38 Unique Considerations in Upper Facial Surgery
Abstract
This chapter addresses particular preoperative, intraoperative, and postoperative considerations that arise with the upper facial surgery techniques reviewed in this book. Available evidence and consensus guidelines are summarized to provide a framework for the surgeon to answer questions such as whether and when to stop blood-thinning medications, what kind of perioperative antibiotics are indicated, and how to safely use electrosurgical and other energy-based devices. Certain patient comorbidities that may impact surgical planning are also presented.
38.1 Introduction
When should anticoagulants or antiplatelet agents be held before surgery? Are perioperative antibiotics necessary? What form of cautery is safest with patients who have implanted electronic devices? In the course of appropriate preoperative evaluation and surgical planning, these and many other questions arise.
The evidence for holding or prescribing perioperative medications is reviewed in the following sections, focusing on drugs that may exacerbate bleeding, and on infection prevention. The final section reviews safety considerations with various energy-based devices used in plastic surgery. Common perioperative issues that arise for the upper facial surgeon are reviewed to raise awareness of potentially serious risks for certain patients and to summarize the existing evidence and guidelines to help clinicians assess and manage these risks. Treatment should always be tailored to the individual patient.
38.2 Perioperative Medications
In this section, we review perioperative blood thinner and antibiotic medication use.
38.2.1 Blood-Thinner Considerations
Antithrombotic medications increase the risk of bleeding, which may lead to increased operative time, intraoperative complications, postoperative bruising, and poor postoperative cosmesis; rarely, orbital compartment syndrome and significant vision loss occur. One study at a large oculofacial plastic surgery practice found that 40% of patients used at least one antithrombotic agent. 1 Given the aging population and recommendations for aspirin as prevention for cardiovascular disease, this proportion will continue to increase; although recent recommendations suggest aspirin may not be as beneficial, it will likely take years for this to take effect. 1
There are no randomized controlled trials on perioperative management of antithrombotic medications in oculofacial surgery. Management is guided largely by retrospective studies and trials in other surgical fields. The oculoplastic surgeon must balance the potentially life-threatening risk of thromboembolic events with the risk of bleeding complications, such as orbital compartment syndrome, and, rarely, the need for blood transfusion. Understanding when to stop and restart these agents is critical to perioperative management.
38.2.2 Classes of Blood Thinners
There are three main classes of blood thinners currently approved by the Food and Drug Administration (FDA) for use in the United States: (1) antiplatelet agents, (2) anticoagulants, and (3) direct oral anticoagulants.
Antiplatelet Agents
The antiplatelet agents inhibit platelet aggregation and thrombus formation. Antiplatelet agents include aspirin, clopidogrel (Plavix), ticagrelor (Brilinta), cilostazol (Pletal), dipyridamole (in Aggrenox), and prasugrel (Effient). The two most commonly used antiplatelet agents are aspirin and clopidogrel. Aspirin is indicated for both primary and secondary prevention of cardiovascular disease, though many patients use it for analgesia unrelated to cardiovascular disease. Because it is easily obtained over-the-counter, many patients forget to include aspirin when reporting a medication list, particularly if it is a low dose (e.g., 81 mg or “baby” aspirin). 1 In contrast, clopidogrel is used as secondary prevention in patients with prior thromboembolic event, prior myocardial infarction, or an implanted device such as a cardiac stent. Aspirin and clopidogrel may be used synergistically (termed dual antiplatelet therapy) in patients at high risk for thromboembolic event. These patients tend to bleed more than patients on a single agent. 2
Nonsteroidal anti-inflammatory drugs (NSAIDs) also inhibit platelet activity, though the effect is usually of shorter duration. NSAIDs may be nonselective (e.g., ibuprofen, indomethacin, or naproxen) or selective (e.g., celecoxib). The effect of nonselective NSAIDs on intra- or postoperative bleeding complications is unclear; some studies suggest increased risk, while others suggest there is no increased risk of bleeding complications. 3 , 4 There is evidence that the selective COX-2 inhibitor celecoxib (Celebrex) does not significantly affect platelet function or intraoperative bleeding. 5 Other NSAIDs that affect COX-2 more than COX-1, such as meloxicam and etodolac, have also been shown to have little impact on bleeding risk. 6 , 7 For postsurgical pain, the intravenous NSAID ketorolac (Toradol) is often offered by the anesthesiologists as an alternative to narcotics, but there have been conflicting studies over whether this may cause increased risk of postoperative bleeding. 8 A study in patients undergoing endoscopic sinus surgery comparing ketorolac to fentanyl showed no increase in postoperative hemorrhage and equal analgesia. 9 A recent randomized controlled trial of 100 patients undergoing levator advancement surgery found better analgesia scores with IV ketorolac compared to usual care, and no patients had significant postoperative hemorrhage. 10
Anticoagulants
The anticoagulants directly inhibit clotting factors in the coagulation cascade and are indicated in patients with prior pulmonary or venous thromboembolism, or prophylactically in the setting of atrial fibrillation, prosthetic heart valves, and rheumatic heart disease. Warfarin (Coumadin) is the most commonly used oral anticoagulant. Heparin is delivered intravenously, but its derivative called fractionated or low-molecular-weight heparin is available by subcutaneous injection.
Warfarin inhibits the production of vitamin K-dependent clotting factors. It acts on the extrinsic pathway of the coagulation cascade and is monitored by prothrombin time (PT) or its derivative, the international normalized ratio (INR). In contrast, heparin primarily affects the intrinsic pathway and is monitored by the partial thromboplastin time (PTT). These values essentially quantify the amount of anticoagulant effect of the particular agent. Warfarin is a complicated medication, with many food and drug interactions, a narrow therapeutic index, and frequent monitoring for dose titration. In the event of emergency surgery or uncontrolled intraoperative or postoperative hemorrhage, the anticoagulation effect of warfarin is reversible with vitamin K and fresh frozen plasma.
There are several low-molecular-weight heparin agents available, the most common of which is enoxaparin (Lovenox). The oculofacial surgeon may encounter enoxaparin for it use as a bridging agent in patients on warfarin. Essentially, in select patients, the warfarin is held preoperatively and the patient is started on subcutaneous injections of enoxaparin instead for a brief period before and after surgery. The enoxaparin is a shorter-acting agent whose dose can be held immediately prior to surgery with the goal of mitigating intraoperative bleeding while allowing for appropriate perioperative reduction in thromboembolic risk. A meta-analysis on bridging therapy in moderate-risk patients with atrial fibrillation on warfarin showed, however, that bridging therapy increased bleeding risk without decreasing thromboembolism risk, calling into question the utility of bridging therapy. 12 , 13
Direct Oral Anticoagulants
The direct oral anticoagulants (DOACs), sometimes referred to as new oral anticoagulants (NOACs), were invented as an alternative to warfarin. Their advantage lies in the fact that they have a more predictable pharmacologic profile, fewer food and drug interactions, and require no regular monitoring. They have a more rapid onset of action (average 2–3 hours vs. 3–4 days) and a shorter half-life (average 12 hours vs. 20–60 hours) compared to warfarin. 13 However, their disadvantage is that they lack a reversal agent, and lab tests for monitoring their effect are less readily available. The currently available DOACs are apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto). All are indicated in patients with atrial fibrillation, and dabigatran and rivaroxaban are also FDA-approved for pulmonary embolus and deep venous thrombosis.
38.2.3 Balancing Thrombotic Risks and Bleeding Risks
The decision to cease or continue blood thinners prior to surgery requires a careful understanding of risk. In the oculoplastic literature, the risk of major hemorrhage intraoperatively or postoperatively is less than 1%, 14 and the risk of vision loss from retrobulbar hemorrhage after blepharoplasty is even lower (0.0045% from survey data). 15 The data on bleeding risk in oculofacial surgery with and without blood thinners are sparse without randomized trials in eyelid, lacrimal, or orbital surgery. A prospective study by Custer et al of 1,500 oculoplastic procedures reported an overall rate of severe hemorrhage of 0.4%. 14 The authors found that patients who continued antiplatelets and anticoagulants had no increased risk of intraoperative bleeding, postoperative bruising, or severe bleeding complications compared to controls; however, they noted “troublesome bleeding” prolonging 9% of surgeries. 14
Recommendations in the facial plastics and dermatologic literature suggest continuation of blood thinners is associated with low rates of severe hemorrhagic complications. 16 ID#b2a976a800_17 – ID#b2a976a800_18 19 Importantly, intraoperative and postoperative hemorrhages in oculofacial surgery carry special risk compared to facial plastic or dermatologic surgery because of the potential for orbital compartment syndrome and vision loss. Therefore, although these fields have larger, more robust studies on perioperative blood thinner use, it is difficult to extrapolate their findings.
Bleeding risks must be balanced with the risk of thrombotic event should blood thinners be held. No randomized trials exist that report the rate of thrombotic event in patients who discontinued blood thinners for surgery. In patients who have warfarin stopped for any reason, including perioperatively, there is an approximately 1% risk of a thromboembolic event within 30 days. 20 This risk increases fourfold in patients with mechanical heart valves. 21 One meta-analysis estimated the additional risk of any vascular event of withholding aspirin for 7 days perioperatively at roughly 1 cardiac event to 1.4 cardiac events per 1,000 patients. 22 Therefore, the upper facial surgeon must weigh a 1% or greater risk of thromboembolic events with the less than 1% risk of a severe hemorrhagic surgical complication.
The American College of Chest Physicians has released evidence-based guidelines for patients on blood thinners undergoing elective procedures. This requires risk-stratification of patients for perioperative thromboembolism (Table 38.1) and of procedures for bleeding (Table 38.2). Reconstructive plastic surgery falls within the high bleeding risk category, defined as greater than or equal to 2% 2-day risk of major bleed. 23 Eyelid and brow oculoplastic procedures likely do not require categorization in this group, but one could classify orbital and sinus cases as high-risk bleeding procedures. These guidelines are patient-driven: in high-risk patients, guidelines recommend stopping DOACs and warfarin and bridging with low-molecular-weight heparin; low-risk patients should also stop these medications, but do not require bridging. High-risk patients should continue antiplatelet agents when possible, and low-risk patients may stop antiplatelet agents. 24
Patients with recent cardiac stents are particularly high risk, and recent guidelines state that “elective noncardiac surgery should not be performed within 30 days of bare metal stent or 12 months of drug-eluting stent implantation because of in-stent thrombosis as well as bleeding risk from dual antiplatelet therapy during surgery.” 25
38.2.4 Time to Stop Blood Thinners Preoperatively
Recommendations in the literature vary on appropriate timing to stop blood thinners preoperatively. Platelet function takes longer to recover than anticoagulant effect, so the antiplatelet agents require stopping the soonest before surgery than other classes. As most of the antiplatelets irreversibly inhibit platelet function, generation of new platelets must occur to regain clotting effect. Generally, most sources recommend stopping aspirin and prasugrel 7 days prior to surgery and clopidogrel and ticagrelor 5 days prior. 26 , 27 Warfarin can be stopped 5 days prior to surgery. The DOACs can be stopped 2 days before surgery, except in the context of renal dysfunction, which alters the clearance rate of dabigatran because it is cleared by the kidneys (Table 38.3). All agents can be restarted the day after surgery.
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