Endotracheal General Anesthesia & Facelift Surgery

Plastic surgeons have long known facelift surgery performed under general anesthesia requires a longer recovery due to the side effects from the general anesthesia administered during surgery. Addressing post-surgical facelift swelling has always been an important factor to most facelift surgeons. However, facelift surgeons have never figured out how to reduce it when the procedure is performed under general anesthesia. The face swells in recovery when the patient’s blood pressure goes up.

facelift swelling

Alabama facelift surgeon Dr. Paul Howard is board certified and is one of the top facelift surgeons of the South. Dr. Howard also offers mini face lift, neck lift, eyelid surgery, rhinoplasty, brow lift, cheek augmentation, ear pinning surgery, and fat grafting to the face. Schedule your facelift consultation with Dr. Howard today 205-871-3361.

General anesthesia is a state of reversible coma induced by intravenous drugs and inhalation anesthetic agents. The effects of the drugs and inhalation agents cause the entire body to become insensate, cannot feel pain, and have both amnesia and what is called, retrograde amnesia, so that the patient has no recollection of the surgical events or the preceding days in some instances.

While under the effects of the anesthetic drugs, the CRNA (Certified Registered Nurse Anesthetist) under the supervision of the MD Anesthesiologist, must control all bodily functions, mainly breathing and oxygenation, blood pressure and patient awareness. About one in twenty thousand patients experience awareness and pain even while under the effect of the anesthetic agents.

Very few patients die under general anesthesia (one in three hundred thousand). They are usually the highest risk patients who are ill and at the extreme of the age groups: either very young or very old. People “allergic” to an anesthetic agent or have a congenital disease that effects the metabolism of certain drugs is even rarer yet. Malignant Hyperthermia Syndrome is a reaction to certain anesthetic agents and is also very rare.

The anesthetic agents have improved incrementally over the last thirty years but have not improved the incidence of minor complications such as memory impairment (post-operative delirium), prolonged sleepiness, inability to urinate, sore throat, muscle aches, nausea and vomiting. Another complication which could be considered minor is swelling after head and neck surgical procedures, and sometimes whole-body edema.

Swelling is considered more of an expected sequella than a complication because it happens uniformly, especially in patients over fifty and those with high blood pressure.

The practice of administering anesthesia has changed dramatically over the last three decades. It used to be the convention, and still is in hospitals, for the MD Anesthesiologist to be present for the induction of anesthesia, including the securing of the airway, and for the emergence from and reversal of the anesthetic agents. It was assumed that these are the most dangerous parts of the “anesthetic flight”: likened to the take-off and landing of an airplane.

Now the take-off and landing must be safer as many office operating facilities do not require the presence of an MDA for general anesthetic procedures. This is true for virtually all the office-based operating facilities that provide cosmetic plastic surgery delivered under general anesthesia.

Alabama State Board of Medical Examiners and the Alabama State Board of Health-Division of Licensure and Certification require registration with the state and the practice of general anesthesia to be performed by competent licensed personnel working under a physician certified and licensed in the State of Alabama. There is no actual requirement for a CRNA or an MDA to preside over general office-based surgical anesthesia.

Fifteen years ago, unhappy with the way general anesthesia was being delivered without the presence of an anesthesiologist, we began working on the techniques used today in our practice to perform facial plastic surgery under specialized local anesthesia with oral sedation.

Two things became clear immediately: The patients were happier not suffering from the effects of general anesthesia and they had very little facial swelling and bruising causing their recovery to be much shorter and more comfortable. A second and equally important improvement was that the procedures are done in the office without the high OR and anesthesia fees charged for general anesthesia.

Local anesthesia is least likely to cause side effects. Local anesthesia with sedation requires much less of the strong medicines that shock the system and therefore is always preferred for older patients who may take a number of medicines that would interact with general anesthetic agents and who would take longer to emerge from general anesthesia sometimes requiring professional care for a day or two after surgery.

Younger patients, who usually have jobs and family commitments, simply prefer the cost and much shorter down times for return to normal activities.

Some discerning shoppers ask what kind of facelift can be done under local anesthesia, usually having been told only minor or skin-only facelifts can be done under local. The fact is that I do the same facelift I used to do when I used general anesthesia. In fact, the facelift I now do under local is much more intricate and modern than before as shown in our facelift gallery of photos at Continue reading

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The Howard Lift: A Modern Facelift

Self-esteem, or more importantly, the lack of self-esteem is an expected occurrence in a society that pays a high premium on the physical attributes of the body and face. The premium that is placed on good looks is not debatable, it has been a well -documented fact for almost a century. The proof is found in the amount of money that is spent every year on cosmetics, weight loss schemes, hair care products, scar and wrinkle creams and the myriad of other commodities used to maintain an attractive, healthy body and a youthful face and neck.

The premium society exacts on us can affordably be paid with a healthy exercise program, a reasonable diet, a good skincare program including a sunblock, staying away from nicotine and in some cases, appropriately timed and well thought out plastic surgery.

The science behind the latest lotions and potions to attack facial wrinkles is a multi-billion-dollar industry. These products, all of which work if actually used on the face and not allowed to languish on the bathroom counter. They are a good investment realizing the limitations of what can be achieved in an aging face only using products applied to the skin. Improved texture-yes, fewer discolorations-yes, fewer fine wrinkles-yes, improved coloring-somewhat, improved stretch marks- not likely and tighter, lifted face and neck skin-never.

facelift

Dr. Paul Howard is board certified in plastic surgery and is one of the top facelift surgeons of the South. Dr. Howard also offers mini face lift, neck lift, eyelid surgery, rhinoplasty, brow lift, cheek augmentation, ear pinning surgery, and fat grafting to the face. Schedule your facelift consultation with Dr. Howard today 205-871-3361.

Once the effects of gravity are in full effect, it is the rare person who can reverse the sagging without a surgical procedure. The timing of that procedure will determine how much surgery is necessary; the earlier in the aging process, the less surgery.

As a general rule, when the lower eyelid dark crescents reveal themselves, the nasolabial folds deepen, marionette lines form between the corner of the mouth and the chin-jaw area and the once tight jawline is interrupted by “bubbles” of fat that represent cheek fat and skin sliding down toward the neck, then anti-gravity, lifting surgical procedures are necessary.

Facelifts, especially among baby boomers, have long been thought to be prohibitively expensive and thus available only to the few. Thus, plastic surgery is summarily dismissed as family and personal issues take precedence. Self-sacrifice becomes a way of life and self-esteem suffers, becoming very difficult to retrieve even with a successful diet and a perfect skincare regiment. The entire mass of skin and fat tissue from the lower lids to the jawline must be lifted, separately, which is the basis of the mid-face portion of the modern facelift.

What is a modern facelift? Modern is a deceptively simple word with many meanings. A modern facelift is new, fresh and up-to-date as well as novel and innovative. To create a modern facelift sounds complicated but is deceptively simple for the plastic surgeon with an open mind and open ears. Two of my mentors, Dr. John Kirklin and Dr. Ralph Millard, coming from different backgrounds and directions (cardiac surgery and plastic surgery), both taught that if you listen carefully, the patient will tell you what’s wrong and what they want from you as a doctor.

The modern facelift evolved from listening to patients with a completely open mind and blessed with a full toolbox of plastic surgery principles from which to choose and a creative disposition finding no limits to what is possible.

A background in chemistry and anatomy has helped base the modern facelift securely in the realm of medical science; just as Dr. Kirklin would have demanded and Dr. Millard has written in Principalization of Plastic Surgery.

The first patient requests for something new in facelift surgery was the most challenging and time consuming but had not been addressed in the plastic surgery literature in recent history. Not a single person wanted to undergo general anesthesia to have a facelift, regardless of who administered the anesthesia. Was it perceived danger, expense or the fact that general anesthesia requires a large volume of strong drugs that make people sick? From the patient’s viewpoint, it was all the above. From the plastic surgeon’s viewpoint, it is the wild fluctuations in blood pressure these strong drugs cause as well as bruising, swelling, hematomas and a longer recovery that occur with all general anesthetic protocols.

My unique use of three different and pharmacologically distinct local anesthetics was devised and in use today. The combination of local anesthetics burn less when injected, work quicker to make the face and neck numb and last longer reducing postoperative pain- all desirable traits. Each of the local anesthetics is augmented by epinephrine which helps to keep blood loss to a minimum.

Oral sedation was chosen for the smoothness of onset, the slower metabolism of the drugs and the minimal effect on blood pressure greatly reducing the risk of hematoma. The oral sedation can be adjusted as necessary during the procedure per the tolerances of the individual patient and the amount of sedation desired.

Patients requested for the modern operation to offer an equivalent result to other facelifts done under general anesthesia with incisions as short as possible. Initially, the short incisions sounded like a deal breaker but upon further consideration there are certain maneuvers concerned with the order and type of suturing that can shorten the incisions behind the ear. It was discovered that certain incisions in front of the ear served no purpose in making the results better and were dropped. While not exactly a “short scar” facelift, the modern facelift is definitely a “shorter scar” version of our previous facelifts.

All patients requested less swelling with less downtime and a quicker return to work and normal activities. Everyone wants this and all plastic surgeons try to accommodate this request with very little success unless they adulterate or simplify the facelift procedure to be less invasive compromising the result. We realized almost immediately that the swelling was much less about the operation as performed but was mostly a product of general anesthesia, regardless of the agents used to put the patient asleep or anesthesia provider-nurse or doctor. Changing from general to local anesthesia reduced our postoperative swelling, all other factors being equal, by at least 75%.

Even with improvements in swelling and down time with local anesthesia, more was needed as this was one of the more important requests. It was almost as important as cost. It was clear that the more so-called dead space that existed during the dissection of the face, the more hematomas, both large and small, and resultant swelling and bruising occurred. After the multi-vector, tightening of the SMAS, we began to use what is called progressive- tension- suturing which allows for maximal skin tightening with minimal dead space, minimal bruising and minimal tension on the skin closure helping reduce unwanted scarring and downtime.

This suturing technique may sound too good to be true but it is well known, but not for facelift surgery. The technique also allowed us to decrease the size of drains and the length of time they are necessary. Our drains are hand-made from 21-gauge butterfly needles and are removed in less than twenty-four hours as the dead space to be drained is minimal. These “micro-drains” require only hemovac tubes as the suction and drainage receptacle usually draining no more than a teaspoon of blood per side.

It is common for patients to inquire about the facelift and its effect on the mouth and perioral area. The answer is that the facelift, by itself, does not help rejuvenate the mouth. This was about the time fat grafting and Dr. Sidney Coleman burst on the plastic surgery scene. Using his new fat processing techniques, we were able to use a person’s own abdominal fat (or any fat for that matter) and inject the fat into the wrinkles and areas around the lips to rejuvenate, thinner, aging lips –permanently.

Although not a specific patient request, adding contour to the effacement (flattening) caused by tightening and elevation of the cheeks was a constant struggle. Fat injections in the cheek area answered a lot of plastic surgeon’s prayers. We now could offer rejuvenation in a permanent fashion to the cheeks, lips, peri-oral area, nasolabial folds and marionette lines with fat injections. Unlike many other modalities, fat injections can be revised easily and are considered permanent. Most patients request more fat rather than less.

The lower eyelids and their contribution to the mid-face aging process was all that was left to tackle even though it rarely was a request except by the most discerning of patients. The lowering of the thin eyelid skin from the effects of gravity onto the upper cheek with its intendant dark crescent circles and tear trough deformity could not be left unaddressed. This required lower eyelid blepharoplasty, cheek-lid blending, fat manipulation and sometimes fat grafting in the tear trough. This is most effective when done simultaneously with the modern facelift.

Today, our recommended surgical procedures, when indicated, for facial rejuvenation all fall under the rubric The Modern Facelift:

 Short scar facelift incisions with multivector SMAS plication, intraoperative open neck liposuction with jawline refinement, progressive tension suturing, micro-drains, fat injections to the cheeks, peri-oral, nasolabial folds, marionette lines, tear troughs and lower blepharoplasty with fat manipulation, septal closure, cheek-lid blending and temporary lower lid suture tightening. Anesthesia is multi-agent local anesthesia with oral sedation augmented with IM Toradol and clonidine to blunt the systemic effects of epinephrine. The price is under $10,000 all inclusive.

Realizing our increased life expectancy, more people question how long the modern facelift will last. This is what Dr. Millard called a crystal ball question. He had a crystal ball on his desk that he referred to the patients accentuating the complexity of predicting the unknown. He would then explain that the answer depended on you, the patient, more than the surgery performed. He also would explain that aging is a continuous, life long process and any further surgical procedure may depend on the patient’s tolerance for imperfection rather than an identifiable time frame.

When pressed he would usually say five years which seemed to please most people as a reasonable number. I tend to offer three years since my tolerance for imperfection is less than most and we have developed a number of inexpensive “tuck-up” procedures that address the aging issues that tend to re-occur more quickly than other aspects of normal aging regardless of the type and extent of the plastic surgery performed.

All requests by patients for further surgical refinements are encouraged will be considered so that the modern facelift remains “modern.” The last provision of the modern facelift is to continue listening to patients and follow their lead to avoid, at all costs, the “rut of routine.”

The Misunderstood Facelift

Facelift procedures have been a part of the plastic surgery lexicon since the early 1900’s. At that time, there were no board certifications, Teddy Roosevelt was President, the Great World Wars had yet to begin and antisepsis and anesthesia were in their infancy. Against this backdrop of medical history facelifts, eyelids, and rhinoplasty were performed in doctor’s offices and in front of crowds of people for marketing purposes. Howard Crum, MD wrote of his experiences with live surgery demonstrations in front of “thousands” of rapt on-lookers as well as a number of psychologically disturbed voyeurs hoping to see some blood and maybe a mishap or two. Cosmetic surgery was done in hotel lobbies, at conferences, and in ballrooms to standing-room-only crowds punctuated with a police presence. The surgeons performing these dramatic operations were the “rock-star” doctors of the day carrying reputations about reproach. As the market for these surgeries expanded the number of unscrupulous practitioners increased dramatically. The unskilled and poorly trained surgeons were making a mockery of cosmetic surgery and in fact, became dangerous to the point where one such surgeon tried to make a patient taller by breaking her legs and resetting the normal bones. Unfortunately, the patient lost both of her extremities. Reputable surgeons responding to these rogue doctors tried to limit physician marketing seeing these advertisements as a way to circumvent the tried and true patient referral sources which tended to enrich doctors with good results at the expense of those whose results were not as good. Marketing expertise had taken the place of surgical expertise. Plastic surgical training programs began to spring-up across the country after WWI where the horrific injuries associated with “trench” warfare were shipped to England and the USA for reconstruction. The best surgeons were on the front lines of repairing war injuries and as far back as the 1920’s Sir Harold Gillies of England and New Zealand was of the early proponents of the so-called “cosmetic reconstruction.” That is, reconstructive surgery of the face with the ultimate goal being not only a good or reasonable appearance but an attractive face. Dr. Gillies and his famous trainee, Dr. Ralph Millard, wrote a textbook to this effect in 1954 and Dr. Millard continued to be the “poster child” for the relationship between reconstructive and cosmetic surgery. It sounds foolish and ignorant for a surgeon to claim some sort of providence in facial aesthetics yet offers no educational training or pertinent experience as a surgeon to back up their improvable claims of superiority in our field of plastic surgery. In fact, aesthetic considerations are so pervasive in the plastic surgery residency that almost every patient and every challenge, whether cosmetic or reconstructive, is evaluated under the prism of Drs. Gillies and Millard. We aspire to surpass the normal and attempt to achieve the “Ideal Beautiful Normal” (D. Ralph Millard, MD).

Trying to answer the question “who are the best cosmetic surgeons” is impossible because the question applies to each individual surgeon and not entire groups of surgeons. On a group basis, competence can only be determined by training and education, and subsequent certification and not by marketing skill.

Dr. Howard has been a Top Facelift Plastic Surgeon for over 20 years.  To learn more, please visit his web sites:

Read more about top facelift surgeon Dr. Paul Howard in Birmingham, Alabama.

Read more about Dr. Paul Howard’s popular short incision face lift with no general anesthesia.

The Mid-Facelift by Paul S. Howard, MD, FACS

Facial aging is complicated by genetics, environment, sun damage, smoking, and drinking.  There is not a single procedure that works for everyone, therefore it is important that individualized evaluation leads to an operation which is specific for that person.  The uniqueness of all faces as well as the patient’s desires may lead to a slightly different surgical approach for each individual.  Another way to say this is that the one-size-fits-all facelift has become antiquated.  To facilitate individualized care we prefer to look at each part of the face separately leading to a unique surgical treatment plan.

We divide the face into its component parts; forehead, eyes, midface, and neck with primary emphasis on the midface.  Midface aging is characterized by sagging of the facial soft tissues causing a deepening of the nasolabial folds, dark circles beneath the eyes, and the development of marionette lines from the corner of the mouth to the jaw line.  The jaw line becomes less defined as the sagging facial soft tissues drop below the mandible causing jaw line “bubble.”  In addition to the sagging soft tissues aging always involves a loss of volume and a loss skin elasticity.  It is the surgeon’s charge to address individual manifestations of aging for each component part of the face.  Elevating the soft tissues must be done and requires a specific vector or direction of elevation which may be unique for each face.  This maneuver defines the jaw line, improves the deep nasolabial folds, addresses the marionette lines, and elevates the lower eyelid skin.  This procedure is always required and must be performed accurately with minimal incisions.  Elevation of the cheek tissues is so important that it must be done under direct vision with the results being technique dependent.  The incisions are much less obvious than the old facelift scars.  While elevating the cheek and malar tissues some augmentation of the malar prominence (cheek bones) is achieved.  The need for additional volume can be affected by adding autogolous fat to the procedure.  As a rule of thumb, we rarely, if ever, remove fat from the midface but frequently add fat back to replace the soft tissues we lose over time.

The next issue to be addressed is the blending of the cheek elevation with the lower eyelids.  These procedures are typically done together; that is lower blepharoplasty and midface lift.  The elegance and effectiveness of the midface lift sets up the rejuvenation of the remaining parts of the face.

Dr. Paul Howard

Read more about Dr. Paul Howard’s minimal incision face lift with no general anesthesia.