163
CHAPTER 11
Continuing Facial Analysis
CHAPTER 11
11.1 Meet the Patient the Day Before theOperation 164 11.2 Continuing Facial Analysis in the Operating Room 164 11.2.1 The Basic Preoperative Documents
are Hanging up in the Operating Room 164 11.2.2 Problems Related to General Anesthesia
and Patient Positioning During Facial Surgery 164 11.3 The Intraoperative and Postoperative
Procedure Documentation 165 11.4 The Continuing Facial Analysis
in the Early Postoperative Phase 165 11.5 The Continuing Facial Analysis
in the Late Postoperative Phase 166 References 166
“The important thing is not to stop questioning”
Albert Einstein
164
Following the “Spiral of analysis” re- quires continuous effort in many phas- es of our practice. When you have an in- dividually tailored and patient-accepted treatment plan for the following day’s surgery, these continuous efforts are directed towards the checking activity.
Again, the most important advice is not to stop analyzing and questioning.
11.1
Meet the Patient
the Day Before the Operation One of my favorite moments in the pr- eoperative phase is the meeting the day before. Even if all the preoperative steps are concluded and the informed-con- sent documentation is signed, I like to go over the goals of the procedure together with my patient only a few hours before the surgery. The other main points of the meeting the day before are:
Q Verify all the medical records. Do they contain evidence of first-visit pa- tient education? Do they contain evi- dence of the procedure you will later perform? Do they include a complete history and physical examination? Do they include a complete and itemized patient priority list? Are the preop- erative analysis and planning sheets ready for tomorrow? ...
Q If the patient is a smoker, verify that she has stopped smoking before the procedure.
Q Verify that she has not taken aspirin in the previous two weeks.
Q Verify that you have the opportunity to meet the patient’s wishes with the treatment plan!
I believe it is absurd and dangerous to operate on a patient without a recent and conclusive preoperative meeting.
11.2
Continuing Facial Analysis in the Operating Room
11.2.1
The Basic Preoperative Documents are Hanging up in the Operating Room For any major facial surgery procedure, I hang the following documents up on the nearest wall of the operating room:
Q The step-by-step operative surgical sequence planned.
Q The printed photographs containing the notes written during the previous consultation together with conven- tional radiographs, CT scans, etc.
Q The itemized list of goals for the pro- cedure.
At any time during the procedure, I can stand up, take two or three steps, and verify, on the documents, that my sur- gery fits the treatment plan.
11.2.2
Problems Related to General Anesthesia and Patient Positioning During
Facial Surgery
But, suddenly, they were like a car that loses its headlights
while speeding down a mountain road on a dark night.
J. Champy and N. Nohria [1]
Looking at the patient’s face a moment before the surgical incisions, you can note several important problems:
Q It is probably the first time that you have seen this patient in the supine position.
Q The head positioning is technically limited to avoid the risk of cervical trauma and to assure a stable and safe body position on the operating table.
Q Your viable points of view are quite different from those utilized during the consultation.
Q Gravity acts on mobile structures, the mandible and the soft tissue, with a vector oriented from the tip of the nose toward the ear instead of the usual cephalo-caudal axis.
Q The effects of gravity on the soft tis- sue are not counteracted by muscular CHAP TER 11 Continuing Facial Analysis
165 tone due to the effects of general an-
esthesia.
Q The drapes partially hide the face and, due to their weight, stretch and deform the facial skin.
Q The intense operative light illumi- nates a restricted area and produces hard and unnatural shadows.
Q Around the operative field the light brightness decreases, creating a visu- al contrast.
Q The endotracheal tube and the surgi- cal tape utilized to fix it deform and hide some areas of the face.
Q Orthognathic surgery and other fa- cial procedures require a particular head position, such as the extended one, which contributes to an unnatu- ral way of visualizing.
Q The disinfecting solution partially erases your preoperative skin draw- ings.
Q The infiltration of the soft tissue with local anesthetic solution produces a localized swelling.
These 12 intraoperative problems, which are only partially avoidable, require that, during every step of the surgical proce- dure, the surgeon can see and compare his actions to the preoperative photo- graphic and planning documentation.
Again, keeping a well-prepared preop- erative work in the operating theater is fundamental for facial surgery.
11.3
The Intraoperative and Postoperative Procedure Documentation
Taking intraoperative photographs or small video sequences of the main sur- gical steps should be common practice in the operating theater, at least for the most demanding procedures, and in eve- ry case something of particular interest is found.
The surgeon should describe the sur- gical steps in detail immediately fol- lowing surgery, not delegating the task to others. Making drawings during the operation, or filling in specific graphi- cal templates, can be useful in the post- operative analysis to enhance the value
of the work performed in the operating theater.
For each of my open rhinoplasty cas- es, for example, I have adapted a mod- ified version of the “Gunter diagram”
(Fig. 11.1) printed onto a worksheet with a form reporting the most utilized steps of the procedure [2, 3].
11.4
The Continuing Facial Analysis in the Early Postoperative Phase The final result is not the unique result!
When treating the face, the most vis- ible – important – anatomical region of a person, we are also responsible for the postoperative discomfort of our pa- tients, the postoperative external aspect, the time needed to return home, the time needed to return to work, and the time needed to restart physical activity.
Close monitoring of the healing phase, sometimes with accurate photo- graphic documentation, offers particu- lar extra value to the surgeon, such as:
Q The possibility of judging the imme- diate and early effects of the treatment on the patient.
Q The chance to reassure the patient about the unavoidable small problems of the postoperative phase.
Q The opportunity to check that the pa- tient correctly follows the postopera- tive therapy.
Q A further opportunity to vary the postoperative therapy, if necessary.
11.3 The Intraoperative and Postoperative Procedure Documentation CHAP TER 11
Fig. 11.1.
Open rhinoplasty description worksheet. On one side, the sur- geon fills in the form and reports any steps or adjunctive proce- dures performed. On the oth- er side, he draws and adds notes over a modified version of the
“Gunter diagram,” enhancing the amount and value of the infor- mation recorded
166
Q A further way to maintain direct – uninterrupted – communication with the patient.
11.5
The Continuing Facial Analysis in the Late Postoperative Phase The initial clinical facial analysis mate- rial should not become a freeze-frame of an old case. It is the starting point of a dynamic process in which we must find as many cause-and-effect relationships as possible.
For any major surgical procedure, the routine postoperative photographs are taken at least 3 months and 1 year post-
operatively. The new photographic set is taken only after reviewing the initial one to select the same projections in order to obtain the best comparative values.
References
1. Champy J, Nohria N (2000) The arc of ambi- tion. Perseus Books, Cambridge, p 113 2. Gunter JP (1989) A graphic record of intraop-
erative maneuvers in rhinoplasty: the missing link for evaluating rhinoplasty results. Plast Reconstr Surg 84: 204
3. Tebbetts JB (1998) Practice management documents for rhinoplasty – Appendix D. In:
Tebbetts JB (ed) Primary rhinoplasty. A new approach to the logic and techniques. Mosby, St. Louis
Continuing Facial Analysis CHAP TER 11
