When you read articles at sites like MedScape or MedPage Today, you are often referred to other articles of interest. That’s how I came across this one on the MedPage Today site. I went there to read the one on “Sinus Infections Cause Toxic Shock Syndrome in Children”. Both are interesting articles, but I want to discuss the article referenced below that was discussed on MedPage Today.
The topic is postoperative infections in face lift surgery. The stated objective of the article:
To determine the incidence of methicillin-resistant Staphylococcus aureus (MRSA)-positive surgical site infections after face-lift surgery and to discuss the screening, prevention, and treatment of such infections.
MRSA infections are never a good thing, but as a postoperative face lift infection – really not a good thing.
The article mentions having done a literature review and finding only one published article (second reference below) on the incidence of postoperative surgical site infections (SSIs) after rhytidectomy. It was a retrospective study performed more than 10 years ago on 6166 consecutive face-lifts. In that study only 11 infections requiring hospitalization were found (0.18%) and none of the cultures were positive for MRSA.
This current article is also a retrospective study. Charts of 780 patients from January 2001 to January 2007 were reviewed. These patients all had a deep-plane rhytidectomy. Some had other procedures such as blepharoplasty, browpexy, rhinoplasty, autologous fat transfer, laser resurfacing, and chemical peel. All were done as outpatients.
The article highlights the techniques used for infection prevention:
The morning of surgery, all patients showered and washed their hair with chlorhexidine solution.
After the induction of anesthesia and before incision, the patients' faces were scrubbed with chlorhexidine and povidone-iodine. Attention was placed along the areas of the face-lift incision, including the hair-bearing scalp 5 cm posterior to the hairline.
Sterile towels were then secured around the patient's head to sterilely secure the surgical site.
Before incision, 1 g of intravenous cefazolin sodium (Ancef) was administered (clindamycin if the patient was allergic to penicillin).
After surgery, all patients were given a 7-day prescription for oral cefadroxil (Duricef).
The patients were then seen on postoperative days 1, 5, 8 (suture removal), 21, and 40. During each visit, they were examined for any signs of infection, such as erythema and fluid collection.
There were 4 patients (out of 780) who developed postoperative wound infections with cultures that were positive for MRSA. Another patient developed a wound infection that yielded anaerobic skin flora. This gave an overall infection rate was 0.6%. As noted in the article 80% (4/5) of the infections were MRSA related.
The article highlights each of the five patients with individual case reviews. I want to highlight the outcomes in terms of scarring. With the exception of the first case, there is really not enough follow up on the scar evaluation.
Case 1: “Six months after surgery, the scarring was barely perceptible.”
Case 2: “Four weeks after surgery, the patient had healed completely. She had no scarring, and the area of the incision that was opened had healed well.”
Case 3: “and the patient healed uneventfully over the next 7 days.”
Case 4: “The patient healed rapidly, and she had no evidence of infection or scarring after 7 days of treatment.”
Case 5 (non-MRSA): “She improved rapidly and healed well”
The article makes some nice points for setting up screening protocols. For the facelift patients, perhaps preoperative cultures of the nose and throat.
Those cases with MRSA colonization and no clinical infection were treated with mupirocin (Bactroban) nasal ointment 3 times daily and 2% triclosan (Aquasept) washes twice daily for 5 days.
Povidone-iodine (Betadine) mouthwash was also used 2 to 3 times daily as gargle for 5 days. Chlorhexidine mouthwash was used in patients with a contraindication to iodine.
The article does a very nice job of point out the importance of postoperative surveillance, aggressive early treatment (incision and drainage, culture, antibiotics).
Once MRSA infection is diagnosed after a face-lift, aggressive treatment is advised to prevent rapid progression of the infection. Prompt initiation of appropriate antibiotic therapy, along with incision and drainage, is essential. The cosmetic nature of rhytidectomy may make facial plastic surgeons hesitant to open wounds that have an infected collection. However, openly draining wounds that have collected MRSA-positive material is prudent.
The facial plastic surgeon must be quick to culture any suspicious fluid or discharge. The result of the sensitivity and resistance profile from these cultures will be the ultimate guide for the antibiotic regimen. Prompt culture cannot be stressed enough. The infection can spread rapidly along the surgical dissection site and become extensive in a very brief time frame. …….
"Methicillin-resistant staphylococcus aureus-positive surgical site infections in face-lift surgery" Arch Facial Plast Surg 2008; 10: 116 – 123; Zoumalan RA, Rosenberg DB
Infections requiring hospital readmission following face lift surgery: incidence, treatment, and sequelae; Plast Reconstr Surg. 1994;93(3):533-536; LeRoy JL Jr, Rees TD, Nolan WB III.