The image depicts a 67-yr-old man who had significant periorbital skin injury after 5 h of prone spine surgery using a foam headrest with standard taping of eyes. The patient underwent facial laser skin resurfacing 2 months before the event.

Facial pressure ulcers are a serious complication that may lead to pain, additional treatment, longer hospital stays, disfigurement or scarring, increased medical cost, and subsequent lawsuits. Facial pressure ulcer has an incidence of 27% in prone spine surgery lasting more than 3 h and occurs most commonly over the bony prominence of the chin, maxilla, and forehead. Skin damage is due to prolonged and excessive pressure and/or shear that blocks capillary blood flow.  Risk factors include operation duration, hyperthermia, hypotension, aggressive fluid replacement, and cervical hyperextension or hyperflexion.

Patients with recent facial laser skin resurfacing are at greater risk of perioperative facial pressure ulcers due to increased skin fragility.  Laser skin resurfacing uses thermal damage of epidermis and parts of dermis to stimulate repair for ultimate facial rejuvenation.  Complete recovery could take up to 1 yr, particularly in older patients.  Perioperative considerations should include adequate healing of resurfaced skin, consultation with dermatologist, and communication about increased risk of skin injury.

Preventive measures for facial pressure ulcers during prone position surgery include assessment of skin risk area, application of moisturizer barrier cream, using pressure redistribution support surfaces or positioning devices to offload pressure points (silicone-foam dressings, face-contoured prone device, Mayfield clamp, or Gardner–Wells tongs with traction), and minimizing risk factors.