Can a face lift be performed under intravenous (IV) sedation in a patient taking Xarelto (rivaroxaban)?

Management of Rivaroxaban for Face Lift Surgery with IV Sedation

A face lift procedure should not be performed with IV sedation in a patient taking Xarelto (rivaroxaban) without proper discontinuation of the medication beforehand, as this creates significant bleeding risk. 1

Preoperative Management of Rivaroxaban

Discontinuation Timeline

Face lift surgery is considered a high bleeding risk procedure due to the extensive vascularity of the face and the creation of large tissue flaps. Based on current guidelines, rivaroxaban should be discontinued as follows:

• Normal renal function (CrCl ≥50 mL/min): Stop rivaroxaban 3 days before surgery 1
• Moderate renal impairment (CrCl 30-50 mL/min): Stop rivaroxaban 4 days before surgery 1
• Severe renal impairment (CrCl 15-29.9 mL/min): Stop rivaroxaban 5 days before surgery 1

Dosing Schedule Considerations

The exact timing depends on the patient's dosing schedule:

• For once-daily morning dose: Last dose should be taken 4 days before surgery
• For once-daily evening dose: Last dose should be taken 4 days before surgery
• For twice-daily dosing: Last dose should be taken 3 days before surgery 1, 2

IV Sedation Considerations

IV sedation can be safely used for face lift surgery after proper discontinuation of rivaroxaban. However, the following precautions should be observed:

• Avoid neuraxial anesthesia: The French Working Group on Perioperative Hemostasis (GIHP) strongly recommends against spinal or epidural anesthesia in patients with possible residual rivaroxaban concentration 1
• Prefer local anesthesia with IV sedation: This approach allows for better monitoring of potential bleeding during the procedure

Postoperative Management

Resuming Rivaroxaban

• Resume rivaroxaban only after adequate surgical hemostasis is confirmed, typically 24-72 hours after surgery 1
• Initial resumption should be at least 6 hours after the end of the procedure 1
• For face lift surgery specifically, consider delaying resumption to 48-72 hours post-procedure due to the high vascularity of the face

Bridging Considerations

• No preoperative bridging with heparin is recommended when interrupting rivaroxaban 1, 3
• If thromboprophylaxis is needed before rivaroxaban can be safely resumed, consider prophylactic doses of LMWH starting at least 6 hours after surgery 1

Special Considerations

• Laboratory monitoring: Routine monitoring of rivaroxaban levels is not necessary when following the recommended interruption periods 1
• Bleeding risk: Face lifts have a higher bleeding risk than many other cosmetic procedures due to extensive undermining of tissue planes
• Compression dressings: Should be applied post-procedure to minimize bleeding risk
• Renal function: Monitor postoperative renal function if the procedure or patient condition could affect kidney function, as this impacts rivaroxaban dosing 1

Common Pitfalls to Avoid

• Resuming rivaroxaban too early after face lift surgery
• Underestimating the bleeding risk of facial cosmetic procedures
• Failing to adjust discontinuation timing based on renal function
• Performing neuraxial anesthesia in patients with potential residual rivaroxaban concentration

Following these guidelines will help minimize bleeding complications while maintaining appropriate anticoagulation for patients requiring rivaroxaban therapy.