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 Table of Contents  
Year : 2023  |  Volume : 2  |  Issue : 1  |  Page : 47-49

Pressure sore of malar prominence on horseshoe headrest: Prevention of one complication becomes road for another?

1 Department of Anaesthesiology, Pain Medicine and Critical Care (JPNATC), AIIMS, Delhi, India
2 Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
3 Department of Forensic Medicine and Toxicology, ESIC Medical College and Hospital, Faridabad, Haryana, India
4 Department of Neuroanaesthesia and Critical Care, Medanta, Patna, Bihar, India

Date of Submission23-Nov-2022
Date of Decision20-Dec-2022
Date of Acceptance05-Jan-2023
Date of Web Publication25-May-2023

Correspondence Address:
Dr. Sharmishtha Pathak
Department of Anaesthesiology, Pain Medicine and Critical Care (JPNATC), All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jica.jica_39_22

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Pressure sores over bony prominences of heel or sacrum due to positioning are commonly reported, however, the same occurring over malar prominences are rarely seen. We report a case of pressure sore over malar prominence in a patient undergoing surgery in the prone position on horseshoe headrest. These injuries pose a risk of infection, need for surgical intervention, increasing woes, and health cost burden of the patient. Patient care team should aim to prevent such complications by appropriate support device selection, adequate padding, and frequent position changes.

Keywords: Headrest, pressure sore, prone position

How to cite this article:
Pathak S, Agrawal S, Sharma M, Andleeb R, Biswas K. Pressure sore of malar prominence on horseshoe headrest: Prevention of one complication becomes road for another?. J Ind Coll Anesth 2023;2:47-9

How to cite this URL:
Pathak S, Agrawal S, Sharma M, Andleeb R, Biswas K. Pressure sore of malar prominence on horseshoe headrest: Prevention of one complication becomes road for another?. J Ind Coll Anesth [serial online] 2023 [cited 2023 Oct 1];2:47-9. Available from: https://www.jicajournal.in//text.asp?2023/2/1/47/377599

  Introduction Top

Positioning is an important component of patient preparation for surgery. Proper positioning helps the surgeon by improving the access to the surgical site. Prone positioning is thus used to improve surgical exposure of the posterior fossa of the brain.[1] Achieving this position requires the combined effort of the complete operating theater staff. Complications arising due to prone positioning during surgery can lead to significant patient morbidity.[2]

The major concern for anesthesiologist in the prone position is avoidance of pressure over eyes and the resulting visual impairment.[2],[3] Vision impairment is virtually devastating for both the patient and relatives. Sometimes, in the quest for the same inadvertently, we end up causing pressure injuries to the face especially if a horseshoe headrest is being used for facial positioning.[3] These injuries can culminate in pressure necrosis depending on the duration and amount of pressure, friction or shearing forces, and tissue perfusion pressure requiring surgical intervention in the form of debridement and grafting.[4] We present a case of pressure sore on the malar prominence of the face due to prone positioning on horseshoe headrest after obtaining a written and informed consent from the patient for publication.

  Case Report Top

A 12 year old female child, American society of Anesthesiologists (ASA) 1, weighing 35kg, was posted for removal of left intraventricular meningioma in prone position. After induction of general anesthesia, the patient's eyes, face, chest, and iliac crest were adequately padded with cotton and secured with adhesive tape. The patient was then turned prone and the head was placed on a padded horseshoe headrest, which was re-enforced with a double cotton roll. The head was maintained in neutral position and the eyes were checked again to rule out the possibility of any pressure on the eyeballs. The surgery lasted for about 5 h and the intraoperative course was uneventful. Throughout the surgical duration, the patient's head was repositioned at regular intervals and extra cotton padding was used to prevent to prevent the development of excessive pressure at bony points. After completion of surgery and dressing, the patient was turned supine and the facial padding was removed. It was then noticed that, pressure sores were present on the left malar prominence and right supraorbital ridge [Figure 1]. There was no associated facial edema. After the reversal of neuromuscular blockade, the patient was extubated. Antibiotic ointment and paraffin dressing were applied on both the affected areas. Once the patient was stable and shifted to postoperative ward, a referral to the plastic surgery team was sought, and regular dressings were done under their guidance. These sores gradually healed over a period of 10 days without any complications. The patient was then discharged from the hospital.
Figure 1: Pressure sore over left malar prominence (above) and right supraorbital ridge (below)

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  Discussion Top

Prone positioning provides advantages to the surgeon by increasing exposure in posterior fossa tumors and craniovertebral (CV) junction surgeries.[1],[5] It has also been used in critical care setting, especially in patients with acute respiratory distress syndrome as it helps in improving ventilation.[4] This position comes with an array of complications such as cardiovascular instability, raised airway pressures, neurovascular injuries, and pressure-related injuries. Recently, postoperative visual loss in patients in the prone position has raised a lot of concerns.[1],[2],[3] To avoid this devastating complication, extra precaution is taken to prevent pressure on the eyeballs, in doing so sometimes, the other bony prominences of face may get neglected. There are various ways in which the head can be placed in prone position. These include placing the head on foam pillow, horseshoe headrest, or fixing with three- or four-pin fixation device. A commonly employed device is the horseshoe headrest which has a cushioned base to support the forehead and cheeks.[5] This device though adequately padded can still lead to undue pressure over bony prominences, especially in surgeries involving the posterior fossa and CV junction as the face is sandwiched between pressure by surgical instruments from above and headrest from below. The European Pressure Ulcer Advisory Panel has defined pressure ulcers as localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.[6] The inability to check the inaccessible dependent areas plays an important role in the development of pressure sores or ulcers in these regions.[2],[3] Few preventive measures can be employed by the anesthesiologists to prevent this complication like, use of transparent operating table with a foam-cushion face mask, use of mirror below the face of the patient to give a better view of the patient's face once he/she is turned prone, identification of high-risk factors, careful selection of headrest device, and regular checking of areas prone for pressure sore development.[7] Phones with cameras can also be employed to take a picture of the patient and then carefully look for compression of soft areas, especially those above the bony prominences.

In our case, although the horseshoe headrest was padded adequately and eyeballs were free from any pressure, the area surrounding the eyeballs was continuously under pressure during the surgery. The padding done on the face was still intact when the patient was turned supine after surgery; still there was pressure sore over the malar prominence. This got missed due to the extra concern for preventing any pressure on the eyeball. Although the surgical duration was not long, it was enough to produce pressure sores over these areas of the skin. ASA task force on perioperative blindness has also listed horseshoe headrest as a risk factor for increased extraocular compression. The use of three or four pins head fixation device can help alleviate this problem.[1],[8]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.


The authors would like to acknowledge the Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, India.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Shamshery C, Haldar R, Srivastava A, Kaushal A, Srivastava S, Singh PK. An unusual cause of unilateral facial injuries caused by horseshoe headrest during prone positional craniovertebral junction surgery. J Craniovertebr Junction Spine 2016;7:62-4.  Back to cited text no. 1
Contractor S, Hardman JG. Injury during anaesthesia. Contin Educ Anaesth Crit Care Pain 2006;6:67-70.  Back to cited text no. 2
Jain V, Bithal PK, Rath GP. Pressure sore on malar prominences by horseshoe headrest in prone position. Anaesth Intensive Care 2007;35:304-5.  Back to cited text no. 3
Bunker DL, Thomson M. Chin necrosis as a consequence of prone positioning in the Intensive Care Unit. Case Rep Med 2015;2015:762956.  Back to cited text no. 4
Knight DJ, Mahajan RP. Patient positioning in anaesthesia. Contin Educ Anaesth Crit Care Pain 2004;4:160-3.  Back to cited text no. 5
Dorner B, Posthauer ME, Thomas D, National Pressure Ulcer Advisory Panel. The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel white paper. Adv Skin Wound Care 2009;22:212-21.  Back to cited text no. 6
Gupta P, Barik AK, Krishna V, Dhar M. Chin necrosis after prone positioning: A consequence of trans-cranial motor evoked potential monitoring during spine surgery. Indian J Anaesth 2019;63:246-8.  Back to cited text no. 7
[PUBMED]  [Full text]  
Kwee MM, Ho YH, Rozen WM. The prone position during surgery and its complications: A systematic review and evidence-based guidelines. Int Surg 2015;100:292-303.  Back to cited text no. 8


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