Rhytidectomies, commonly referred to as facelifts, have long been among the most popular elective plastic procedures. Popularity and profitability, however, do not always go hand in hand. Patients undergoing elective aesthetic surgery expect to be pampered with extra consideration, courtesy and time, but you need to balance these needs with an eye towards efficiency. To optimize your facility's earning potential for facelifts, which can cost your facility $1,500 or more even if the surgeon does not perform any ancillary procedures, it's essential to manage your time and staff wisely during all parts of the operative process. In this article, three facelift experts present their advice on how to ensure patient satisfaction and profitability.

Pre-op Preparation
Facelifts vary greatly from procedure to procedure. They are usually performed in conjunction with eyelid surgery, and sometimes with forehead surgery, according to Laurie Casas, MD, Head of the Division of Plastic Surgery for Glenbrook Hospital in Glenview, Ill. Because these procedures can be so complex and take so much time-up to six hours from patient arrival to recovery for a basic procedure that does not include work on the eyelids or forehead (although some states do not permit cosmetic procedures to last that long)-and because patients have particularly high expectations, you may find that you need to modify or allow extra time for your standard pre-op steps. Here's how our experts recommend that you modify some of your standard pre-op protocols:
- Obtain informed consent ahead of time: To save time, Dr. Casas obtains informed consent during an office visit well in advance of the day of surgery.
- Allow time to pamper the patient: Make sure you allow extra time to greet and reassure patients, perhaps as much as half an hour, says James Yates, MD, president of The Center for Cosmetic Surgery in Camp Hill, Pa., since these patients may be more nervous than the average patient and may expect to be treated in a ????-??spa-like' environment. You may also want to make sure that the patient is prepped in a different area than patients who are having non-elective procedures to minimize the feeling that they are, in fact, undergoing major surgery. Also, have a friendly staff member greet patients as soon as they arrive, suggests Dr. Casas. The greeter's duties should include helping patients remove their street clothes and put on surgical attire and shepherding them into the pre-op area, all the while maintaining a professional, yet friendly and upbeat attitude. "Personality, not academic degrees, is what is most important here," says Dr. Casas.

Dr. Yates employs a full-time aesthetician in his facility for the sole purpose of helping to relieve his patients' anxieties. "These patients in particular are concerned about their post-operative appearances. A skilled aesthetician can address their fears regarding bruises and swelling, and can offer useful advice on how they can look their best until they heal."
- Warn patients about post-op pain: Patients who do not anticipate discomfort are often more likely to have prolonged stays in your recovery area than patients who know what to expect. Prior to surgery, inform the patient about the type of pain and swelling he or she is likely to experience, advises Paul Weiss, MD, Clinical Professor of Plastic Surgery at the Albert Einstein College of Medicine in New York. Talk about what pain medications patients will need and how to use ice to minimize swelling. Also explain and demonstrate how to use specific post-op care items such as a "bleph" kit for eye care (the kit typically includes sunglasses, topical agents, etc.), a chin support garment, dressing materials, and drains, if these are used, recommends Dr. Weiss.

Standardize equipment and supplies
There are certain elements in every facelift procedure that will always remain the same, regardless of differing surgical techniques and surgeon preferences, reports Dr. Casas. Accordingly, she suggests ordering and stocking facelift set-ups before even scheduling a procedure. Dr. Casas' typical facelift set-up contains the following:
- Approximately 20 4 x 4 gauze;
- 2 gowns;
- 2 sets of gloves (one for the surgeon and one for the assistant);
- 2 drapes;
- 2 10 cc syringes with 27g needles;
- pack of sterile towels;
- 1 plastic cup (for local anesthesia);
- 1 comb;
- rubber bands; and
- special rhytidectomy scissors.

Dr. Yates recommends including a fiberoptic lighted retractor and suction bovies in the set-up. "Practically all cosmetic surgeons use these instruments when performing rhytidectomies," he reports.

You can also standardize according to your surgeon's preferences, says Dr. Casas. When a new surgeon joins your facility, she explains, ask him or her to give you a detailed list of what he or she requires in a facelift set-up. You can incorporate these requirements from day one, making it easier for the surgical team to learn the doctor's preferences.

When numerous surgeons perform facelifts at your facility, Dr. Casas believes that it is especially important to have set protocols assigned to each surgeon that the surgical staff will automatically follow. Dr. Casas recommends that you maintain a pre-printed and pre-packaged prep set, dressing pack, and operation pack containing each surgeon's preferred dressings and instruments. To prepare for a procedure, your staff simply supplements the initial standardized set-up with the standardized surgeon-specific protocols. This eliminates the need for each surgeon to talk the staff through his or her specific requirements, such as whether or not to include drainage tubes in the pack, which some surgeons use and others don't.

However, you certainly won't be able to standardize all parts of the procedure. For instance, ancillary procedures such as laser peels will require specific topical agents and dressings. To handle individual case requirements smoothly, formulate an operative plan well in advance, says Dr. Weiss. Generally, Dr. Weiss contacts all other individuals involved in the case, such as the anesthesiologist, as soon as the patient books a procedure. In addition, he discusses the procedure with his nurse the night before the surgery is to take place. To fine-tune your case preparation, Dr. Weiss recommends the following:
- Immediately ascertain what special equipment is necessary for ancillary procedures such as laser refinement, autologous fat injection enhancement, or an endoscopic approach. Give yourself as much time as possible to procure equipment that you may not keep in inventory.
- Determine what special supplies (e.g. silicone cheek or chin implants and other filler materials) you'll need.
- Prepare for patients with specific needs (e.g. requirements for patients with hypertension, allergies to antibiotics or anesthesia agents, etc.).

Require advanced payment

Don't wait until the day of the procedure for payment. If you do, the patient may forget to bring adequate payment, forcing you to either reschedule the procedure or proceed with the case and run the risk of not getting paid at all, says Dr. Casas. She requires the facility's charges to be paid approximately two weeks prior to surgery. Dr. Weiss, like many other surgeons, streamlines the payment system by charging a package fee that includes the individual charges for the anesthesiologist, the surgeon, and the facility in one lump sum.

Dr. Weiss reports that some facilities recoup their expenses by charging their patients a cancellation fee, typically 10 percent of the procedure's total cost, when patients cancel a facelift 24 to 48 hours prior to surgery without having a valid medical excuse.

Staffing
Most states will permit a surgical technician to perform scrub duties in the OR as long as a circulating RN supervises him or her, reports Dr. Casas. Using a surgical technician instead of an RN as a scrub tech may be a good cost cutting measure, she says, since on average surgical technicians earn $11 to $17 an hour while RNs are generally paid $18-$30 an hour.

Another member of the surgical team who is critical to the efficiency of the procedure is the anesthesiologist. It is essential that your anesthesiologist have experience with plastic surgery procedures, states Dr. Weiss. Anesthesiologists who are not completely familiar with the specific requirements of aesthetic procedures tend to over-medicate, increasing the patient's recovery time and the expense to your facility.

Post-op Strategies
One method that Dr. Casas uses to recoup the costs associated with prolonged recovery times is to charge patients a nominal fee that directly corresponds to the facility's cost for any extra time the patients spend in recovery. Dr. Casas admits that this is a rather controversial practice, but says that the idea is not to "gouge" the patients, but to cover the expense of RN time. "Most facilities just eat their losses, but there is no need to," says Dr. Casas. "We give our patients a maximum of three hours post-op recovery time as part of their package. Thereafter we charge them the direct, dollar for dollar hourly expense that the facility accrues." Dr. Casas says that in addition to recovering the costs of prolonged patient post-op stays, the surcharge is often enough to dissuade the patient who is capable of being discharged from staying longer than needed.

Dr. Yates is critical of this practice. Additionally, he reports that three hours may not be adequate time for recovery. "Patients generally need recovery times that are equivalent to the length of the procedures. If a procedure takes longer than three hours-and most do-then recovery should be longer as well," he opines.

Before discharging your patients, Dr. Weiss suggests providing them with clearly worded printed instructions for post-operative management. He also recommends that you suggest the use of a scarf and/or glasses by your patients to minimize post-operative self-consciousness.

Dr. Yates advises that you allow your facelift patients to exit through a side door so that they do not have to walk through the waiting room, feeling self-conscious due to facial swelling and bruising.

Provide post-op follow-up
Contact the patient as soon as possible after his or her release from your facility, advises Dr. Weiss. He has the surgical nurse who was in attendance during both the procedure and the recovery call the patient at home on the same day or evening as the surgery. Dr. Weiss says he prefers assigning this responsibility to the same surgical nurse because it gives the patient a sense of continuity.

According to the National Clearinghouse of Plastic Surgery Statistics, facelifts were the fourth most common cosmetic surgery procedure performed last year (after liposuction, breast augmentation, and eyelid surgery). A booming economy, combined with aging baby boomers' zeal to rejuvenate their looks, will undoubtedly increase the trend. A few common-sense moves may be all it takes to ensure that your facility will benefit.