Analysis at consultation and preoperative preparation of the patient before rhytidectomy

Before the initial consultation with a patient who is scheduled for a rhytidectomy, it is important to take care of the appearance of your office. The initial contact with any cosmetic surgery patient begins with an inquiry during a telephone call. At this time, the patient may not yet have reliable information about you as a surgeon to make a decision about a consultation visit with you. The person answering the phone at your office should have a friendly and pleasant voice, be very knowledgeable, and be eager to provide reliable information to the potential patient. However, it is not their job to consult over the phone, as this is the job of the doctor. The question of prices will inevitably arise, and this conversation should not interfere with the patient's visit. The prices asked should be within the competitive range for your area.

When making a short appointment, the patient should receive a comprehensive information pack regarding the procedures to be performed, as well as a booklet or brochure with more information about the procedures that are of interest to them. Well-written, informative brochures and consultation booklets are preferred by thoughtful and discerning patients. These may be academic brochures for each procedure, but the pack should also include the personal information you want to convey to the patient. This will really shorten the consultation and improve the relationship-building process. A well-informed patient who begins communication with the doctor on this level is more likely to be satisfied after the procedure.

The day of the consultation may involve several meetings with your key staff. While advance information about what will happen in the office and what to expect on the day is helpful, the most important meeting for the patient is with the surgeon. It is important that this unhurried, private, and confidential conversation takes place as soon as possible after the patient arrives, and the consultation should begin promptly on time - this will highlight the importance of this patient to you and may be a key moment in the relationship with him.

Immediately prior to meeting the patient, it is advisable to have a photographer take photographs of the patient. A high standard of consultation in modern facial surgery is to visually reconfirm what you think he or she can expect from the operation. A discerning patient in a marketplace will usually insist on this.

During the initial one-on-one consultation, it is important to establish a direct rapport with the patient. It is important to understand the patient's motivations for wanting to improve his or her facial appearance. Is the patient's underlying problem amenable to correction with a standard rhytidectomy? Often, the underlying problem is true superficial facial wrinkles that are more appropriately treated than a facelift. If the patient is primarily concerned with deep buccal-labial furrows and less concerned with the jawline and sagging skin and fat under the chin, a rhytidectomy (more accurately termed a facelift) may not be the appropriate procedure.

The surgeon, with the patient's help, must determine the patient's true motivation for undergoing surgery. A change in life situation, such as divorce, is not in itself a contraindication to facial plastic surgery. However, patients who hope that cosmetic surgery will solve life problems may not be good candidates for the procedure. Those who genuinely believe that they are doing it to enhance their self-esteem, rather than for someone else, are more likely to experience psychological satisfaction. Patients should have a realistic idea of what surgery can and cannot achieve, and the surgeon should provide this information during the consultation.

To determine the expected rate at which tissue elasticity loss and the overall aging process will occur, it is important to evaluate family history. It is necessary to establish lifestyle and social habits that accelerate the aging process (frequency and degree of sun exposure, smoking, etc.).

The patient should complete a detailed anamnestic questionnaire. It is important to establish whether the patient has had previous cosmetic or other surgeries, whether there have been any drug intolerances or complications from anesthesia. This is usually firmly imprinted in the patient's memory. It is very important to prepare the patient for an appropriate positive psychological experience. If the patient is frightened by anesthesia or the very thought of surgery, it is necessary to extinguish this by focusing on the positive aspects of what can be achieved as a result of surgical intervention.

It is certainly important to take a complete medical history to determine if there is any medical condition that would prevent cosmetic facial surgery. Cardiovascular disease itself is not a contraindication to surgery, but a cardiologist should be consulted before surgery. Of course, unstable heart disease is a contraindication to any anesthesia and surgery. It is important to evaluate liver and kidney function to determine the patient's sensitivity to anesthetics. Allergic reactions to any medications that are planned to be used during surgery and pain relief should be taken into account.

There are few diseases that prevent facelift. In particular, these include progressive autoimmune diseases affecting the skin of the face. Scleroderma and systemic lupus erythematosus are not contraindications to surgery if there are no manifestations of the disease on the face. Some other autoimmune diseases should be treated with caution, especially paying attention to the drugs that the patient takes to suppress the autoimmune response. They can suppress the patient's immunity or slow down the healing process. Neither diabetes mellitus as such, nor the constant use of corticosteroids, especially in low doses, are contraindications to surgery. A relative contraindication, depending on the involvement of the parotid glands and stagnation in the salivary glands, may be Sjogren's syndrome. The most important autoimmune diseases are those associated with perivasculitis.

A history of complete radiation therapy to the parotid or lateral neck areas precludes surgical intervention. Long-standing chronic circulatory impairment affecting microcirculation makes skin grafting too risky. The use of isotretinoin (Accutane), although uncommon (in terms of age) in patients seeking a facelift, is a relative contraindication to surgery. There is little evidence that isotretinoin may delay incision healing. Treatments that might interfere with the surgeon's use of a mixture of epinephrine and local anesthetic or a proven allergy to any local anesthetic are contraindications to performing a facelift, even with adequate hemostasis.

Obesity itself is not a contraindication to facelift surgery, as long as you take into account that the results of the surgery may not be satisfactory. A patient who is overweight and plans to lose a significant amount of weight in the next 3-6 months should certainly be advised to lose weight before undergoing a surgical facelift. A loss or gain of 10-15 pounds after surgery will generally not affect the overall outcome. In contrast, any patient who is in the middle of a diet that may lead to vitamin and nutrient deficiencies should be advised against undergoing surgery. Not only should the patient be healthy at the time of surgery, but a proper diet is essential for the healing process to proceed properly. Patients who are significantly overweight should be discouraged from undergoing a surgical facelift due to its inherent limitations, even when extensive liposuction is used. A facelift itself is not a weight-loss procedure, and thinning the skin of the midface is inappropriate and fraught with complications.

During the examination, the surgeon should be able to explain to the patient what outcome to expect from the rhytidectomy. A physical examination is absolutely necessary before the surgeon can show the patient on a computer screen the likely final appearance of the neck and cheek line. A good candidate for a facelift is a patient with slightly thickened skin, minimal sun damage, and retaining elasticity appropriate to chronological age. In patients whose skin has prematurely lost elasticity, despite its smoothness and lack of photodamage, the improvement may be very short-lived.

Obese patients with thick skin should not expect too much from rhytidectomy. This concerns not only the achievement of initial results, but also the period during which the soft tissues will maintain tension and elevated position may be shorter than average due to the increased tissue mass and the action of gravitational forces.

The obvious loss of elasticity of the cheek tissues, as well as the laxity of the skin, platysma, and submental fat, would seem at first glance to be a reason to plan a facelift as an appropriate procedure for the patient. Of course, the expected improvement should largely justify the surgical intervention and the possible risks. There are patients with very minor soft tissue sagging or other signs correctable by a facelift who should be advised either to undergo other procedures or to return later when the signs of aging have become more pronounced and surgery is appropriate. Today's patients have become more discerning about the timing of a facelift. The surgeon must be responsible for not recommending, and the patient must not insist on, an operation with questionable benefits.

Patients suitable for surgical facelift may have a prominent chin and strong bone structure, particularly prominent malar bones. Patients with heavy cheeks and minimal malar eminences may be disappointed with the outcome of an isolated soft tissue lift. Improving facial contours can be achieved by augmenting the malar eminences. In addition, submalar augmentation is often required to achieve the rejuvenating effect of a standard facelift when there is hypoplasia or loss of subcutaneous soft tissue in the midface due to congenital causes or the aging process. An alternative to these two techniques is a midface lift or a hybrid facelift approach. Patients with class II malocclusion, hypoplasia of the chin, or microgenia have similar difficulties in achieving a good neck line. In such cases, bite correction or at least alloplastic chin augmentation is indicated during a facelift to achieve satisfactory aesthetic results. One of the obvious advantages of pre-operative video recording is that it allows the patient to observe the results of the lift obtained during interventions on soft tissues or after modification of bone structures.

It is important for the surgeon to determine the cervicomental angle, which is determined by the underlying muscle tissues and the position of the hyoid bone. Many patients have difficulty achieving cervical angle improvement due to the low position of the hyoid bone, and this must be carefully demonstrated to them in the mirror and on video. The surgeon should not simulate an overcorrection of the cervical angle on the computer but should take into account the true angle of the underlying tissues of the patient's neck to avoid creating a false or unrealistic impression of what can be achieved with a facelift. It is ethically important to demonstrate to the patient the correct possible results of a facelift. This may affect the patient's satisfaction with the surgeon. Repositioning the hyoid bone or reshaping the digastric muscle has been described but is not recommended in the cervical portion of a standard rhytidectomy. It is important to understand what can be achieved with formative lipectomy and platysmaplasty, which can sometimes give excellent results but have their own limitations.

Before the end of the consultation, the surgeon should answer all of the patient's questions and discuss the operation in general, its possible alternatives, dangers, and limitations. A fully informed patient understands the risks and benefits of surgery and the alternative treatments that may be used in his or her case. The patient should understand what will be done during the operation and how, even if he or she does not understand or does not want to know the details of the surgery. The complications of rhytidectomy, or facelift surgery, will be discussed at the end of the chapter. The patient should at least be adequately informed of their possibility and relative frequency. The dangers of anesthesia should be discussed in general terms, in terms of choices and alternatives. But questions about the dangers of specific anesthetics can be clarified by the physician (anesthesiologist) administering them.

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