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I had a mini lift 10 days ago now, at by Day 3, these livid red patches started on my cheeks in front of my ears, both sides, and got worse until Day 6, after which they've stabilised.
The doctor says he's only seen them behind the ears before, and slightly on smokers (I don't smoke, nor have diabetes). He recommended oxygen, which I've been inhaling and also having applied directly on to the areas. Slight progress, but very slight, but I'm not very reassured that there isn't something else I could be doing. The photo makes them pinker than they are. They're almost "port wine" birthmark pitch.
I wondered if perhaps you were familiar with this condition and could advise please?
I'm reposting my previous response on beautyfan's thread. One other thought is possible infection, but I'm assuming that if your surgeon placed you on oxygen (hyperbaric oxygen therapy or HBO) that you would also be on antibiotics to cover a possible infection. If there is any pus coming out from the edges of the skin, potentially that could be cultured to see if it is an antibiotic-resistant bacteria, which makes regular oral antibiotics ineffective.
Here is my previous response:
Hi VeryWorried,
Thank you for sharing your pictures. It appears that the skin is lacking oxygen, but the oxygen therapy seems to have helped. Without a history of diabetes or smoking, the chance of skin necrosis is rare. Also, the areas where it occurs is where the flap of skin that was lifted up is longest, in other words, the blood needs to travel the furthest. The skin flaps on the front of the ear are usually shorter, maybe 2 inches plus or minus, while the skin flap behind the ears is usually longest, and there may be more tension pulling on the skin behind the ears which also can contribute to lack of blood flow and lack of oxygen. Usually the skin in front of the ears is sewn with minimal tension for the best scar and cosmetic result, so lack of oxygen to the skin in front of the ear is less common, but does happen occasionally. When it is seen, it is usually only on one side, because it is rare for this to occur in general, and if it does it happens only to one side.
It appears that the skin should survive, although as the surgeon I would be on the look out for blistering of the surface layer of skin, but the chance of a full thickness skin loss does not appear to be happening.
The strange thing about the story is that it is happening simultaneously on both sides in the same location. One last possibility that I usually consider when a patient has redness is an allergic reaction to the antibiotics, which can result in redness and inflammation of the skin. If the antibiotic ointment is stopped, it may still take a couple of more days for the allergic reaction to subside, since some of the antibiotic had already penetrated the skin. The patient can use a different antibiotic ointment, vaseline, or water-based ointment to keep the incisions moist while healing.
If there were skin necrosis, the skin essentially turns black like a scab. The full thickness of the skin lacked oxygen and blood flow, so the skin dries up and essentially looks like a scab. It doesn't appear that this is happening.
You should, of course, keep close follow-up with your plastic surgeon to make sure it is healing well, and in case there are any changes in the appearance.
Dear Dr. Yang, Thank you so much for kindly taking the time to consider my concerns so comprehensively. You’re quite brilliant. Apologies for my belated reply – I’m new to this site and was slow in finding my way back to my message thread.
So I had my stitches out about 56 hours ago. Although there’s a diminished depth of redness immediately around the stitched area, nothing much has changed either color or size wise, on both cheeks. Here’s a photo from today (Day 13). My stomach is in knots, and I’m having mini panic attacks randomly, as I fear some sort of port wine stain type result, lurking indefinitely, and I’m back at work full time on 4th Jan, where I do face time all the time!
I finished my antibiotics on Day 5, and only used an antibacterial cream for the stitches. The red patches were brewing from Day 3, when the bandages were taken off. I think they were thought to be just pressure points from the wrappings. It was only when I went back on Day 5 that the problem was articulated.
The surgeon had said to me directly after surgery that he’d been surprised my skin was so thin. So was I, as for my age, my skin’s always been remarked upon by strangers as being very smooth etc (which I thought must be quite strong). I wondered if it was thin because I’d had Fraxel 3 weeks before (not the Repair, the other one, for pigmentation etc). I’ve been doing O2 from an Oxygen Bar rather than the tank, and they’ve been “squirting” O2 directly on to the patches too. But I’m going back to the HBO tank place today and tomorrow.
I’m using Nitric Oxide cream twice a day from the surgeon, and have been using since Day 5. I’m taking Arnica and Bromelain tablets.
Is there ANYTHING else I could be doing to diminish the red patches? Thanks again for you time and care. It is MASSIVELY appreciated.
I think there are two separate issues occurring simultaneously. Your surgeon is worried about skin necrosis or loss of skin, while you are worrying about the red patches and whether or not they will stay like this long term. Between the two, the preventing the skin necrosis is the priority. The red patches is something will improve somewhat as the skin thickens and heals and any residual is relatively easily treated using a pulsed dye laser.
Skin Necrosis From a skin necrosis standpoint, now that you revealed that you had Fraxel 3 weeks prior to your mini-lift, it makes more sense why this may have happened. What lay people don't realize is that although the healing on the surface appears to be completed, there is usually more healing occuring under the skin. For example, your mini-lift stitches have been removed, but 3 weeks after the facelift, the tissues under the skin have only begun to heal. Same is true for the laser resurfacing. Although the laser is fractionated (which means the laser was performed in a grid-like pattern to leave some normal skin in between the lasered areas for faster healing), the laser still penetrated deeply enough to try to improve your skin. This also makes the area under the skin "angry" or inflamed. This inflammation may have been the reason why your surgeon felt your skin was thin. I don't like to perform revisions of my facelifts weeks or months after the initial facelift because the tissues are weak and the blood supply is not fully established yet.
Most surgeons who perform facelifts will not perform full face lasering simultaneously as a facelift. If they do perform laser resurfacing, they will only laser around the mouth and around the eye area. Why? The surgeon doesn't want to laser the skin in front of the ears, because this would mean the skin is injured both below the surface from the facelift and on the surface from the laser. This is a recipe for skin necrosis. Although your Fraxel and mini-lift both sound like they are minimally invasive procedures, the small patch of skin in front of your ear doesn't know whether you had a full facelift or a mini-lift, since the skin is lifted the same way for that area for both procedures. Also, it doesn't know if you had full laser resurfacing versus fractionated lasering, it only knows that it isn't happy yet. The fractionated lasering helps to prevent the wet, drippy, messy, peeling post-lasering period that we have come to expect during the week after the procedure. It is more humane, but we still want results, so the goal is to cause enough laser injury under the surface of the skin to make the skin heal closer to that of a full laser resurfacing, without removing the entire upper surface layer of the skin.
Continue with the HBO tank (hyperbaric oxygen therapy) to increase the oxygen levels in the tissues of the skin. Spraying oxygen on the skin does nothing to the oxygen levels of your skin, other than depleting the $$$ from your wallet. If anything you will get more out of the oxygen by breathing it than spraying it on the skin. If someone is suffocating, the oxygen on the skin won't help them oxygenate their tissues, only breathing will. Oxygen tanks can be set to deliver more or less oxygen. If it is at 2 Liters/minute through a nasal cannula, it isn't much better than the oxygen you are receiving by room air. For a sick patient, they may turn the oxygen up to 5-10 liters per minute, and switch to a mask or a non-rebreather to really get the oxygen in for a patient with a low oxygen level. If the person is already at 95-99% oxygenation, then it may not do much more to improve them, since they are already doing a good job on their own.
Most likely you are using nitroglycerin cream or ointment usually used on the chest pain patients, where in the Emergency Room the nurses may be instructed to apply 1" to the chest wall. Your surgeon is likely have you apply it directly to the affected area of the skin. Interestingly, when our tissues are lacking oxygen, they will produce a molecule called Nitric Oxide which will promote neovascularization or formation of blood vessels. You can imagine if diabetic's foot it lacking oxygen, and it sends out a "help signal" in the form of nitric oxide for more blood flow, then your body responds by making more pipelines to deliver that oxygen in the form of blood vessels.
From the skin necrosis standpoint, I think you are out of the woods, but please continue with your surgeon's treatment until he or she says that it is okay to stop. Preventing the skin necrosis, it the primary goal. The alternative to the red patches is skin loss. Instead of the skin turning red, it turns into a black scab. When the scab peels off, there is a full thickness skin loss underneath which will take weeks to heal. Luckily this doesn't appear to be happening.
Red patches Now that you have avoided the bigger problem, you are facing the red stained skin which you describe as similar to Port-Wine Stains. Most likely if you push on the red patches, the skin turns a normal color and when you let go, you can almost see the blood filling the blood vessels slowly and turning it back red again. This is from the newly formed blood vessels brought in to feed your skin. The process is called neovascularization, neo- means new, and vascularization is the formation of blood vessels. Although you don't like the look of the redness, these new blood vessels are your "friends" and are mostly responsible for saving that red patch of skin from dying. Don't get rid of these friends just yet. The skin also appears quite thin in this area similar to patients who have had a regular laser resurfacing. These patients will have a period of months where their skin appears "pink" and they need to use concealer and other heavy powder to hide the pinkness. As the skin thickens, the surface blood vessels are pushed down and better covered by the surface skin cells and they don't appear as pink anymore. I think your patches are a combination of the laser resurfacing with the facelift. Patients who have had facelifts (but without any lasering) can also develop small vessels in the exact same area in front of the ear, but we normally don't see them right away. It may show up weeks or months later as a few spidery looking small veins.
Luckily these vessels can be lasered with relative ease. Pulsed Dye Lasers or PDL are used for treating vessels as well as birthmarks which are blood vessel related. The wavelength of the pulsed dye laser is absorbed well by hemoglobin which is the main component of red blood cells. This way the energy is absorbed by the red blood cells and leaves the remaining tissues alone. Very targeted. Interestingly, PDL are used for Port-Wine Stains and other birthmarks are caused by blood vessels. V-beam is a Pulsed Dye Laser by Candela (a major medical laser manufacturer) and is excellent for targeting vessels. Many people may have those troublesome small vessels that form around the nostril area commonly are treated with this type of laser.
When to laser them? Check with your surgeon and your laser doctor, unless they are one and the same, when best to laser the red patches of blood vessels. My feeling is to wait at least a few months for the skin to thicken and the blood flow in the area to be well established before lasering whatever is remaining. In the meantime, you show get some "heavy duty" cover-up. Makemeheal.com sells them in their Shop (see the top left hand corner of this page) and look for a greenish based color which helps to offset the redness. They are opposites on the color wheel and help to cancel each other out. Jane Iredale or Dermablend seem to be the most popular recommendations for post-facelift patients.
I think you are out of the woods, and looking for the silver-lining in this, covering a red patch of intact skin is much easier than covering an open wound that is in front of your ears for many weeks. After the skin necrosis area is healed there will be a scar remaining as well as a similarly red stained skin. The Port-Wine Stain-like redness from the small vessels can easily be treated later with a Pulsed Dye Laser, but should wait for the skin to heal and thicken before subjecting your skin with another round of lasers. You may need to exercise some patience and help to hide the area with makeup in the meantime.
I hope this response puts things into perspective and helps to reassure your stomach knots and mini-panic attacks that everything will turn out okay.
Dear Dr. Yang, I simply could not have asked for a more comprehensive, clear and constructive response. THANK YOU SO VERY, VERY MUCH! I really feel I now know what happened, what I'm dealing with, and how to progress ..... and to manage my own expectations time wise, as miserable as that might be do deal with on an on-going basis. At least I know that there are solutions to the current worst case scenario.
I shall send you an updated picture and progress report in a couple of weeks!
Hello Dr.Yang! I'm slower at posting an updated picture than I said I would be.... I kept hoping that I'd have a great heal, and put a positive photo up. Regrettably, although I improved during those first three weeks, I've hit something of a wall these last three, and both sides have remained the same.... I've been checkin by doing regular photos, and checking in zoom!.
I'm rather dejected (this is an understatement!), and have had my hair cut off so that it now bobs around my face, yet still can't mix with people without lots of makeup (a friend saw me recently, no make up, hair behind the ears, and yelped, WTF!!??) . So I'm not over estimating the odd look.
I am so regretful for allowing the lower / mini facelift 17 days after Fraxel!
Am taking Vit K, and popping on creams, but is there anything else you suggest whilst awaiting enough time before PDL?
You're at 6 weeks after surgery, which is still considered very early. I don't know of anything that will help accelerate the healing. Most likely you will have some residual vessels which will need to be lasered, so your current waiting is not so much to see much improvement in the red coloration (although you may see some improvement). It is more to give your skin a chance to heal, so that it can withstand the lasering for the blood vessels, without any problems. Check with your laser surgeon on the timing of when would be the earliest time for it to be safe to laser the red areas.
If it did happen, the time it would take for the skin to cover the open wound could be months. You are already light years ahead of the game, not having had the skin necrosis. So now being patient and waiting for a "safer" time interval prior to having the redness lasered will eventually get you to your final goal.
Even if the close call did not happen, the final result of normal healing will likely look the same as your final result after healing with some lasering for the redness.
I hope this puts things into perspective while you patiently wait for further treatments. Talk your plastic surgeon and laser surgeon for additional support and also timing of your laser treatments. Maybe if you can have it prescheduled in the future, you will feel like you have more control over the situation.
Dear Dr. Yang, Thank you so much for all of this, it's both really helpful and reassuring. I shall update you in due course as to how things pan out. Very best wishes. VW
You're welcome. One thing that you can do in the mean time is to use a good cover up to hide the redness. The most popular makeup for after surgery is the Jane Iredale and Dermablend brands. Usually choosing a green based cover up will help neutralize the redness (red and green are on opposite sides of the color wheel.)
Hello, 3 weeks ago i had Juverderm applied on my nasolabial areas. One side of my face developed what i believe to be necrosis. I returned to the doctor and he gave me some antibiotics that has cured the infection also the scabs have disappeared. What i have now is the redness that will not go away. He gave me a topical solution that is suppose to help aliviate the redness. It has been 3 days and i do not see any improvements. Can you please inform me how long will it take for the redness , due to necrosis, to go away? thank you. AlexM.
The improvement in the redness will not go away in days, by using a topical solution. Please ask your surgeon how the topical solution will help in reducing the redness, and how long it will take. I have not used any topical solutions for my patients for this purpose, so I can't give you a specific time frame.
Depending on your skin type it can take several weeks to several months for the redness to fade naturally. Sometimes, the redness doesn't fade and upon closer examination of the skin, there is tiny blood vessels which is causing the redness. After the skin is fully healed, lasers can be used to reduce the redness caused by the blood vessels. Other people will have some thing called PIH or post-inflammatory pigmentation, where the skin starts off red, but then fades to a pigmented patch. I tend to get PIH after pimples, and for my skin, the redness can take weeks to fade, and then I am left with brown pigmentation which usually lasts for months. I think this is the case for Asian skin in general, although there are obviously exceptions.
Thank you so much for your response. It has been 2 weeks since the scabs were gone. Next week i have a "Fraxel restore" procedure beign done on my skin . Would it be wise to apply that laser over the redness in order to improve ? Or should i not allow the laser to touch the affected area?
The decision to use laser for the redness, which laser works best, and the timing of the laser, needs to be discussed with your doctor.
It was discussed earlier in this thread:
Red patches Now that you have avoided the bigger problem, you are facing the red stained skin which you describe as similar to Port-Wine Stains. Most likely if you push on the red patches, the skin turns a normal color and when you let go, you can almost see the blood filling the blood vessels slowly and turning it back red again. This is from the newly formed blood vessels brought in to feed your skin. The process is called neovascularization, neo- means new, and vascularization is the formation of blood vessels. Although you don't like the look of the redness, these new blood vessels are your "friends" and are mostly responsible for saving that red patch of skin from dying. Don't get rid of these friends just yet. The skin also appears quite thin in this area similar to patients who have had a regular laser resurfacing. These patients will have a period of months where their skin appears "pink" and they need to use concealer and other heavy powder to hide the pinkness. As the skin thickens, the surface blood vessels are pushed down and better covered by the surface skin cells and they don't appear as pink anymore. I think your patches are a combination of the laser resurfacing with the facelift. Patients who have had facelifts (but without any lasering) can also develop small vessels in the exact same area in front of the ear, but we normally don't see them right away. It may show up weeks or months later as a few spidery looking small veins.
Luckily these vessels can be lasered with relative ease. Pulsed Dye Lasers or PDL are used for treating vessels as well as birthmarks which are blood vessel related. The wavelength of the pulsed dye laser is absorbed well by hemoglobin which is the main component of red blood cells. This way the energy is absorbed by the red blood cells and leaves the remaining tissues alone. Very targeted. Interestingly, PDL are used for Port-Wine Stains and other birthmarks are caused by blood vessels. V-beam is a Pulsed Dye Laser by Candela (a major medical laser manufacturer) and is excellent for targeting vessels. Many people may have those troublesome small vessels that form around the nostril area commonly are treated with this type of laser.
When to laser them? Check with your surgeon and your laser doctor, unless they are one and the same, when best to laser the red patches of blood vessels. My feeling is to wait at least a few months for the skin to thicken and the blood flow in the area to be well established before lasering whatever is remaining. In the meantime, you show get some "heavy duty" cover-up. Makemeheal.com sells them in their Shop (see the top left hand corner of this page) and look for a greenish based color which helps to offset the redness. They are opposites on the color wheel and help to cancel each other out. Jane Iredale or Dermablend seem to be the most popular recommendations for post-facelift patients.
Thank you for your response. Last weekend i had the V-Beam pulse light applied on the afffected red area. I can see some improvement. I'll see my doctor after a month so that he can re-evaluate the redness and if necessary apply another round of V-Beam procedure. I'm hopeful that the redness should disappear in time.
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