TRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.com.
Since its introduction in the early 1900s, rhytidectomy, or “facelift,” has been one of the most commonly performed cosmetic procedures in facial plastic and reconstructive surgery for treatment of the aging face. Despite tremendous advancements in surgical technique and technology, the risk of hematoma remains significant as the most frequently encountered postoperative complication. The rate of hematoma after rhytidectomy ranges from 0.2% to 8% in the literature and is generally accepted to develop on average in around 3% to 4% of cases. The most well-described risk factors are high blood pressure and male gender, with males having more than double the complication rate as compared to females in some studies. Additional associations have been found with recent aspirin or nonsteroidal anti-inflammatory use, performance of anterior platysmaplasty, and smoking. Interestingly, large-scale studies have not demonstrated a significant relationship with facelift technique, revision surgery, anesthesia type, or patient age and comorbidities other than hypertension.
Hematomas may range in severity from minor bruising necessitating only conservative management to large expanding collections that require aggressive surgical drainage and may even pose a threat to the airway in extreme cases. Potential adverse sequela include increased patient discomfort, need for additional intervention, higher infection rate, and the risk for delayed wound healing, skin flap necrosis, and scarring. Numerous methods have been employed over the years in attempt to prevent hematoma formation after facelift; however, there still exists a significant variation in clinical practice. The most commonly used techniques are drain placement, compression dressings, and the use of tissue sealants. This review describes the evidence available from current literature to support a best practice for minimizing the risk of hematoma formation following rhytidectomy.
Certainly, there is no replacement for meticulous surgical technique and adequate intraoperative hemostasis in reducing the risk of postoperative hematoma after rhytidectomy. Interestingly, the series by Jones et al. found a higher hematoma rate in patients infiltrated with a tumescent solution containing epinephrine, presumably due to temporary vasoconstriction of small bleeding vessels that could not be identified at the time of surgery. Independent of their conclusions, if proper hemostasis is not achieved prior to closure, there is no drain or dressing that can reliably prevent postoperative complications from occurring.
The most commonly used adjunctive measures for minimizing the risk of hematoma formation in the postoperative setting are drain placement, application of tissue sealant, and use of compression dressings. In terms of drain use after facelift surgery, the majority of studies have failed to demonstrate a significant clinical benefit and do not support their routine use. The highest quality investigation, a prospective trial from 2007, did show a reduction in bruising with drain placement that the authors surmise may lead to more rapid return to regular activities and therefore greater patient satisfaction. When contemplating drain placement following rhytidectomy, this may be a factor to be considered against the potential downsides of this practice.
The literature for tissue sealant use is somewhat more controversial. As mentioned, a recent meta-analysis including three prospective randomized studies did not show a significant reduction in hematoma rate with tissue sealant use, although there was a trend toward improved outcomes. Another large series without drains did find a significant decrease in hematoma formation with application of tissue sealant; however, the study design was retrospective in nature. Until larger prospective studies are conducted, the routine use of tissue sealants during rhytidectomy is not clearly justified.
Last, although compression dressings have also not been shown to significantly improve outcomes following facelift surgery, a lightly placed pressure dressing may serve to enhance overall patient comfort and satisfaction in the early postoperative period. A recent study has demonstrated a reduction in hematoma rate with proactive control of pain, blood pressure, and vomiting in the acute postoperative setting. Although it is difficult to advocate a specific pharmacologic regimen based on the findings of this single investigation, the results highlight the importance of optimizing the patient environment both during and after surgery to minimize the risk of complications.
Taken together, the current literature does not definitively support one particular method for reliably preventing postoperative hematoma after rhytidectomy. Best practice recommendations based on available evidence include optimization of blood pressure throughout the perioperative period, meticulous surgical technique, and intraoperative hemostasis, as well as the use of a light compression dressing in the first 24 hours after surgery. Pain and nausea should also be adequately controlled in the postoperative setting to prevent abrupt increases in blood pressure and agitation at the surgical site. In higher-risk patients defined by hypertension, male gender, recent aspirin or NSAID use, extended anterior dissection, and smoking, consideration may be given for the use of tissue sealant and/or drain placement in attempts to reduce the incidence of postoperative edema, ecchymosis, and fluid collections, although this is not clearly dictated by current literature. (Laryngoscope. 2015;125:534-536).