An unhappy patient is a complication - particularly in your waiting room. This remains true no matter how good you think the result is. It is wise therefore to take the time needed for a full pre-operative assessment and not to operate on candidates that you believe are not suitable. Rees’ red flags are important to remember when evaluating your patients:
insatiable aesthetic surgery candidates (“cosmetic surgery junkies”)
The wise surgeon never says that a patient ‘needs’ a face-lift, nor does he promise that the patient will look younger. Rather, a rhytidectomy ... often produces a ‘refreshed’ or ‘rested’ look, but certainly it is not the fountain of youth. (Courtiss) Patients must be warned about the possibility of surgical complications such as haematoma, skin slough, hair loss - temporary or permanent, sensory or motor nerve damage and poor scarring. Should a complication occur the surgeon must acknowledge this to both the patient and him/herself. Appropriate measures must be taken to remedy the problem and the surgeon must be available to see the patient as often as is necessary to alleviate the associated anxiety.
Surgical complications can be placed in 2 broad categories:
Infection Infection following facelift procedures is rare with a reported incidence of <1%. Prophylactic shampoo and face-wash the night before and on the day of the operation are advised, but there is no evidence to support the use of prophylactic antibiotics. Minor localized infections around sutures are easily treated by suture removal and evacuation. Suppurative infection beneath the flaps is usually the result of untreated haematoma, and management consists of suture removal, drainage and specific antibiotics. Acute chondritis may occur when postauricular sutures are placed through the perichondrium and cartilage; prompt therapy must be instituted to minimize cartilage destruction.
Small haematomas This is the most common complication following rhytidectomy. They are usually small, localized collections varying from 2 - 30ml in size with a reported incidence of approximately 15%. Very small haematomas usually absorb spontaneously within a few weeks and leave no trace. Collections may often not be detected until the oedema has subsided - they will then appear as an area of firmness, ecchymosis or skin surface irregularity. They will liquefy between the seventh and fourteenth days when every effort should be made to evacuate or aspirate them. If the haematoma is far from a suture line, it is sometimes possible to evacuate it by placing a small stab incision in a natural skin crease overlying the haematoma and then expressing it. After the 14th day the haematoma becomes firm again and a puckering or minor contour deformity of the overlying skin may occur; this could take several months to resolve. Some recommend small doses of intralesional steroid during this organizational phase of clot formation to minimize the deformity.
Smokers have an increased risk of hematoma ?related to smoking
Extensive ecchymosis and pigmentation Following a rhytidectomy some localized ecchymosis is usually seen which resolves within 1 - 2 weeks. Patients with thin, transparent skin and hypopigmentation, and those with a history of unusual bruising are prone to severe, extensive ecchymosis. This may extend down to the lower aspect of the sternum and require many months to resolve. Resolution is usually complete, but patients with darker skins may have a residual brown pigmentation due to haemosiderin deposition. (Usually, hyperpigmentation from haemosiderin deposits resolves within 6 - 8 months.)
Patients with small telangiectasias preoperatively may develop new lesions following the procedure and they should be forewarned of this possibility. A permanent reddish discoloration of the neck and cheeks may occur. This is usually best managed with the use of cosmetics, although large telangiectatic lesions may be electrocoagulated.
Oedema Oedema secondary to venous stasis is usual and normally resolves by the 2nd postoperative week. Oedema lasting >3 weeks is unusual and thought to be due to lymphatic stasis. This, too, usually subsides with no residual sequelae. Gentle tissue handling will help to minimize postoperative oedema. Diuretics are NOT recommended.
Local disfigurements Ear deformities pixie ear
loss of pretragal pit
hair growth in pinna with pretragal incisions
Most rhytidectomy incisions require a 75% or more circumscription of the pinna. If excessive tension is applied to it during closure, the ear may become dislocated or twisted on its axis. The pixie ear is the most common type of ear deformity - this results from adherence of the lobe to the skin of the cheek. One must take care when trimming the pre- and postauricular skin to ensure that an exact fit of the lobe is attained without tension. Furthermore, the first suture of the postauricular flap should never be hung on the fascia of the earlobe, but tension and fixation should be at the peak of the postauricular incision through the mastoid fascia.
Pre-auricular incisions carried behind the tragus in an attempt to minimize visible scars may result in unsightly distortion of the tragus when wound contraction occurs. A significant ear deformity may require a complete wound revision as a secondary procedure.
Dog-ears Small dog-ears may persist in the temporal region or nape of the neck despite all precautionary measures taken at the time of surgery. Although most will resolve over a few months, they are frequently annoying to the patient and excision and correction may need to be done as an outpatient procedure.
Submental depression Removal of all submental fat may result in adhesions with fixation of skin to the underlying muscle, causing unsightly contour irregularities that are very prominent during swallowing or neck motion. It is therefore important to leave a small adipose layer attached to the skin.
Small dog-ears usually remain at the ends of the submental incision and must be carefully trimmed or unsightly bumps will remain.
Excessive excision of skin and fat - especially in patients with microgenia or mandibular retrusion - may result in webbing in the vertical dimension of the neck.
This is usually due to excessive tension on the wound or secondary to trauma.
There must be NO tension on the pre- and postauricular incisions.
D Baker and Rees recommend that 6.0 Nylon sutures be used for the pre- and postauricular lines and removed at 5 days to prevent suture marks; 4.0 Nylon is used for the temporal scalp and mastoid skin (most tension) and removed on the 10th to 12th postoperative days.
Wound dehiscence may be treated with Steri-strips or resuturing.
Scars and keloids
Fortunately, hypertrophic scars and keloids seldom occur following rhytidectomy.
Hypertrophic scars, if they occur, usually occur in the postauricular area where the greatest tension exists, and not in the preauricular region.
Incisions closed under tension in the nape of the neck or temporal areas may result in wide or hypertrophied scars, made more noticeable if there is associated hair loss.
Wound closure without tension is the best prevention.
Should they occur, hypertrophic scars must be treated with patience and possibly intralesional steroids.
Re-excision should only be considered after maturation is complete.
Keloids should be treated by intralesional steroids and silicone gel, and if necessary, excision, intralesional steroids and possibly radiation.
superficial undermining with injury to the hair follicles
excessive tension on the skin flaps
interference with the blood supply to the hair follicles
incidence ranges from 0 - 3%, most commonly in the temporal region.
Fortunately, most hair loss is temporary and the hair will regrow within several months
An obvious hair-loss may be noted in the postauricular scalp as a “stair-step” if the hairline has not been accurately approximated.
Male patients should be warned that the hairless preauricular area will be narrowed, and the beard area will alter, possibly necessitating shaving behind the ear. If hair loss is unusually extensive, a dermatological consult should be requested.
Sensory nerve injury and paraesthesias Temporary numbness and paraesthesias over the earlobes and cheeks are common in the early postoperative period. This is usually due to transection of the small sensory nerves, and full sensation returns in weeks to months.
Permanent injury to the great auricular nerve (the most common significant nerve injury) may occur if dissection is too deep over the midportion of the sternocleidomastoid muscle. This causes a permanent loss of sensation over the lower portion of the ear, and the immediate pre- and postauricular areas. With the head turned 450 toward the contralateral side, the great auricular nerve consistently crosses the midportion of the sternocleidomastoid muscle at a level 6.5cm below the caudal edge of the bony external auditory canal. It then courses cephalad just beneath the SMAS, 0.5cm posterior and parallel to the external jugular vein. Mckinney and Gottlieb recommend that the safest place to incise the SMAS-platysma during rhytidectomy is at a point anterior to the sternocleidomastoid muscle. Should one recognize injury to the great auricular nerve intraoperatively, an immediate, meticulous repair should be performed in an attempt to restore as much sensory function as possible and to prevent the development of a painful neuroma. Patients with earlobe anaesthesia should be cautioned against wearing compressive jewelry.
Pain Significant post-operative pain is not usual - it should arouse suspicion of haematoma which will need investigation.
Plication of the platysma often leads to patients complaining of a tightness in the neck for the first few days to weeks postoperatively. Reassurance that this is normal and will subside with time is all that is required. Chronic, intractable pain is rare, and thought to be due to injury to branches of the cervical sensory nerves as they emerge from the posterior border of the sternocleidomastoid muscle. Even this will usually subside within 6 months, but regional sensory nerve blocks or muscle relaxants may be required for temporary relief.
Large expanding haematomas that cause pain, swelling and ecchymosis demand immediate attention and should be evacuated as an emergency procedure.
usually manifest within the 1st 24 hours but may occur as late as 10 - 14 days.
excessive pain after facelift is unusual, and it warrants an examination and removal of the dressing. This in turn may result in venous engorgement and circulatory compromise of the flap, and eventual flap necrosis.
On identification of a large haematoma, sutures should be removed immediately at the bedside, and the clots evacuated to relieve tension on the skin flaps. Thereafter the patient is returned to the operating theatre where the rest of the blood is evacuated and the source bleeding stopped. Following successful management of this, ecchymosis and oedema will be prolonged but the final result is usually not compromised.
Incidence of large haematomas requiring surgical evacuation varies from 0.9 - 8.0%, with an overall average incidence of 3.7% in 9352 patients.
Most plastic surgeons agree that men tend to bleed more at the time of the procedure, and have a higher incidence of post-operative haematomas. Two studies confirm this - that by Pitanguy and colleagues revealed a 7.7% incidence in men undergoing facelift procedures (n=52), and Baker and colleagues showed an 8.8% incidence (n=137). Baker and colleagues suggested that this may be related to the increased blood supply to the beard but this has not been proven.
Numerous reports have analyzed the causes of haematoma - essentially the more extensive the undermining the higher the incidence of post-operative haematoma.
The most meticulous haemostasis, various drainage methods, use of dressings versus no dressings, and immobilization have all been tried but failed to show a decrease in the incidence of haematoma formation.
General anaesthesia or hypotensive anaesthesia also does not reduce the incidence of post-operative haematoma.
One factor that does appear to play a role is post-operative hypertension. Berner and colleagues studied the pre- and postoperative blood pressures of 202 facelift patients. During the first 2 hours postoperatively the blood pressure levels were similar to the preoperative recordings. However, during the succeeding 3 hours most patients demonstrated blood pressures well in excess of their preoperative level. The authors pointed out that this was at the point when the pre- and intra-operative drugs lose their effect and the adrenergic response to pain and anxiety manifests itself. They recommended the use of chlorpromazine in the intra- and early postoperative period to reduce the reactive hypertension.
Straith and colleagues looked at 500 consecutive face-lift patients and found a strong correlation with the admission blood pressure and the incidence of haematoma; patients with a blood pressure > 150/100 had a 2.6 X greater risk of developing a major haematoma postoperatively.
Imperative that aspirin and aspirin-containing compounds are stopped two weeks before the procedure and not taken for one week thereafter. Aspirin irreversibly inhibits the adherence mechanism of platelets and as little as 10g a day can prevent normal platelet aggregation. This effect lasts for the lifetime of the platelet which is approximately 10 days
Important to ensure that anti-hypertensive medications are taken in the morning of the operation