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Russell W. H. Kridel and Peyman Soliemanzadeh
The patient should be given detailed typewritten postoperative instructions before the surgery to allow the patient and his or her family to read the instructions in detail and ask questions before surgery. After surgery, the patient and family are informed again of problems that might arise and instructed to call the physician for any questions.
We use a large bulky dressing right after surgery, partly to discourage turning of the head, which can lead to hematoma formation. Patients often complain that their bandage is too tight right after surgery, which usually indicates that they are feeling the tightening of the lift and the bandage. If a compressive dressing is used, the surgeon can make a vertical incision in the midline of the dressing at the inferior border and see if there is any relief, but patients must be ready to accept a feeling of tightness.
Postoperative orders are geared toward keeping the patient calm and as pain free as possible. Increased pain leads to increased blood pressure, which can increase the likelihood of complications. Likewise, a full bladder after a long procedure can increase blood pressure.
The surgeon should check on the patient the night of surgery. Any unilateral pain that is unrelenting and unresponsive to routine pain medication should alert the physician to possible hematoma formation and must be addressed as soon as possible. The patient also should be seen on the first postoperative day; drains are usually removed at this time, depending on the amount of drainage noted. Before releasing the tension of the bandage and removing the drains, fluffs are held over the area from which the drains are going to be removed, and pressure is applied. Pressure is maintained in those areas until a new bandage can be reapplied. This step helps to keep down the flaps and prevent hematoma or seroma formation. Before placing the new dressing on the first postoperative day, antibiotic ointment or cream is applied on all incisions (we prefer gentamicin cream), making sure to apply some at the external auditory canal to prevent any Pseudomonas from the external canal from contaminating the incisions.
Usually by the second or third postoperative day, the large bulky dressing can be totally removed, and an elasticized facial sling can be used. This helps the skin flap to maintain close contact with the subcutaneous tissue and provides faster revascularization and even contraction. It is important to pad the ears because these elasticized bandages can rub the thin skin of the pinna and thus cause irritation.
Usually at the fifth postoperative day, a few of the anterior preauricular stitches are removed and the patient’s hair is washed in a shampoo sink in the office. Patients are cautioned not to use hair dryers in the immediate postoperative period because some numbness of the periauricular and scalp areas will be present, possibly causing patients to burn their skin with the hair dryer due to lack of sensation.
Over ensuing visits, all the sutures are removed and the incisions examined under the microscope, especially in the hair-bearing areas to check for ingrown hairs, which can occur up to several months after surgery. After performing beveled incisions, this step also ensures that the hair will actually grow through the incision for camouflage. Often hairs become trapped and need help to come through the advanced flap.
Almost all patients have significant swelling or bruising postoperatively, and often this is difficult for the patient to accept. Gentle reassurance is key in the first postoperative weeks. As Goin and Goin (1) pointed out, if everything has gone well and the results are good, it is important for the physician to tell the patient so. Patients do not know how they should look and whether things were done well unless the doctor says so. Patients often forget what they looked like before surgery. For that reason, giving them prints of their preoperative photographs at the first or second postoperative visit is extremely helpful. This allows patients to compare their preoperative and postoperative conditions.
1. Goin JM, Goin MK. Changing the body: psychological effects of plastic surgery. Baltimore: Williams & Wilkins, 1981.