Can a face lift be safely performed under intravenous (IV) sedation in a high cardiac risk patient taking aspirin (acetylsalicylic acid)?

Perioperative Aspirin Management for Face Lift Surgery in High Cardiac Risk Patients

For high cardiac risk patients, aspirin should be continued during face lift surgery performed under IV sedation, as the cardiovascular benefits outweigh the bleeding risks.1

Risk Assessment and Decision-Making Algorithm

Thrombotic Risk Considerations

• High cardiac risk patients typically include those with:

  • Recent coronary stents (especially within 6 months)
  • History of myocardial infarction
  • Cerebrovascular disease
  • Peripheral arterial disease
  • Multiple cardiovascular risk factors

• The ASINC trial showed that aspirin reduced major cardiac events by 80% in high-risk patients undergoing non-cardiac surgery without significant increase in bleeding risk 1

Bleeding Risk Considerations

• Face lift surgery involves extensive tissue manipulation with potential for hematoma formation
• However, bleeding during face lift surgery is generally controllable with:
  • Meticulous surgical technique
  • Careful hemostasis
  • Proper anesthetic management
  • IV sedation allows for blood pressure control during the procedure

Evidence-Based Recommendations

Aspirin Continuation Protocol

• For patients on long-term aspirin therapy (up to 300 mg/day), maintain the same dosage throughout the perioperative period 1
• Do not reduce the aspirin dosage for surgery in high cardiac risk patients 1
• Ensure the surgical team is aware of continued aspirin therapy to prepare appropriate hemostatic measures

Surgical Considerations

• Inform the plastic surgeon about the patient's cardiac risk and aspirin therapy
• Consider additional hemostatic measures during surgery:
  • Meticulous surgical technique
  • Careful vessel identification and ligation
  • Use of electrocautery for small vessels
  • Application of topical hemostatic agents as needed
  • Careful postoperative monitoring for hematoma

Special Situations

Dual Antiplatelet Therapy (DAPT)

• If the patient is on DAPT (aspirin plus P2Y12 inhibitor):
  • Continue aspirin throughout the perioperative period 1
  • Consider postponing elective face lift surgery until completion of recommended DAPT duration
  • If surgery cannot be postponed, consult with the patient's cardiologist regarding P2Y12 inhibitor management 1

Very Recent Stent Placement

• For patients with stents placed within the past month, elective face lift surgery should be postponed 1
• If surgery is urgent, it should be performed in a facility with 24/7 cardiac catheterization capability 1

Common Pitfalls to Avoid

• Discontinuing aspirin in high cardiac risk patients can lead to a rebound hypercoagulable state 1
• The POISE-2 trial suggested discontinuing aspirin, but this recommendation doesn't apply to high cardiac risk patients 1
• Bridging with other anticoagulants or intravenous antiplatelet medications is poorly studied and generally discouraged 1

Postoperative Management

• Resume aspirin as early as possible after surgery, ideally the same day, if it was discontinued 1
• Monitor closely for both bleeding complications and cardiovascular events
• Ensure adequate pain control to prevent blood pressure spikes

By following these evidence-based recommendations, face lift surgery can be safely performed under IV sedation in high cardiac risk patients on aspirin therapy, with the cardiovascular benefits outweighing the bleeding risks.