, writing - review &
editing.
|
WFFJ
|
Analysis and/or data interpretation, conception and design study,
final manuscript approval, investigation, project administration,
visualization, writing - original draft preparation, writing -
review & editing.
|
CEGL
|
Analysis and/or data interpretation, conception and design study,
final manuscript approval, methodology, project administration,
supervision, writing - review & editing.
|
FXC
|
Analysis and/or data interpretation, conception and design study,
data curation, final manuscript approval, formal analysis, writing -
original draft preparation, writing - review & editing.
|
LML
|
Analysis and/or data interpretation, conception and design study,
data curation, final manuscript approval, formal analysis, writing -
review & editing.
|
LRL
|
Analysis and/or data interpretation, conception and design study,
data curation, final manuscript approval, formal analysis, writing -
review & editing.
|
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1. Cló & Ribeiro Cirurgia Plástica, Belo
Horizonte, MG, Brazil
2. Clínica Leão, Belo Horizonte, MG,
Brazil
3. Universidade Católica de Minas Gerais,
Faculdade de Medicina, Betim, MG, Brazil
4. Fundação José Bonifácio Lafayette de Andrada,
Faculdade de Medicina de Barbacena, Barbacena, MG, Brazil.
Corresponding author: Ticiano Cesar Teixeira
Cló Alameda Oscar Niemeyer, nº 1268 - Vila da Serra, Nova Lima, MG,
Brazil Zip Code 34006-065 E-mail: ticianoclo@gmail.com /
felipeclo@hotmail.com
Article received: August 31, 2018.
Article accepted: November 11, 2018.
Conflicts of interest: none.