The FFS postop period is one of the main sources of concern of facial feminization patients. Here you will find information on the topic of your care and well-being during the entire facial feminization process. No answer here? Just ask!
During the FFS post-op period, patients will generally encounter two phases as the healing evolves:
1. Inflammatory Phase:
Usually lasting 3-4 months, this part of the FFS postop may be divided into two sub-stages:
1.1. Early inflammatory Stage: During the first 3-4 weeks after surgery, when the noticeable bruising and swelling persists. Pain and discomfort during this period may occur. Numbness is typically at it´s maximum level. During this period, wearing compression bandages to reduce the swelling may be recommended after chin or jaw surgery.
1.2. Late inflammatory Stage: During the 2-4 months after surgery. At a much lesser degree, minor symptoms are common such as residual swelling, fibrous tissue presence, irregularities, asymmetry etc. which may vary from day to day or even from morning to night. Continuous pain is not expected, but some discomfort may still be present, especially stiffness in the area. Numbness diminishes gradually, slowly regaining sensation even up to a year or more.
2. Re-adaptation Phase:
Re-adaptation of the tissues initiates when the majority of the edema (swelling) has diminished to about 80%. It takes 12 to 15 months approximately to fully repair. Primarily, the soft tissues will need to readapt to the new bone surface. The remaining residual swelling will continue to subside gradually over the year, when the final results are more definitive (except with a rhinoplasty, which may take 18-24 months).
One of the most important aspects of the FFS postop process involves the appropriate aftercare management of the patient, both immediately after the operation as well as on the long-term. Proper recovery has a strong influence on whether the patient returns to her usual routine swiftly. The immediate postoperative period is the most intensely influential one, both physically and emotionally. It requires a strict protocol to ensure that the patient receives constant care and is made to feel that she can count on the close support of the professionals involved in her treatment. While the situation may vary according to the patient, the face usually experiences significant inflammation after surgical manipulation, which is most obvious in the eyelid, nose, jaw, and chin areas.
How to prevent and treat post-surgical edema:
- In advance as well as postop FFS, use of arnica-based topical balm
- Medical prescription for anti-inflammatory and analgesic medicine
- Compression bandage and the application of cold to the operated area (hilotherapy)
- Manual lymphatic drainage
- Acupuncture: traditional, auriculotherapy, electroacupuncture and laser acupuncture
The prior use of arnica balm combined with the immediate application of hilotherapy and the early administration of manual lymphatic drainage and acupuncture considerably decrease any edema and speed the recovery and adjustment of the soft tissues. Finally, we recommend using compression therapy (elasticated facial garment provided) for 2-3 weeks after jaw and chin recontouring surgery to assist in tissue repositioning.
Hilotherapy is a thermal-enabled therapy that promotes the healing of damaged tissue. It is used for surgical procedures, injuries and chronic diseases that can produce swelling, hemorrhages, edema and inflammation. Hilotherapy not only promotes healing in the FFS postop process but also reduces pain intensity, thus lessening the need for analgesics.
Hilotherapy is the product of the knowledge gained about the healing processes of injured and/or traumatized tissue. In these processes the key points are:
- The role of oxygen supply and the supply of nutrients
After injuries or surgeries, the oxygen and nutrient supply to the affected tissue is considerably disturbed because of the formation of edemas and hemorrhages. The metabolic speed increases as the tissue becomes overwarm from inflammation of the affected area. The need for oxygen is therefore considerably higher as well. Consequently, the damaged area is no longer supplied with the amount of oxygen needed for maintenance and regeneration. Due to this lack of oxygen (ischemia), further cells die off and liquid-binding proteins become free, producing additional edemas and a vicious cycle that leads to hypoxic damage. The medical requirement is to lower the oxygen need of the affected tissue.
- The role of vascular functions
In craniofacial surgery, vascular dilatation works positively on the postoperative healing process. This vascular dilatation is achieved by warming the affected areas. But nonselective warming leads to an increase in the body’s core temperature and an associated rise in the temperature of the soft tissue surrounding the surgical area. The consequences are various side effects for patients, including an increased risk of infection. The medical requirement is to apply only the exact, low-threshold heat directly to the affected area, with very precise temperature control.
Application and the therapeutic response
The immediate application of a controlled cooling therapy (Hilotherm Clinic device, Hilotherm GmbH, Ludwigsburg, Germany) helps resolve edemas quickly and produces a subjective feeling of well-being in the patient. The thermal effect is applied by means of water, which circulates through a mask-type device. The water temperature is set by the medical team to the exact value needed and is then maintained for as long as necessary.
Several studies have shown that the use of the Hilotherm cooling device significantly reduces FFS postop swelling, pain and the length of hospital stays when compared with conventional cooling systems. Satisfaction with the cooling method was significantly higher in the Hilotherm group than with patients receiving conventional cooling.
The applied temperature is set at +16°C in our case for 48 h, which does not impede lymphatic drainage. Thus, in this situation, hilotherapy clearly reduces the oxygen requirement in the area around the affected face part, reducing the metabolism speed, so that the amount of oxygen that reaches the injury is sufficient for regeneration.
The concept is to encourage a more comfortable FFS postop recovery while providing a little extra attention to patients, who will, in turn, benefit from pleasant sensations that neutralize the negative effects of the surgery, manual lymphatic drainage (MLD) is administered beginning shortly after the operation. The prompt application (1-5 days after surgery) of MLD by specialists considerably decreases any edema and speeds the recovery and adjustment of the soft tissues.
Physiotherapy in the FFS postop period has two main goals:
- First, to improve the physical and psychological welfare of patients using different techniques to reduce any negative consequences resulting from the surgery and resolve any concerns patients may have about their evolution.
- Second, to ensure speed recovery, enabling the patient to return to their personal or professional activities as soon as possible. To meet these objectives, we adapt the physiotherapy to each patient and type of surgery to achieve optimal results in the evolution of tissues.
What is manual lymphatic drainage?
Manual lymphatic drainage (MLD) is a massage technique that works on the skin’s surface, following the anatomic lymphatic pathways of the body, accelerating and even redirecting superficial lymphatic circulation and accelerating the absorption of edemas. A manual lymph drainage session begins in the neck to clear out the main lymphatic pathways, facilitating drainage from the face. Unlike other types of massage, it produces neither redness nor pain and does not have a stimulant effect. To successfully administer this technique, knowledge of the anatomical distribution of the lymphatic and superficial ganglions and their interconnections is necessary. MLD descends to facilitate the flow of the lymph from the affected areas to unaffected ones. It is possible to perform MLD in the case of late or latent edema three days after surgery if contraindications do not exist. MLD must be applied by a specifically trained physical therapist. The procedure takes approximately 40 min and is usually performed at least twice a week for 2 to 4 weeks. It has been demonstrated that the greatest reduction of the edema is obtained during the first week of treatment; during the second week the results become stable.
Why is MLD recommended?
Manual lymphatic drainage is very important in the postoperative treatment and care of facial feminization surgery. A manual technique that improves lymphatic circulation, its use helps, above all, to eliminate post-surgical edemas. MLD improves tissue scarring, decreases postoperative discomfort and accelerates recovery. Manual lymphatic drainage is a proven technique that we employ with all of the aesthetic and facial feminization surgeries that we perform, including:
- Forehead reconstruction, rhinoplasty, jaw recontouring and mentoplasty
These are the operations that most benefit from correct post-surgical manual lymphatic drainage treatment, since edemas often appear around the eyes, nose, and jaw.
- Lifts, blepharoplasty
Manual lymphatic drainage helps eliminate edemas more quickly, accelerates tissue recovery and decreases postoperative pain and discomfort after a lift or blepharoplasty. It must be administered carefully, especially in the areas near the incisions.
- Scar treatment
When treating scars, manual lymphatic drainage is the first measure employed to facilitate scarring. By reducing the edema, it fosters the supply of nutrients and the elimination of metabolic waste, both of which are necessary for good scarring.
What are the objectives of MLD after surgery?
- To accelerate the reabsorption of edemas and hematomas
- To eliminate the residues of the medicine, anesthesia and saline solution used in the operation
- To foster the regeneration of any lymphatic vessels and capillaries after submental liposuction
- To decrease discomfort and ensure postoperative well-being
- To decrease the length of the postoperative period
- To accelerate tissue recovery
- To prevent the scar from reddening and forming cysts, which could produce a permanent retraction in the skin
- To accelerate the reabsorption of fibrous areas by stimulating the macrophages
- To improve the condition of the skin
- To accelerate the recovery of the skin’s sensitivity
- To facilitate skin retraction
MLD makes it possible to control postoperative recovery and help the patient feel better. Moreover, the patient is aware of the very close, positive support of the health staff, which contributes to a faster recovery, eliminating the negative perception of this stage.
The World Health Organization (WHO) has approved the use of acupuncture as an adjuvant therapy alongside conventional pharmacological therapy in the treatment of post-surgical pain. The goals of this therapy with our patients are adapted to their particular postoperative situation: reducing inflammation, reducing pain, reducing stress and increasing relaxation with improved sleep quality.
The strategy behind the therapy is twofold:
- The regulating signal from the nerve fibers that conduct the pain signal transmitted by acupuncture has physiological effects that decrease pain during the postoperative period.
- It has also been shown that acupuncture increases the level of endorphins, natural substances with an analgesic and comforting effect, in the blood. The skin fibers of the autonomic nervous system are stimulated, producing vascular and lymphatic regulation, which helps reabsorb edemas and inflammation. The higher cerebral centers are also activated, reducing post-surgical stress, increasing psychological and physical relaxation and providing a repairing sleep.
The application of laser acupuncture (without needles) to specific points on the face and forehead focuses on specific edema and inflamed areas with the powerful anti-inflammatory action provided by the laser light due to the thermal and mechanical stimulation of the tissues.
What the therapy is like
This therapy is done with the patient lying down in comfortable clothing that leaves the neck, shoulders, forearms, hands, calves and feet exposed. The patient removes all rings, bracelets and earrings. Two morning sessions are done on two consecutive days or one session in the morning and one in the afternoon, as needed. The sessions last around 30 minutes.
Throughout the therapy, the patient must stay as relaxed as possible with their eyes closed. If the patient can sleep, that’s even better. Once the therapy is over, the patient should stay relaxed and lying down for a while, then sit up briefly before standing up, maintaining the state of relaxation.
Various techniques are available that complement each other: acupuncture, auriculotherapy, electroacupuncture and laser acupuncture.
Acupuncture is a technique from traditional Chinese medicine that involves the insertion of very fine-gauge needles into specific points on the body, known as acupuncture points. The punctures are practically painless and the therapy provides the relaxing, comforting sensation that is necessary in the first few days after surgery.
Observational studies have shown that auriculotherapy, which involves applying pressure to auricular points, has an analgesic effect in the postoperative period, reducing the intensity of the pain and the need to take opioid analgesics when compared with a placebo.
The therapy that we do consists of puncturing auricular points with the tip of a Number 11 scalpel. With acute processes, like post-surgical facial edema in facial feminization surgery, the auricular bleeding technique usually has more powerful short-term results than other auricular techniques (needles, laser acupuncture, pressure balls, etc.). This type of puncture is more painful than conventional acupuncture needles, but it is usually well tolerated by most of the patients who receive it. It is contraindicated for patients taking anticoagulant or antiaggregant drugs and patients with coagulation alterations. This therapy should be applied between the second and sixth day after surgery, since it is more effective when the hematoma extravasates into the skin.
Electroacupuncture is a form of acupuncture where a low-intensity electrical current passes between pairs of acupuncture needles. Electrostimulation applied to the needles produces a completely tolerable tingling sensation. According to some acupuncturists, this practice amplifies the results of regular acupuncture, restoring health and well-being, and is especially good for treating pain.
Electroacupuncture is quite similar to traditional acupuncture, since it stimulates the same points during the treatment. Like traditional acupuncture, needles are inserted into specific points around the body. The needles are connected to a device that generates continuous electrical impulses using small clips. These devices are used to adjust the frequency and intensity of the impulse, depending on the condition being treated. Electroacupuncture uses two needles at the same time, such that the impulses pass from one needle to the other. Several pairs of needles may be used simultaneously, usually not for more than 30 minutes.
Laser acupuncture consists of stimulating the muscular-skeletal target points in acupuncture with a low-intensity laser as an alternative to stimulation with metal needles. This therapy has the advantage of being non-invasive and is recommended for areas that are less accessible to needles. Depending on the point being acted on, the patient may notice some local heat, which is usually not uncomfortable. This has a marked effect on the localized reduction of inflammation and edemas.