Definition
Rhytidectomy or face-lift is the excision of redundant facial skin and subcutaneous tissue to minimize wrinkles and rejuvenate the appearance of the face.

Discussion
Rhytidectomy (“face-lift”) is performed to minimize the appearance of wrinkles and restore a youthful contour to facial skin.The procedure may include a lift of the forehead, neck and the central facial zone; excess skin in these areas is excised. Blepharoplasty, is often combined with rhytidectomy. Numerous nonsurgical modalities have been developed to augment or postpone rhytidectomy. Examples include the injection of various “fillers” such as collagen and synthetics, autologous fat, Botox injection, laser application, chemical irritants (“peel”), dermabrasion, and use of innumerable nonprescription “cosmetic” creams. An endoscopic approach to rhytidectomy permits lifting the tissues selectively, without extensive incisions. Rhytidectomy combined with blepharoplasty is the standard; patients often require a second procedure within several years to maintain the result.The extensive procedure includes meticulous hemostasis and may take several hours. Preoperative consultation is comprehensive, explaining various technicalities and review of “before and after” photos of other patients.No guarantee of “acceptable” result is given; preoperative photos are taken and included in the patient’s record. Many of these procedures are performed in a surgeon’s private operatorium.
Procedure
The incision follows previously made markings that follow the anterior contour of the ear, extending superiorly into the scalp, inferiorly curving about the posterior aspect of the ear, and extending posteriorly to the scalp. The skin and subcutaneous tissue are mobilized by undermining. Dissection of tissues under the platysma muscle, referred to as the submuscular aponeurotic system (SMAS) procedure, minimizes the amount of skin that must be undermined. Care is taken to avoid injury to nerves (e.g., the facial nerve branches and the greater auricular nerve). After hemostasis is secured, plication sutures are placed in the musculofascial tissues. Tension is placed on the flap, directing it superiorly and posteriorly as anchoring sutures are placed. Excess skin is trimmed.Wound closure is completed with fine interrupted sutures. Care is exerted not to distort the ear. A closed suction drainage unit may be placed. A pressure dressing is applied, taking care to pad the ears. Ice compresses are applied immediately following the procedure.

Preparation of the Patient
Anesthesia may be local or general, but local anesthesia with conscious sedation is usually preferred, as these patients are usually discharged on the same day. The table may be turned 90 to facilitate the surgeon’s access. The surgeon usually marks the face prior to skin preparation and injects the local anesthetic. The patient is in supine position with the back slightly elevated; a padded or gel headrest may be used. One arm may be extended on a padded armboard and the opposite arm padded and tucked in at the patient’s side, or both arms may be padded and secured at the patient’s sides. A pillow may be placed under the knees to avoid straining the low back, or the table may be flexed for comfort. Bony prominences and areas vulnerable to skin and neurovascular pressure or trauma are padded. An electrosurgical dispersive pad is not usually applied as bipolar electrosurgery is used.

When the procedure is performed under local anesthesia, in the absence of an anesthesia provider, a perioperative RN, in addition to the circulator, is required to monitor the patient and administer conscious sedation, as directed by the surgeon for the responsibilities of the perioperative RN monitoring the patient. Hair is rarely shaved, but the surgeon may request that hair around the hairline be secured.

Special Notes

• In the PACU, the perioperative practitioner observes the patient for signs of excessive bleeding or hematoma formation; observations, nursing interventions, and the appearance of the face are documented for medicolegal reasons.
• In the PACU, the perioperative practitioner checks that head of the patient’s bed is elevated and ice packs are applied. Both measures serve to reduce any postoperative swelling.

Definition
Blepharoplasty is the excision of redundant muscle and skin of the eyelids to enhance one’s physical appearance.

Discussion
The eyelids of the mature adult are one of the first areas to show progressive permanent changes due to aging and genetics. The tissues surrounding the orbit loose their elasticity, resulting in the appearance of “baggy” eyelids. Blepharoplasty is designed to negate this aspect of the aging process. For many years, blepharoplasty meant the transcutaneous or transconjunctival excision of the pseudoherniated fat pad and correction of muscle and skin laxity in the lower eyelids. In the mid-1990s, the plastic surgeon’s approach to blepharoplasty was revised.The fat pad of the lower lids is no longer excised but instead preserved and repositioned over the orbital rim to correct the groove over the nasojugal fold. Excessive muscle is transected, and after redraping, the excessive skin is excised from the lower eyelids transcutaneously.The amount of muscle and skin that is resected depends on the severity of the deformity, i.e., the amount of redundant muscle and skin and the age of the patient. When the upper lids are redundant so as to interfere with vision, correction is regarded as a medical necessity rather than cosmetic procedure; health insurance may cover a portion of the expenses incurred for the surgery. The cosmetic procedure is distinguished from blepharoptosis (drooping eyelid due to paralysis).
Procedure
Transcutaneous Approach to Blepharoplasty of the Upper Lid is described. An elliptical incision is made in the recess of the orbitopalpebral fold of the upper lid according to previously placed markings. The orbicularis oculi muscle is incised parallel to its fibers at the apex of the bulge. The fat protrudes through the incision and is excised. The upper-lid incisions may be covered with moist saline sponges while resection of a portion of the lower lids is done. The skin is undermined. The orbicularis oculi muscle is split. Fat compartments are isolated; the fat is repositioned, the skin is redraped, and the redundant skin is resected. The upper lids are checked for bleeding; hemostasis is obtained. Incisions in the upper lids are closed with fine interrupted sutures.The procedure is repeated for the lower lids.An occlusive (not pressure) dressing is applied. A consideration encountered when performing the blepharoplasty of the lower lids transconjunctively is that while the procedure is performed through a “hidden” incision, the excess tissue must be excised transcutaneously.The second incision for the excision of the redundant skin may show just as much as if the entire procedure were performed via transcutaneous approach.

Preparation of the Patient
Local anesthesia is usually preferred. The table may be turned 90 to facilitate the surgeon’s access. The patient is in supine position; a padded or gel headrest may be used. One arm may be extended on a padded armboard and the opposite arm padded and tucked in at the patient’s side, or both arms may be padded and secured at the patient’s sides. A pillow may be placed under the knees to avoid straining the low back, or the table may be flexed for comfort. Bony prominences and areas vulnerable to skin and neurovascular pressure or trauma are padded. An electrosurgical dispersive pad is not required when bipolar electrosurgery is used.

If an anesthesia provider is not in attendance, a perioperative RN, in addition to the circulator, is required to monitor the patient and to administer conscious sedation as directed by the surgeon. For a description of the role of the RN monitoring the patient

Definition
Rhinoplasty is defined as the modification of the external appearance of the nose.

Discussion
Rhinoplasty is performed to improve the appearance of the nose and thereby enhance the patient’s physical appearance. In addition to cosmetic considerations, this procedure is performed to alleviate nasal airway obstruction due to deviation of the septum and/or nasal trauma not relieved by closed reduction. Goals of rhinoplasty may include tip reshaping, hump removal, narrowing of the nares, and septoplasty (straightening the nasal septum). The rhinoplasty procedure is modified according to each patient’s needs. The surgeon must endeavor to obtain a shape, symmetry, and proportion of the nose in proportion to the other components of the patient’s face. Before the surgeon performs the surgery, he/she interviews the patient to be assured that the patient’s expectations of the outcome of the surgery are realistic. Mentoplasty Augmentation is often necessary in conjunction with rhinoplasty to achieve a more balanced appearance to the face.

Procedure
For Rhinoplasty, an intercartilaginous incision is made through the nares along the rim of the upper lateral cartilage bilaterally.The incisions are connected, freeing the skin from over the dorsal septum, and the columella anteriorly. Prominent septal, lateral, and alar cartilages are excised and, after reassessment, are retrimmed as necessary. The nasal bones are osteotomized laterally and medially (and horizontally, if necessary) and compressed to infracture the bones, creating a more “normal” contour. Rasping smooths bony irregularities.Alignment of the septum is achieved. The anterior septum and columella are sutured; alar incisions and marginal (rim) incisions of the lower lateral cartilages are sutured as well. Intranasal packing is inserted, and an external splint is applied.
Preparation of the Patient

Anesthesia may be local or general, but local anesthesia with conscious sedation is usually preferred, as these patients are often discharged the same day. The patient is in supine position; a padded or gel headrest is often used. One arm may be extended on a padded armboard and the opposite arm padded and tucked in at the patient’s side, or both arms may be padded and secured at the patient’s sides.A pillow may be placed under the knees to avoid straining the low back, or the table may be flexed for comfort. Bony prominences and areas vulnerable to skin and neurovascular pressure or trauma are padded.An electrosurgical dispersive pad is applied. The surgeon often does a preliminary nasal preparation before the skin prep. If an anesthesia provider is not in attendance, a perioperative RN, in addition to the circulator, is required to monitor the patient and to administer conscious sedation as directed by the surgeon. For a description of the role of the RN monitoring the patient.

Skin Preparation
An interior nasal prep is not done. This is considered a “clean” procedure. If a prep is requested, check with the surgeon regarding the type of prep solution to use. Begin at the external nose; prep the face and neck, extending the prep from the hairline to the shoulders and down to the table at the sides of the neck.

Care is taken to avoid getting prep solution in the eyes. The eyes are irrigated with normal saline from inner to outer canthus. Moist cotton pads are placed over the eyes; when general anesthesia is employed, antibiotic ointment is placed in the conjunctival sacs. Small cotton plugs or cotton balls are placed in the ears to prevent prep solution from pooling in the ears (they are removed with a mosquito forceps before draping). Prep solutions are not allowed to pool on the drapes, as the prep solution excoriates the skin.To avoid a fire hazard, prep solutions should not pool in the drapes.

Special Notes

• An otorhinolaryngologist or a plastic surgeon usually performs a rhinoplasty procedure.When preparations are made for the surgery, consider choosing items from the surgeon’s specialty.
• Reminder: Assess and document the patient’s anxiety regarding the surgery and the unfamiliar environment, provide emotional support, such as maintaining eye contact and holding the patient’s hand during the administration of anesthesia, etc., and answer questions in a knowledgeable manner. Documentation is done as a patient care measure and for medicolegal reasons.
• N.B. Reminder: When cocaine is used, both the circulator and the scrub person must observe the discarding of any remaining cocaine following the procedure. Both persons must observe the cocaine being discarded; discarding the cocaine is documented for medicolegal and accountability reasons.
• N.B. Note: In the PACU, the perioperative practitioner must observe, report,and document nursing interventions regarding observing the wound for bleeding (e.g.,in hemorrhage,the pad under the noose is soaked through) and for breathing difficulties (e.g.,airway obstruction may be caused by tissues swelling); a negative observation should be documented,as well.

Definition: Correction of fracture(s) of the cheek bones.

Discussion
Many facial fractures are the result of complex forces applied to the midface, e.g., injuries to the cheek bones are rarely simple. Depressed fractures of the cheek may be fractures of the arch and/or three fractures of the zygoma (sometimes referred to as trimalar fractures). Closed reduction is the treatment of choice for simple zygomatic arch fractures, whenever possible. No anatomical fixation is required. However, when the fracture is severe, as in depressed trimalar fractures, or in comminuted fractures, ORIF is performed; the bones are elevated and secured with pins or wires, or miniplates with miniscrews or microplates with cyanoacrylic cement are required. Controversy exists over the closed reduction treatment of zygomatic complex and depressed zygomatic arch fractures. CT scans are a valuable means of making the diagnosis.

The multiple approaches to fractures of the zygoma, include temporal and supraorbital, gingivobuccal sulcus, transconjunctival, coronal, and endoscopically assisted procedure. Fractures of the zygomatic complex frequently result in infraorbital nerve dysfunction and sensory disturbances.


Procedure
A temporal approach is described to correct fractures of the zygoma. Small access incisions to the fracture fragments are made in the lateral third of the eyebrow and in the infraorbital region.The periosteum is elevated conservatively to prevent devascularization. When there is a gap 5 mm in the bone, bone graft with calvarial bone is indicated. This bone is less resorbed than bone taken from other sources. If the interfragment gap is 5 mm, wires or miniplates and/or microplates with screws are required for the fixation. Antibiotics intravenously and in irrigation solutions may be employed to avoid infection.

The resorbable microplate with cryoacrylate fixation is believed to be adequate in most instances for fixation of the zygoma; the microplate offers a more cosmetic result, but if the repair must be stronger, a miniplate with miniscrews or two microplates may be used. The plate(s) is removed after the bone heals.The position of the bone fragments can also be “fixed” by stainless-steel wires (e.g., Kirshner wires), Steinmann pin, and titanium devices.The device is chosen according to the surgeon’s experience, the location of the fracture, and preference of the surgeon. Holes are drilled into the fragments. The fragments are realigned, and the fixation device of choice is applied.The wound is irrigated with saline or antibiotic irrigation, and the incisions are closed.

Preparation of the Patient
Anesthesia may be local or general with endotracheal intubation; however, general is most often used.The table is usually turned 90 to facilitate the surgeon’s access; the anesthesia provider is at the patient’s side. The patient may be in supine position with the head supported on a padded or gel headrest. One arm may be extended on a padded armboard and the opposite arm padded and tucked in at the patient’s side, or
both arms may be padded and tucked in at the patient’s side.A pillow may be placed under the knees to avoid straining the low back and/or the table may be flexed for comfort. Bony prominences and areas vulnerable to skin and neurovascular pressure or trauma are padded. An electrosurgical dispersive pad is applied if monopolar electrosurgery is used.

Special Notes

• Reminder: Ascertain that the correct x-ray films for the correctly identified patient are in the room prior to starting the surgery.
• The surgeon may wear a fiber-optic headlight for both the closed and open procedure (for better visualization of the wound).The circulator pins the cord from the headlight to the back of the surgeon’s shirt.
• Reminder: When local anesthesia with epinephrine is administered, the patient may have increased feelings of fear and anxiety regarding the surgery and the unfamiliar environment due to the effects of the epinephrine in the anesthetic.
• Reminder: Assess and document the patient’s anxiety, provide emotional support, such as maintaining eye contact and holding the patient’s hand during the administration of anesthesia, etc., and answer questions in a knowledgeable manner. This is done for continuity of patient care and for medicolegal reasons.
• Reminder: Provide emotional support to the patient regarding feelings of altered body image and give the patient an opportunity to express his/her feelings.

Definition
Realignment and fixation of fractured nasal cartilage, bones, and/or septum.

Discussion
Fractures of the nasal bones, cartilage, septum, and frontal processes of the maxilla due to trauma may occur in multiple combinations. Most often, reduction is accomplished by the closed method. When closed reduction is unsuccessful, open reduction is indicated.

Procedure
When local anesthesia is employed, the surgeon will insert topical anesthetic (cocaine pledgettes or other agents such as pontocaine, lidocaine, etc.) and inject lidocaine with epinephrine; these serve to provide anesthesia and effect some degree of hemostasis.When general anesthesia is employed, the surgeon may elect to apply these same agents to effect hemostasis and provide postoperative analgesia.

A forceps (e.g., Asch) is placed to provide traction under the nasal bones. External digital manipulation reduces the fracture. Nasal packing is inserted, and a nasal splint is applied.

If the results of closed reduction are unsatisfactory, open reduction exposing the septum and portions of the nasal bones is indicated. Modified techniques similar to rhinoplasty may be necessary for realignment of the malpositioned bony and cartilaginous fragments.The fragments may be stabilized with packing or by intranasal sutures. Following the insertion of nasal packing (with antibiotic ointment), an external nasal splint is applied.

Preparation of the Patient
Anesthesia may be local or general. The patient may be in supine or semi-Fowler’s (“beach chair”) position. A padded or gel headrest may be used. One arm may be extended on a padded armboard and the opposite arm padded and tucked in at the patient’s side, or both arms may be padded and secured at the patient’s sides with padded restraints. A pillow may be placed under the knees to avoid straining the low back, or the table may be flexed for comfort. Bony prominences and areas vulnerable to skin and neurovascular pressure or trauma are padded. An electrosurgical dispersive pad is applied.

When the semi-Fowler’s (“beach chair”) position is employed, the table is raised from the middle break, and the foot of the table is lowered; the knees are positioned over the lower break of the table.The arms are placed in the patient’s lap on a pillow and secured with padded restraints. A pillow may be placed behind the legs. A padded footboard is secured to the table and the heels are padded as necessary to avoid pressure injury.The safety strap is secured across the thighs. The table may be turned 90 , with the anesthesia provider opposite the operative side (surgeon’s side). An electrosurgical dispersive pad is applied. Extra caution must be taken to avoid injury to the patient’s fingers when the semi-Fowler’s position is employed and the foot of the table is raised at the conclusion of the procedure.

Most surgeons do a preliminary nasal preparation. If an anesthesia provider is not in attendance, a perioperative RN, in addition to the circulator, must be present to monitor the patient and to administer conscious sedation at the surgeon’s direction; see responsibilities of the perioperative RN monitoring the patient.

Special Notes

• Reminder: Use safety precautions to identify, label, and dispense medications or solutions and to avoid medication errors. It is mandatory that all medications and solutions on the sterile field be labeled by name and strength.The medication bottles are retained in the room until the procedure has concluded.

• Particularly when surgery is performed using only local anesthetic or local and conscious sedation, keep movement and conversation in the room to a minimum, as the patient hears all that is said.

• Reminder: Assess and document the patient’s anxiety regarding the procedure and the unfamiliar environment; provide emotional support, such as maintaining eye contact and holding the patient’s hand during the administration of anesthesia, etc., and answer questions in a knowledgeable manner. Document that these measures were done for patient safety regarding continuity of care and for medicolegal reasons.

• Reminder: Provide emotional support to the patient regarding feelings of altered body image and give the patient an opportunity to express his/her feelings.

• N.B. When cocaine is used, both the circulator and the scrub person must observe the discarding of any remaining cocaine following the procedure. Both persons must observe that the cocaine is discarded; the discarding is documented for medicolegal and accountability reasons.

• N.B. Note: In the PACU, the perioperative practitioner must observe, report, and document the actions taken regarding checking for bleeding (e.g.,hemorrhage) and for breathing difficulties (i.e., airway obstruction may be caused by tissues swelling) and the outcomes of the interventions in the Perioperative Record.