T he demand for cosmetic surgery in persons of advancing age is increasing as the result of the coupling of two trends. First, the population of the United States is aging. As of the year 2000, approximately one in eight Americans was 65 or older, according to the United States Census Bureau.1 This percentage is expected to grow as the baby boom generation ages. Additionally, over the past several years cosmetic surgery has become more mainstream with the number of procedures performed each year steadily increasing over the past decade. The increased demand for cosmetic surgical intervention in the elderly raises the question of whether or not these patients can be safely and effectively treated. The elderly population is a heterogeneous group defined solely on the basis of age. This group includes healthy, vital individuals as well as debilitated, frail persons. For the purposes of this discussion we will define the geriatric population as being those persons 75 years of age and older. This seems a reasonable definition as the average life expectancy of a child born in 2002 is 77.2 years.2 Some might argue that the risk inherent in elective procedures is too great in the geriatric population. This line of reasoning overlooks the benefits of an improved appearance. Beauty is rewarded in our society in measurable ways, from improved self esteem to preferential treatment by those around us.3 A more youthful appearance supports a more vital frame of mind, which, in turn, has a positive effect on overall health. To deny these positive effects to a segment of the population on the basis of age would be unwarranted discrimination. In this article we explore face lifting in the geriatric population. We present a discussion of special considerations in the surgical treatment of geriatric patients and a few vignettes of representative cases of patients over 75 years old who have successfully undergone face lifting procedures in our practice. The Importance of a Pre-Op Assessment As the three cases presented in this article (see cases) illustrate, face lifting can be performed safely and effectively in elderly patients. Successful outcomes depend on appropriate pre-operative counseling and assessment, sound operative practices, and close follow-up with adequate support during the recovery period. The general principles of cosmetic surgery in the elderly are the same as for younger patients; however, deviations from these principles are less forgiving in the geriatric patient than in younger patients. As with all cosmetic surgeries, a successful outcome begins with a careful patient selection. During this phase, clearly delineate the patient’s cosmetic concerns and explain all treatment options. This should include a discussion of possible risks, likely course of post-operative recovery, and the range of results that may be expected. Time for the patient to ask questions and for the surgeon to be comfortable with the patient’s decision to have surgery must be allowed. Having a family member(s) present for the consultation is highly recommended. After the patient’s cosmetic concerns have been adequately addressed, assess the patient’s general health status. Chronologic age and physiologic age are sometimes disparate. A very fit 80-year-old may be a better surgical candidate than a 65-year-old with many comorbidities. Evaluating each patient individually and obtaining appropriate medical clearance from the the patient’s primary care physician and/or other specialists is in order. During this phase, give consideration to conditions that might place the patient at higher risk for adverse events. Patients can be categorized according to the American Society of Anesthesiologists general classification of physical status.6 (See Table I) By definition, patients over 80 years of age are placed in Class II. Make a special effort to identify any coexisting cardiovascular disease as this is the single greatest contributor to operative morbidity.7 The Goldman criteria and risk categories can be used to estimate a patient’s risk for post-operative cardiac complications.8,9 (See Tables II and III) Age greater than 70 years is assigned a point value of five in this scheme. During the pre-operative evaluation, be sure to do a thorough history taking and physical exam to actively seek symptoms of heart disease and other underlying conditions. An older patient who self nominates for cosmetic surgery may be so functional as to have never needed a thorough medical evaluation, and relatively asymptomatic diseases, such as hypertension, diabetes mellitus, and chronic renal insufficiency, may be present but undiagnosed. Additionally, assess the patient’s mental status and competency to make medical decisions. Planning the Surgery After medical pre-operative clearance is obtained, final preparations for surgery can be made. Before the operation, perform and review the following: an electrocardiogram, a chest radiograph, and laboratory evaluation including complete blood count, coagulation studies, liver enzymes, serum chemistries, blood urea nitrogen, creatinine, and urinalysis. Review the operative plan with the patient and clarify all pre- and post-operative instructions. Written information should be in a print size so as to be easily read,10 and all instructions should be simple to understand and follow. It’s helpful to include supportive family members or close friends in this stage of the process and to enlist their help in the surgical recovery period. Anesthesia for the procedure should be approached more carefully than in younger patients. Conscious sedation can be attained in an ambulatory surgery center setting with judicious use of midazolam and propofol (Diprivan).11 When administering these drugs, low initial doses are carefully titrated to the desired effect. Particularly, keep in mind the prolonged plasma half life of midazolam in the elderly.12 In the aging patient, volumes of drug distribution may be altered and hepatic metabolism and renal excretion may be impaired.13 This can result in increased sensitivity to the effects of the medicines administered and to a slower recovery from anesthesia. The use of adequate local and tumescent anesthesia is also important to reduce the depth of conscious sedation that the patient requires. When using local and tumescent techniques, you must track the total dose and volume of the anesthetic. It is also advisable to avoid excessive use of epinephrine, especially in patients with cardiac risk factors. To further ensure patient safety, monitor the patient’s vital signs continuously during and after anesthesia. During the procedure, strive to be efficient. Prolonged operative times increase the risk for complications including deep vein thrombosis from immobility. Shorter procedures also mean decreased exposure to anesthesia. If multiple procedures are indicated, they may be better tolerated when undertaken in separate surgical sessions. In this way operative times are reduced and the stress on the body to heal after the procedure is diminished. Also, ensure support of homeostasis during the procedure with oxygen supplementation and avoidance of hypothermia, both of which are beneficial to surgical patients.14,15,16 The Recovery Period In the post-operative period, follow the patient’s recovery closely with special attention to pain control, adequate hydration and good nutrition. Effective pain control is essential to ensure quick post-operative mobility. Immobile patients are predisposed to atelectasis and deep vein thrombosis. Pain medicines should be started at a low dose and titrated to the desired effect. As previously mentioned, altered volumes of drug distribution and slowed metabolism and excretion may make the elderly more sensitive to medications. Encourage proper nutrition. Some elderly persons consume very few calories or have diets lacking in variety. Suggest dietary supplementation with a multiple vitamin and protein-calorie drinks, since many face-lift patients have difficulty chewing due to tightness. Talk to the patient about the need to make arrangements to have adequate support at home to assist with dressing changes, the administering of medicines, and other necessary post- operative care. Assess patients frequently during the post-operative phase to be sure these issues are addressed and that the recovery from surgery is proceeding in a timely manner without complications. We recommend follow-up in person or by phone within 24 hours of the procedure with further follow-up schedules tailored to the procedure performed. Options for the Elderly Cosmetic surgery continues to gain broader acceptance by the general public. This trend coupled with the overall aging of the population in the United States will lead to an increased demand for cosmetic procedures in persons with advancing age. Face lifting can be performed safely and effectively for carefully selected patients in this group. However, even the healthiest elderly patients have limited physiologic reserves when compared with their younger counterparts creating a smaller margin for error in these patients. For this reason, every effort must be made to carefully assess the patient’s general health before surgery, to work efficiently and precisely during the procedure, and to maintain adequate support during the post-operative period. In so doing, the beneficial results of face lifting can be extended to the geriatric population. Case 1 A 75-year-old woman (BK) presented for evaluation of neck and facial skin laxity. She had a medical history of hypertension and her medications included cetirizine (Zyrtec) and ramipril (Altace). She subsequently underwent a minimal incision face and neck lift with liposuction of the neck and jowls4 and fat transfer to the nasolabial folds and oral commissures. The operation was performed under conscious sedation. She tolerated the procedure without complications. Her post-operative phase was without incidence, and she had a good aesthetic outcome. (Figures 1 and 2) After full recovery the patient desired more complete correction of her facial laxity. Three months after the first procedure she had a revision of her initial procedure and also underwent carbon dioxide laser resurfacing to her entire face.5 Again the procedures were performed under conscious sedation and were well tolerated. Her post-operative recovery was without complications, and she was satisfied with the final result. Case 2 A 75-year-old woman (MS) desired correction of facial rhytids and excess tissue of the face and neck. She was in generally good health, and her medicines included diltiazem (Cardizem, Tiazac), digoxin (Digitek, Lanoxicaps, Lanoxin), and hydrochlorothiazide/triamterene (Dyazide, Maxzide). She underwent a minimal incision face and neck lift with liposuction of the neck and jowls4 under conscious sedation. The procedure was tolerated well, and her post-operative course was uncomplicated. She was aesthetically pleased with the outcome. (Figures 3 and 4) Five years later she desired additional intervention for excess skin laxity. In the interim she had coronary artery bypass grafting. Her health was stable on a medical regimen of digoxin, metoprolol, famotidine (Pepcid) and aspirin. Because of her ischemic heart disease she was discouraged from pursuing surgical intervention. However, the patient insisted on further consideration. She held a family conference to discuss the issue with her children. She was still very busy with many social events and club activities and wanted a more youthful appearance to match her active lifestyle. A second consultation with her family members present was scheduled during which she clearly expressed her belief that the beneficial effects of her desired cosmetic surgery outweighed any inherent risk. Her cardiologist was consulted and gave medical clearance for her surgery. She underwent a repeat minimal incision face and neck lift with neck and jowl liposuction4 under mild conscious sedation without incident. No epinephrine was used in her local anesthesia and the doses of intravenous medicines used for sedation were carefully titrated for minimal effect. In the post-operative period her diet was supplemented with protein-calorie nutrition drinks. She again was pleased with the cosmetic result. Case 3 An 83-year-old woman (VM) presented for evaluation of lax skin of the face and neck. She was recently widowed, and part of her motivation for seeking intervention was that she had just begun dating again. She had a remote history of cancer of the cervix and vaginal wall. Her medicines included alendronate (Fosamax) weekly and fexofenadine (Allegra), triamcinolone nasal spray (Nasacort), and valdecoxib (Bextra) on an as-needed basis. The patient subsequently underwent a minimal incision face and neck lift with liposuction of the neck and jowls.4 The procedure was done under conscious sedation. The patient’s operative and post-operative courses were unremarkable, and the patient was happy with the cosmetic outcome. (Figures 5 and 6)
Exploring Aesthetic Interventions, Part IX: Face Lifting in Advancing Age
T he demand for cosmetic surgery in persons of advancing age is increasing as the result of the coupling of two trends. First, the population of the United States is aging. As of the year 2000, approximately one in eight Americans was 65 or older, according to the United States Census Bureau.1 This percentage is expected to grow as the baby boom generation ages. Additionally, over the past several years cosmetic surgery has become more mainstream with the number of procedures performed each year steadily increasing over the past decade. The increased demand for cosmetic surgical intervention in the elderly raises the question of whether or not these patients can be safely and effectively treated. The elderly population is a heterogeneous group defined solely on the basis of age. This group includes healthy, vital individuals as well as debilitated, frail persons. For the purposes of this discussion we will define the geriatric population as being those persons 75 years of age and older. This seems a reasonable definition as the average life expectancy of a child born in 2002 is 77.2 years.2 Some might argue that the risk inherent in elective procedures is too great in the geriatric population. This line of reasoning overlooks the benefits of an improved appearance. Beauty is rewarded in our society in measurable ways, from improved self esteem to preferential treatment by those around us.3 A more youthful appearance supports a more vital frame of mind, which, in turn, has a positive effect on overall health. To deny these positive effects to a segment of the population on the basis of age would be unwarranted discrimination. In this article we explore face lifting in the geriatric population. We present a discussion of special considerations in the surgical treatment of geriatric patients and a few vignettes of representative cases of patients over 75 years old who have successfully undergone face lifting procedures in our practice. The Importance of a Pre-Op Assessment As the three cases presented in this article (see cases) illustrate, face lifting can be performed safely and effectively in elderly patients. Successful outcomes depend on appropriate pre-operative counseling and assessment, sound operative practices, and close follow-up with adequate support during the recovery period. The general principles of cosmetic surgery in the elderly are the same as for younger patients; however, deviations from these principles are less forgiving in the geriatric patient than in younger patients. As with all cosmetic surgeries, a successful outcome begins with a careful patient selection. During this phase, clearly delineate the patient’s cosmetic concerns and explain all treatment options. This should include a discussion of possible risks, likely course of post-operative recovery, and the range of results that may be expected. Time for the patient to ask questions and for the surgeon to be comfortable with the patient’s decision to have surgery must be allowed. Having a family member(s) present for the consultation is highly recommended. After the patient’s cosmetic concerns have been adequately addressed, assess the patient’s general health status. Chronologic age and physiologic age are sometimes disparate. A very fit 80-year-old may be a better surgical candidate than a 65-year-old with many comorbidities. Evaluating each patient individually and obtaining appropriate medical clearance from the the patient’s primary care physician and/or other specialists is in order. During this phase, give consideration to conditions that might place the patient at higher risk for adverse events. Patients can be categorized according to the American Society of Anesthesiologists general classification of physical status.6 (See Table I) By definition, patients over 80 years of age are placed in Class II. Make a special effort to identify any coexisting cardiovascular disease as this is the single greatest contributor to operative morbidity.7 The Goldman criteria and risk categories can be used to estimate a patient’s risk for post-operative cardiac complications.8,9 (See Tables II and III) Age greater than 70 years is assigned a point value of five in this scheme. During the pre-operative evaluation, be sure to do a thorough history taking and physical exam to actively seek symptoms of heart disease and other underlying conditions. An older patient who self nominates for cosmetic surgery may be so functional as to have never needed a thorough medical evaluation, and relatively asymptomatic diseases, such as hypertension, diabetes mellitus, and chronic renal insufficiency, may be present but undiagnosed. Additionally, assess the patient’s mental status and competency to make medical decisions. Planning the Surgery After medical pre-operative clearance is obtained, final preparations for surgery can be made. Before the operation, perform and review the following: an electrocardiogram, a chest radiograph, and laboratory evaluation including complete blood count, coagulation studies, liver enzymes, serum chemistries, blood urea nitrogen, creatinine, and urinalysis. Review the operative plan with the patient and clarify all pre- and post-operative instructions. Written information should be in a print size so as to be easily read,10 and all instructions should be simple to understand and follow. It’s helpful to include supportive family members or close friends in this stage of the process and to enlist their help in the surgical recovery period. Anesthesia for the procedure should be approached more carefully than in younger patients. Conscious sedation can be attained in an ambulatory surgery center setting with judicious use of midazolam and propofol (Diprivan).11 When administering these drugs, low initial doses are carefully titrated to the desired effect. Particularly, keep in mind the prolonged plasma half life of midazolam in the elderly.12 In the aging patient, volumes of drug distribution may be altered and hepatic metabolism and renal excretion may be impaired.13 This can result in increased sensitivity to the effects of the medicines administered and to a slower recovery from anesthesia. The use of adequate local and tumescent anesthesia is also important to reduce the depth of conscious sedation that the patient requires. When using local and tumescent techniques, you must track the total dose and volume of the anesthetic. It is also advisable to avoid excessive use of epinephrine, especially in patients with cardiac risk factors. To further ensure patient safety, monitor the patient’s vital signs continuously during and after anesthesia. During the procedure, strive to be efficient. Prolonged operative times increase the risk for complications including deep vein thrombosis from immobility. Shorter procedures also mean decreased exposure to anesthesia. If multiple procedures are indicated, they may be better tolerated when undertaken in separate surgical sessions. In this way operative times are reduced and the stress on the body to heal after the procedure is diminished. Also, ensure support of homeostasis during the procedure with oxygen supplementation and avoidance of hypothermia, both of which are beneficial to surgical patients.14,15,16 The Recovery Period In the post-operative period, follow the patient’s recovery closely with special attention to pain control, adequate hydration and good nutrition. Effective pain control is essential to ensure quick post-operative mobility. Immobile patients are predisposed to atelectasis and deep vein thrombosis. Pain medicines should be started at a low dose and titrated to the desired effect. As previously mentioned, altered volumes of drug distribution and slowed metabolism and excretion may make the elderly more sensitive to medications. Encourage proper nutrition. Some elderly persons consume very few calories or have diets lacking in variety. Suggest dietary supplementation with a multiple vitamin and protein-calorie drinks, since many face-lift patients have difficulty chewing due to tightness. Talk to the patient about the need to make arrangements to have adequate support at home to assist with dressing changes, the administering of medicines, and other necessary post- operative care. Assess patients frequently during the post-operative phase to be sure these issues are addressed and that the recovery from surgery is proceeding in a timely manner without complications. We recommend follow-up in person or by phone within 24 hours of the procedure with further follow-up schedules tailored to the procedure performed. Options for the Elderly Cosmetic surgery continues to gain broader acceptance by the general public. This trend coupled with the overall aging of the population in the United States will lead to an increased demand for cosmetic procedures in persons with advancing age. Face lifting can be performed safely and effectively for carefully selected patients in this group. However, even the healthiest elderly patients have limited physiologic reserves when compared with their younger counterparts creating a smaller margin for error in these patients. For this reason, every effort must be made to carefully assess the patient’s general health before surgery, to work efficiently and precisely during the procedure, and to maintain adequate support during the post-operative period. In so doing, the beneficial results of face lifting can be extended to the geriatric population. Case 1 A 75-year-old woman (BK) presented for evaluation of neck and facial skin laxity. She had a medical history of hypertension and her medications included cetirizine (Zyrtec) and ramipril (Altace). She subsequently underwent a minimal incision face and neck lift with liposuction of the neck and jowls4 and fat transfer to the nasolabial folds and oral commissures. The operation was performed under conscious sedation. She tolerated the procedure without complications. Her post-operative phase was without incidence, and she had a good aesthetic outcome. (Figures 1 and 2) After full recovery the patient desired more complete correction of her facial laxity. Three months after the first procedure she had a revision of her initial procedure and also underwent carbon dioxide laser resurfacing to her entire face.5 Again the procedures were performed under conscious sedation and were well tolerated. Her post-operative recovery was without complications, and she was satisfied with the final result. Case 2 A 75-year-old woman (MS) desired correction of facial rhytids and excess tissue of the face and neck. She was in generally good health, and her medicines included diltiazem (Cardizem, Tiazac), digoxin (Digitek, Lanoxicaps, Lanoxin), and hydrochlorothiazide/triamterene (Dyazide, Maxzide). She underwent a minimal incision face and neck lift with liposuction of the neck and jowls4 under conscious sedation. The procedure was tolerated well, and her post-operative course was uncomplicated. She was aesthetically pleased with the outcome. (Figures 3 and 4) Five years later she desired additional intervention for excess skin laxity. In the interim she had coronary artery bypass grafting. Her health was stable on a medical regimen of digoxin, metoprolol, famotidine (Pepcid) and aspirin. Because of her ischemic heart disease she was discouraged from pursuing surgical intervention. However, the patient insisted on further consideration. She held a family conference to discuss the issue with her children. She was still very busy with many social events and club activities and wanted a more youthful appearance to match her active lifestyle. A second consultation with her family members present was scheduled during which she clearly expressed her belief that the beneficial effects of her desired cosmetic surgery outweighed any inherent risk. Her cardiologist was consulted and gave medical clearance for her surgery. She underwent a repeat minimal incision face and neck lift with neck and jowl liposuction4 under mild conscious sedation without incident. No epinephrine was used in her local anesthesia and the doses of intravenous medicines used for sedation were carefully titrated for minimal effect. In the post-operative period her diet was supplemented with protein-calorie nutrition drinks. She again was pleased with the cosmetic result. Case 3 An 83-year-old woman (VM) presented for evaluation of lax skin of the face and neck. She was recently widowed, and part of her motivation for seeking intervention was that she had just begun dating again. She had a remote history of cancer of the cervix and vaginal wall. Her medicines included alendronate (Fosamax) weekly and fexofenadine (Allegra), triamcinolone nasal spray (Nasacort), and valdecoxib (Bextra) on an as-needed basis. The patient subsequently underwent a minimal incision face and neck lift with liposuction of the neck and jowls.4 The procedure was done under conscious sedation. The patient’s operative and post-operative courses were unremarkable, and the patient was happy with the cosmetic outcome. (Figures 5 and 6)
T he demand for cosmetic surgery in persons of advancing age is increasing as the result of the coupling of two trends. First, the population of the United States is aging. As of the year 2000, approximately one in eight Americans was 65 or older, according to the United States Census Bureau.1 This percentage is expected to grow as the baby boom generation ages. Additionally, over the past several years cosmetic surgery has become more mainstream with the number of procedures performed each year steadily increasing over the past decade. The increased demand for cosmetic surgical intervention in the elderly raises the question of whether or not these patients can be safely and effectively treated. The elderly population is a heterogeneous group defined solely on the basis of age. This group includes healthy, vital individuals as well as debilitated, frail persons. For the purposes of this discussion we will define the geriatric population as being those persons 75 years of age and older. This seems a reasonable definition as the average life expectancy of a child born in 2002 is 77.2 years.2 Some might argue that the risk inherent in elective procedures is too great in the geriatric population. This line of reasoning overlooks the benefits of an improved appearance. Beauty is rewarded in our society in measurable ways, from improved self esteem to preferential treatment by those around us.3 A more youthful appearance supports a more vital frame of mind, which, in turn, has a positive effect on overall health. To deny these positive effects to a segment of the population on the basis of age would be unwarranted discrimination. In this article we explore face lifting in the geriatric population. We present a discussion of special considerations in the surgical treatment of geriatric patients and a few vignettes of representative cases of patients over 75 years old who have successfully undergone face lifting procedures in our practice. The Importance of a Pre-Op Assessment As the three cases presented in this article (see cases) illustrate, face lifting can be performed safely and effectively in elderly patients. Successful outcomes depend on appropriate pre-operative counseling and assessment, sound operative practices, and close follow-up with adequate support during the recovery period. The general principles of cosmetic surgery in the elderly are the same as for younger patients; however, deviations from these principles are less forgiving in the geriatric patient than in younger patients. As with all cosmetic surgeries, a successful outcome begins with a careful patient selection. During this phase, clearly delineate the patient’s cosmetic concerns and explain all treatment options. This should include a discussion of possible risks, likely course of post-operative recovery, and the range of results that may be expected. Time for the patient to ask questions and for the surgeon to be comfortable with the patient’s decision to have surgery must be allowed. Having a family member(s) present for the consultation is highly recommended. After the patient’s cosmetic concerns have been adequately addressed, assess the patient’s general health status. Chronologic age and physiologic age are sometimes disparate. A very fit 80-year-old may be a better surgical candidate than a 65-year-old with many comorbidities. Evaluating each patient individually and obtaining appropriate medical clearance from the the patient’s primary care physician and/or other specialists is in order. During this phase, give consideration to conditions that might place the patient at higher risk for adverse events. Patients can be categorized according to the American Society of Anesthesiologists general classification of physical status.6 (See Table I) By definition, patients over 80 years of age are placed in Class II. Make a special effort to identify any coexisting cardiovascular disease as this is the single greatest contributor to operative morbidity.7 The Goldman criteria and risk categories can be used to estimate a patient’s risk for post-operative cardiac complications.8,9 (See Tables II and III) Age greater than 70 years is assigned a point value of five in this scheme. During the pre-operative evaluation, be sure to do a thorough history taking and physical exam to actively seek symptoms of heart disease and other underlying conditions. An older patient who self nominates for cosmetic surgery may be so functional as to have never needed a thorough medical evaluation, and relatively asymptomatic diseases, such as hypertension, diabetes mellitus, and chronic renal insufficiency, may be present but undiagnosed. Additionally, assess the patient’s mental status and competency to make medical decisions. Planning the Surgery After medical pre-operative clearance is obtained, final preparations for surgery can be made. Before the operation, perform and review the following: an electrocardiogram, a chest radiograph, and laboratory evaluation including complete blood count, coagulation studies, liver enzymes, serum chemistries, blood urea nitrogen, creatinine, and urinalysis. Review the operative plan with the patient and clarify all pre- and post-operative instructions. Written information should be in a print size so as to be easily read,10 and all instructions should be simple to understand and follow. It’s helpful to include supportive family members or close friends in this stage of the process and to enlist their help in the surgical recovery period. Anesthesia for the procedure should be approached more carefully than in younger patients. Conscious sedation can be attained in an ambulatory surgery center setting with judicious use of midazolam and propofol (Diprivan).11 When administering these drugs, low initial doses are carefully titrated to the desired effect. Particularly, keep in mind the prolonged plasma half life of midazolam in the elderly.12 In the aging patient, volumes of drug distribution may be altered and hepatic metabolism and renal excretion may be impaired.13 This can result in increased sensitivity to the effects of the medicines administered and to a slower recovery from anesthesia. The use of adequate local and tumescent anesthesia is also important to reduce the depth of conscious sedation that the patient requires. When using local and tumescent techniques, you must track the total dose and volume of the anesthetic. It is also advisable to avoid excessive use of epinephrine, especially in patients with cardiac risk factors. To further ensure patient safety, monitor the patient’s vital signs continuously during and after anesthesia. During the procedure, strive to be efficient. Prolonged operative times increase the risk for complications including deep vein thrombosis from immobility. Shorter procedures also mean decreased exposure to anesthesia. If multiple procedures are indicated, they may be better tolerated when undertaken in separate surgical sessions. In this way operative times are reduced and the stress on the body to heal after the procedure is diminished. Also, ensure support of homeostasis during the procedure with oxygen supplementation and avoidance of hypothermia, both of which are beneficial to surgical patients.14,15,16 The Recovery Period In the post-operative period, follow the patient’s recovery closely with special attention to pain control, adequate hydration and good nutrition. Effective pain control is essential to ensure quick post-operative mobility. Immobile patients are predisposed to atelectasis and deep vein thrombosis. Pain medicines should be started at a low dose and titrated to the desired effect. As previously mentioned, altered volumes of drug distribution and slowed metabolism and excretion may make the elderly more sensitive to medications. Encourage proper nutrition. Some elderly persons consume very few calories or have diets lacking in variety. Suggest dietary supplementation with a multiple vitamin and protein-calorie drinks, since many face-lift patients have difficulty chewing due to tightness. Talk to the patient about the need to make arrangements to have adequate support at home to assist with dressing changes, the administering of medicines, and other necessary post- operative care. Assess patients frequently during the post-operative phase to be sure these issues are addressed and that the recovery from surgery is proceeding in a timely manner without complications. We recommend follow-up in person or by phone within 24 hours of the procedure with further follow-up schedules tailored to the procedure performed. Options for the Elderly Cosmetic surgery continues to gain broader acceptance by the general public. This trend coupled with the overall aging of the population in the United States will lead to an increased demand for cosmetic procedures in persons with advancing age. Face lifting can be performed safely and effectively for carefully selected patients in this group. However, even the healthiest elderly patients have limited physiologic reserves when compared with their younger counterparts creating a smaller margin for error in these patients. For this reason, every effort must be made to carefully assess the patient’s general health before surgery, to work efficiently and precisely during the procedure, and to maintain adequate support during the post-operative period. In so doing, the beneficial results of face lifting can be extended to the geriatric population. Case 1 A 75-year-old woman (BK) presented for evaluation of neck and facial skin laxity. She had a medical history of hypertension and her medications included cetirizine (Zyrtec) and ramipril (Altace). She subsequently underwent a minimal incision face and neck lift with liposuction of the neck and jowls4 and fat transfer to the nasolabial folds and oral commissures. The operation was performed under conscious sedation. She tolerated the procedure without complications. Her post-operative phase was without incidence, and she had a good aesthetic outcome. (Figures 1 and 2) After full recovery the patient desired more complete correction of her facial laxity. Three months after the first procedure she had a revision of her initial procedure and also underwent carbon dioxide laser resurfacing to her entire face.5 Again the procedures were performed under conscious sedation and were well tolerated. Her post-operative recovery was without complications, and she was satisfied with the final result. Case 2 A 75-year-old woman (MS) desired correction of facial rhytids and excess tissue of the face and neck. She was in generally good health, and her medicines included diltiazem (Cardizem, Tiazac), digoxin (Digitek, Lanoxicaps, Lanoxin), and hydrochlorothiazide/triamterene (Dyazide, Maxzide). She underwent a minimal incision face and neck lift with liposuction of the neck and jowls4 under conscious sedation. The procedure was tolerated well, and her post-operative course was uncomplicated. She was aesthetically pleased with the outcome. (Figures 3 and 4) Five years later she desired additional intervention for excess skin laxity. In the interim she had coronary artery bypass grafting. Her health was stable on a medical regimen of digoxin, metoprolol, famotidine (Pepcid) and aspirin. Because of her ischemic heart disease she was discouraged from pursuing surgical intervention. However, the patient insisted on further consideration. She held a family conference to discuss the issue with her children. She was still very busy with many social events and club activities and wanted a more youthful appearance to match her active lifestyle. A second consultation with her family members present was scheduled during which she clearly expressed her belief that the beneficial effects of her desired cosmetic surgery outweighed any inherent risk. Her cardiologist was consulted and gave medical clearance for her surgery. She underwent a repeat minimal incision face and neck lift with neck and jowl liposuction4 under mild conscious sedation without incident. No epinephrine was used in her local anesthesia and the doses of intravenous medicines used for sedation were carefully titrated for minimal effect. In the post-operative period her diet was supplemented with protein-calorie nutrition drinks. She again was pleased with the cosmetic result. Case 3 An 83-year-old woman (VM) presented for evaluation of lax skin of the face and neck. She was recently widowed, and part of her motivation for seeking intervention was that she had just begun dating again. She had a remote history of cancer of the cervix and vaginal wall. Her medicines included alendronate (Fosamax) weekly and fexofenadine (Allegra), triamcinolone nasal spray (Nasacort), and valdecoxib (Bextra) on an as-needed basis. The patient subsequently underwent a minimal incision face and neck lift with liposuction of the neck and jowls.4 The procedure was done under conscious sedation. The patient’s operative and post-operative courses were unremarkable, and the patient was happy with the cosmetic outcome. (Figures 5 and 6)
