Smoking increases the risk of skin slough, the second most common complication after facelifting.1 Patients are encouraged to quit smoking permanently. Cigarette smoking, with all its deleterious effects on health, and having a facelift to feel better about oneself are fundamentally contradictory. At the very least, patients should cease smoking 2 weeks prior to surgery. It is important that smokers know that they will never become “nonsmokers”; that is, the effects of smoking never totally disappear and are certainly not gone in 2 weeks.

Because aesthetic surgery is elective, whenever there is a question about a preoperative medical condition, the procedure is postponed until appropriate consultations are obtained and all issues settled.

Photographs are essential for at least four reasons: (a) assistance in preoperative planning; (b) communication with patients preoperatively and postoperatively; (c) intraoperative decision making; and (d) medicolegal documentation.

One of the most difficult challenges for the plastic surgeon is deciding which patients are not candidates, on an emotional or psychological basis, for elective aesthetic surgery. Studies suggest that patients frequently harbor secret or unconscious motivations for undergoing the procedure. A patient may state that he/she wants to feel better about himself or herself when the real motivation is to recapture a straying mate (unlikely to succeed).

Patients who have difficulty delineating the anatomic alterations desired or in whom the degree of the deformity does not correlate with the degree of personal misfortune ascribed to that deformity are not candidates for aesthetic surgery. The demanding, intimidating, 50-year-old lawyer who states that she does not like her jowls is a far better candidate than the seemingly docile patient who cannot articulate what bothers her and defers to “whatever you think doctor.” The surgeon will regret proceeding with an operation when his or her instincts indicate that the patient is an inappropriate candidate.

At the time of the preoperative consultation, the patient is given written information concerning the planned procedure that reinforces the verbal information provided.

In addition to describing to the patient the anticipated results of the procedure, it is necessary to point out the areas where little or no benefit is expected. As described above, the
nasolabial creases may be softened slightly by a facelift but will reappear when the swelling disappears. Ptotic submandibular glands preclude a totally clean appearance to the neck. Fine wrinkles around the mouth will require a resurfacing procedure.

Patients are instructed to shower and wash their hair on the night before surgery. On the morning of surgery another shower and shampoo are desirable. At a minimum, the face is thoroughly washed. Although patients are not allowed to eat anything after midnight, they are instructed to brush their teeth and rinse their mouths with mouthwash.

Given that the single most important step in avoiding a hematoma is control of the blood pressure, patients with any tendency to high blood pressure are given clonidine 0.1 mg by mouth preoperatively. Some surgeons administer the drug routinely to all patients. Clonidine is long-acting, however, and may lead to hypotension in healthy patients. Consequently, this author prefers to use it selectively.

An ideal anesthetic for facelifting would be associated with a constant blood pressure and no need for vasoactive medications to either raise or lower it. Dips in blood pressure treated with vasoconstrictors, or spikes in blood pressure treated with vasodilators, are to be avoided if at all possible. Blood pressure is ideally kept at approximately 100 mm Hg systolic, depending on the patient’s preoperative blood pressure. Excessive hypotension may obscure bleeding vessels that are best coagulated. Hypertension may be associated with excessive bleeding. The anesthesiologist should inform the surgeon of every medication administered, and the surgeon should inform the anesthesiologist of any increased tendency for bleeding. There are no secrets in the operating room. The surgeon will be managing the patient postoperatively so it behooves him/her to learn as much as possible from the anesthesiologist about the particular patient’s blood pressure and response to any agents employed intraoperatively.

Regardless of the type of sedation/anesthesia chosen, the face is injected with local anesthetic solution prior to the dissection. There is some controversy and little definitive data regarding the maximal amount of local anesthetic that can be used. The package insert in the lidocaine bottle states that no more than 7.5 mg/kg of lidocaine should be administered when given in combination with epinephrine. We know, however, that when dilute solutions are used in liposuction of the body, more than 30 mg/kg of lidocaine is safe. There is evidence that the face differs from the body and that the lidocaine doses used in the body are too high for the face. It is reasonable to conclude that doses higher than the 7.5 mg/kg recommended by the manufacturer but less than the 30 mg/kg used in the body are probably safe in the face, but this is unproven. Until such proof exists, plastic surgeons should limit the total dose to approximately 7.5 mg/kg. In the author’s practice, the author dilutes 500 mg lidocaine (one 50 mL vial of 1% lidocaine, which is the approximate maximum dose for a 70-kg patient) to whatever volume is necessary to perform the entire procedure, no matter how dilute that solution is.

The most common solution used by the author is 50 mL 1% lidocaine plus 1 mL epinephrine 1:1,000 plus 250 mL normal saline for a final volume of 301 mL and a final solution concentration of 0.17% lidocaine with epinephrine 1:300,000.

Because of the dilute nature of the solution used and the fact that the total dose of lidocaine does not exceed the manufacturer’s recommendation, the author usually injected both sides of the face at the beginning of the procedure, despite recommendations by some that only one side should be injected at a time. If the patient has an especially heavy neck or is a large male patient, the author may inject one side at a time because the first side will be more time-consuming than average.

If the patient is adequately anesthetized, the injection of the anesthetic solution is rarely accompanied by any change in heart rate or blood pressure. The surgeon must constantly keep the injecting needle moving, however, to avoid a large intravascular injection of the epinephrine-containing solution. If a major change in blood pressure occurs, the surgeon and anesthesiologist must assume that an intravascular injection has occurred and must act quickly to limit the extent of hypertension.

There are five layers of critical anatomy: skin, subcutaneous fat, the SMAS-muscle layer, a thin layer of transparent fascia, and the branches of the facial nerve (Figure 47.2). These five layers are present in all areas of the face, forehead, and neck, but they vary in quality and thickness, depending on the anatomic area.

The first two layers, the skin and subcutaneous fat, are self-explanatory. The third layer (SMAS) is the most heterogeneous.2 It is fibrous, muscular, or fatty, depending on the location in the face. The muscles of facial expression are part of the SMAS layer (e.g., frontalis, orbicularis oculi, zygomaticus major and minor, and platysma). In the temporal region, this layer is not muscular but is fascial in quality and is represented by the superficial temporal fascia (or temporoparietal fascia).

The fourth layer consists of a layer of areolar tissue that is not impressive in thickness or strength, but is always present and is a key guide to the surgeon as to the location of the facial nerve branches. In the temporal area, this layer is known as the innominate or subgaleal fascia; in the cheek, it is the parotid-masseteric fascia; and in the neck, it is the superficial cervical fascia. Once under the SMAS, the facial nerve branches can be seen through this fourth layer. If the layer is kept intact, it serves as verification to the surgeon that he or she is in the correct plane of dissection. If a nerve branch is encountered without this fascial covering, the surgeon must be aware that the dissection is too deep and nerve branches may have been transected. Just as it is convenient, but not totally accurate, to think of the galea-frontalis-temporoparietal fascia-SMAS-orbicularis oculi-platysma as a single layer, it is useful to think of the subgaleal fascia-innominate fascia-parotid/masseteric fascia-superficial cervical fascia as a single layer.

The fifth layer is the facial nerve, which is discussed in detail below.

If the surgeon remembers that the facial nerve branches innervate the respective facial muscles via their deep surfaces, the safe planes of dissection become obvious. Dissection in the subcutaneous plane, superficial to the SMAS-muscle layer, is safely performed anywhere in the face, whether it is the temporal region, cheek, or neck. Dissection deep to the SMAS, superficial to the facial nerve branches, requires care.

There are three to five frontal (or temporal) branches of the facial nerve that cross the zygomatic arch and innervate the frontalis muscle, orbicularis oculi, and corrugator muscles via their deep surfaces.3 Because the layers of anatomy, although present, are compressed over the arch, these branches are vulnerable to injury in this region. Dissection in this region can either be performed superficial to the nerve branches in the subcutaneous plane, or deep to the branches on the surface of the temporalis muscle fascia (deep temporal fascia).4