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Rapid recovery protocol reduces post-op downtime

Article-Rapid recovery protocol reduces post-op downtime

New York— It isn't difficult to understand what a patient likely wants from his or her facelift surgery. The patient wants to look great, without looking like they had surgery, and they want the results to last. But a patient also wants to return to normal life as soon as possible. At the crux of plastic surgery is the expectation of improved recovery time. David Rosenberg, M.D., P.L.L.C., has not only improved recovery time, but has done it without compromising the facelift's outcome.

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."

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