FPSAM - Roundtable 2022 - 6

EXPERT PANEL DISCUSSION
use anything because if it really friction fits in there,
then plates can only cause a problem. If you can
avoid them, then great, although, in 22 years, I have
never seen a problem with the plates.
Is anybody using drains in the forehead? Dr.
Rodman?
Dr. Rodman: Ijuststarted,maybe in thepast6months,
doing this. I used to just do fluffs and pressure dressing.
There was one patient who, while I was doing something
else, developed a hematoma in the temporal area.
I drained it, and put a drain in. Then the next morning,
she had no swelling at all. I did it two or three more times
and I have just found that they get less swelling around
the eyes in the postoperative period. I am not totally sold,
but I've probably done it on the last six patients. I think,
at least for me, the swelling goes down a little faster.
Dr. Spiegel: You are taking them out on postoperative
days 1, 2, 3?
Dr. Rodman: Postoperative day 1. I see everyone Post
op day/either I see them in the hospital, or if they go
home, they come back to my office the next morning.
I take off the bandage and take the drain out at the
same time.
Dr. Spiegel: Great transition. Postoperative care,
are people sending patients home, keeping them in
the hospital, having nursing care? Dr. Knott, do
you want to start this one?
Dr. Knott: I usually keep them overnight in the hospital
and I find that for the significant edema around the
eyes, I try to ice them intraoperatively. I find that is very
helpful. I use TXA as well, intraoperatively, and I try to
minimize bleeding. That has been a huge help for us
because all the scalp incisions do bleed a lot. The
periorbital edema, I find, is one of the issues that can
complicate things when they cannot easily see to walk
around and I like to keep themovernight in the hospital.
Dr. Spiegel: Anybody sending people home? Dr.
Rodman?
Dr. Rodman: I send many people home. My general
rule, the anesthesia group I work with, anything more
than 8 h of anesthesia, they like them to stay, which is
reasonable. Or if I do something in the nose and
something in the mouth at the same time, I have them
stay. I have some patients who just do their forehead
and I send those home.
Dr. Spiegel: Dr. Schechter?
Dr. Schechter: A couple of points on observations
over the years. I think certainly with a full face, we
6
admit overnight and then send home in the morning.
I think one of the things that we have seen in the evolution,
as insurance has extended coverage to many of
the procedures, and we are now caring for individuals, I
think it was Laura who mentioned at Henry Ford, for
individuals who have more significant resource limitations.
I think the issues of aftercare are really important.
Regardless of the anatomic location-chest,
breast, body, genitalia, face-I think recognizing that
one of the most important things we have done in our
practice is to have a social worker in the office.
That's a person who is focused on case management,
and very specific to the aftercare services. Many
people travel, as we know and having a preoperative
plan, in terms of their aftercare, is quite important.
That is often an overnight hospital stay, and then local
housing in the area. We try to lock that down as much
as we can before surgery because I think especially as
we've extended care and services, and access to individuals
who are more resource-limited, I think this is
where people can run into some trouble. It may not be
the operation itself, but it's some issues that may occur
in the postoperative period.
Dr. Spiegel: We have, for the last about 400 cases we
have done, sent everybody home, regardless of
length of case, with nursing care or a friend, and
have found that people have, in our experience,
preferred it because they find the hospital scary,
disconcerting. We have been seeing them back in
the office on postoperative day 1 for a dressing
change, where I switch from a couple of fluffy
things and an ACE wrap to just an ACE wrap. It's
reassuring to tell people, that's it. It's not such a
big, scary procedure. So that has been good, but I
am not sure there is a perfect solution yet. Next area
I want to talk about is the mid face. We are working
our way down, leaving the forehead, which we all
decided at the beginning was the most significant.
Dr. Rodman: I just want to say one thing; that many of
these procedures, even if they are covered by insurance,
are covered as an outpatient. The hospital has to be
willing to ''eat'' the cost of the overnight. Most of my
hospitals are small, or small surgery centers. They are
not willing to eat the costs; that's just something to be
aware of, that they are approved, but your hospital must
allow the patient to stay overnight by just swallowing
the cost, which makes sense if they are doing the imaging
there and you are making other money there, but
not all hospitals are willing to let the patient stay
overnight because they have to eat the cost of the
nursing care, et cetera. For many of my patients, it's
$1,500 to stay overnight. Even people with some resources,
it's another expense, whereas a private nurse in
this area is $500 and many of them opt for that.
ª 2022 American Academy of Facial Plastic and Reconstructive Surgery, Inc.
FPSAM - Roundtable 2022

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