Tips for avoiding or resolving common surgical sequelae

January 1, 2008

Dermatologist Susan H. Weinkle, M.D., provides a series of pearls for addressing common concerns in dermatologic surgery patients.

Key Points

Soft tissue

Dr. Weinkle says molding is one of the most important things that can be done to improve the outcomes of facial soft tissue augmentation. She suggests that when treating the lips, surgeons use the fingertips placed in and around the patient's mouth to assess the evenness of the injected filler and to apply gentle pressure, as needed, for maximizing product distribution.

Anesthesia aids

Providing adequate anesthesia is also important, to improve patient satisfaction and eliminate reluctance to return for future filler injections.

Having used Betacaine Plus satisfactorily for many years as a topical anesthetic, Dr. Weinkle is looking forward to the availability of a new product containing 7 percent tetracaine and 7 percent lidocaine (Pliaglis, Galderma). Pliaglis is applied as a cream that dries to a pliable, easily removable peel.

Various physical anesthesia methods are useful adjuncts. Dr. Weinkle provides patients with a squeeze ball or vibrator, which they can use as distraction tools to lessen perceived pain.

Cold therapy is also helpful, and is most conveniently supplied using ice packs instead of ice.

However, Dr. Weinkle considers the "infusion technique," which involves premixing of lidocaine with the filler, her most valuable pearl for lessening pain when performing augmentation procedures using products not formulated with an anesthetic.

Dr. Weinkle learned the technique from Florida dermatologist Mariano Busso, M.D. It involves infusing the filler with 0.15 cc of 2 percent lidocaine, using a female-to-female adapter (Fluid dispensing connector, R Braun Medical) for connecting the two syringes.

"I used to do mini-nerve blocks routinely, but I have not done a block in months, since I began using the infusion technique.

"Even with a good block, there may be a skip area, so that the total treatment area is not adequately covered. The infusion technique has reduced patient pain ratings from a level of 10 down to 2, and dramatically changed patient opinions about returning for touch-ups," she says.

Bruising

Bruising is the bane of cosmetic surgery procedures, and its possibility must be carefully discussed with all patients. To minimize bruising severity, patients should be told to stop vitamin E, aspirin or NSAIDs preoperatively, and they should be cautioned not to have a procedure immediately before important social events. Anticoagulants are not stopped, but these patients are cautioned they may experience more bruising.

Arnika Forte (DermAvance) has been useful for addressing bruising. It contains arnica, a homeopathic preparation that prevents bruising, along with the enzyme bromelain, which enhances resolution of any bruising that occurs.

"I give patients two tablets prior to the procedure while they are sitting with the topical anesthesia, and if significant bruising develops, have them continue with two tablets a day until it subsides," Dr. Weinkle says.

Woundcare

Pressure dressings, ice, Surgicel (Johnson & Johnson) and QR powder (BioLife) are all valuable tools for dealing with postoperative bleeding. Ice and QR powder are useful for controlling minor oozing, whereas a small piece of Surgicel can be used to control delayed- onset postoperative bleeding or may be placed onto the wound after cautery to prevent bleeding.