------------------------------------------------------------------------------- TITLE: RHYTIDECTOMY (FACE LIFT): TECHNIQUES AND COMPLICATIONS SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: March 31, 1992 RESIDENT PHYSICIAN: Lane Smith, M.D. FACULTY: Karen Calhoun, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. ------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. History A. In modern history the first face lifts were performed at the turn of the century mostly by a few European physicians (Dr. Giles, Dr. Noel, possibly Dr. Joseph). These early physicians performed a simplified operation where skin was simply excised and the closed primarily in the preauricular region, without any undermining of skin. Hence from these early operations arose the name of Rhytidectomy for excision wrinkles because this is exactly what the operation consisted of. Development and progress in this area was slow as physicians who performed these operations were ridiculed and afraid to report their results. B. It was not until the 1930's that undermining of skin was described as part of the face lift technique. Gradually the flaps became longer and longer until the 1950's. This long flap technique remained the technique of choice until the mid to late 1970's. C. In early 1970's Pyronie, Mitz and Skoog described the SMAS technique which is the most commonly used technique today. D. In 1979 (Tessier) and 1985 Hinderer and others began to describe what is now called the "subperiosteal face lift." This procedure is only now gaining wide acceptance. E. In 1989 Hamra described Deep- Plane Rhytidectomy and then later 1991 his advancement of that called the "Composite Rhytidectomy." F. Names for Rhytidectomy include Face Lift, Facelift (one word), Cervicalfacial Rhytidectomy, and Facialplasty. The most accurate term may be facialplasty. II. ANATOMY NOTE: reading the literature about the anatomy of this area is very confusing as many structures have several names (ie. superficial temporal fascia, temporoparietal fascia, superficial sheet of the temporal fascia, or pretemporal fascia), authors have frequently confused and misnamed them and sometimes structures can be made to be overly complex (ie. splitting hairs.) It's similar to FESS. The anatomy of the paranasal sinuses was simple until FESS, then we learned about sinus lateralis, hiatus semilunaris, the bulla ethmoidalis, etc. A. SMAS - superficial muscular aponeurotic system. Greatly simplified it is easiest to understand this as a continuous musculoaponeurotic system that covers the neck, face and scalp. (in reality is may be several fascia or just one which splits and divides in several areas.) It is felt to be a continuation of the platysma that thins and covers the face and temporal area. It is made up of two components: 1. muscular - frontalis, occipital, platysma and risorius. 2. aponeurotic - epicranium and facial fascia in the parotid and masseteric area. Continuing as the platysma fascia and superficial cervical fascia in the neck. B. Essentially it is helpful to think of the facelift in terms of anatomy of three separate areas: 1. Fronto-orbito-temporal-zygomatic region: begins at the zygomatic arch area and extends to the forehead. In this area the SMAS is continuous with/ becomes the superficial temporalis fascia. (It may divide and enclose the temporalis, forming deep and superficial layers depending on source you read) Since the temporal branch of the facial nerve changes plane from deep to superficial in this area, you cannot simply dissect in the sub-smas plane all the way up to the forehead. 2. Auriculo-parotid-Masseteric region: this region extends from below the zygomatic arch to the cervical region (lower border of mandible) and forward to its where it stops at the nasolabial fold. There are actually several layers of fascia and loose areolar planes here and at least two layers of fat described; but it is easiest to think of the SMAS as lying immediately below the subcutaneous layer of the skin and just above the parotid fascia. The parotid fascia is actually continuous with the masseteric fascia and therefore is better named the parotid-masseteric fascia. This fascia is continuous with the superficial layer of the deep cervical fascia. Again we can see that continuing face lift dissection under the SMAS down on to the neck (when you include the parotid-masseteric fascia in your SMAS flap, as you should), would cause you to be under the superficial layer of the deep cervical fascia and put the marginal mandibular nerve at risk. Furnas (Furnas DW: the retaining ligaments of the cheek. Plas Reconstr Surg 83:11, 1989.) stressed the "tethering effect" of the zygomatic ligament (McGregor's patch) on the mandibular, platysma-auricular and anterior platysma-cutaneous ligaments. 3. Cervicomandibular-hyoid region: corresponds to the entire anterolateral region of the neck from the symphysis of the mandible to the sternal notch, above to the lower border of the mandible and behind to the SCM and occipital triangle. The platysma is encircled by the superficial cervical fascia and it and this fascia continues up over the face to make the SMAS (but the theory is the platysma has degenerated over the face and so you don't see a thick muscular layer there). The fat above the fascia of the platysma is relatively bloodless except for a few penetrating vessels int the submental musculature. The fat below the platysma near the floor of the mouth is highly vascular and requires more delicate dissection with greater attention to hemostasis. {Note: it appears to me that damage to the facial nerve can be prevented just about anywhere in the face if you are either very superficial or very deep. The problem is, the SMAS is neither deep nor superficial, it is in the middle. Knowing where and when it is safe to go up or down within this layer (as required by the deep-plane lift of Hamra) can be very confusing.} B. FACIAL NERVE - the two branches of primary concern in rhytidectomy are the frontal and marginal mandibular branch. 1. Frontal branch - in the frontal area above the brow, the nerve lies in a plane deep to the frontalis muscle. In the area just superolateral to the orbit ("red zone") the nerve runs just and just under or on the superficial temporal fascia. Over the zygoma lateral to the orbit, it runs deep to the orbicularis muscle and SMAS. It is the transition plane from deep to superficial over the area of the zygoma and lateral skull that is dangerous. 2. Marginal mandibular branch - exits from the parotid and runs below the mandible in a subplatysmal plane, curving gently up towards the mouth to innervate the depressors of the lip. It remains subplatysmal until approximately 2 cm lateral to the corner of the mouth. C. OTHER NEUROVASCULAR STRUCTURES 1. Greater auricular nerve - runs in the fascia of the SCM, and can be found approximately 6.5 cm below the bony external auditory canal. THIS IS THE NERVE MOST COMMONLY DAMAGED in face lift surgery. 2. External jugular vein - runs in the same plane as the greater auricular nerve approximately 5 mm ventral to the nerve. 3. Superficial Temporal artery lies just under or on the superficial temporal fascia and is often encountered in the superior portion of the dissection. II. PREOPERATIVE EVALUATION A. The patient should be an excellent surgical risk. B. Consider local anatomic factors: a) Conditions surgery is designed to correct. b) Pre-existing conditions that may compromise surgical results. C. Psychological profile of the patient - a) The patient must be informed of all aspects of the procedure, including all peri- operative changes to expect. b) The patient must have realistic expectations of results and the surgeon must select the appropriate procedure for that patient. "If the overall attitude is 'do your best, I don't expect miracles' one can feel safe operating. (Ellenbogen R. Natural Facelift. Current Therapy in Plastic and Reconstructive Surgery, Head and Neck; Editor J. Marsh. B.C. Decker Inc. Philadelphia 1989.) c) Counsel the patient with regard to frequent transient post-operative depression. d) Smokers are extremely poor face lift candidates and surgery should be performed when patient has stopped or severely decreased smoking. III. PROCEDURE A. THE FACELIFT INCISION General Principles: The incision must: 1) allow sufficient exposure to safely undermine skin flaps and remodel underlying fat and fascia. 2) permit proper shifting and redraping of skin to achieve a youthful contour with minimal cosmetic deformity. 3) produce a well camouflaged scar. 4) minimize distortion of surface anatomy. B. There is no agreement between physicians as to the exact way the incision should be made. Temporal Incision: parallels the gentle curvature of the hair line, usually 1 cm within the hair where the density of the follicles is sufficient to hide the scar; to help preserve the temporo-pre-auricular hair tuft, the incision is carried posteriorly above the root of the helix in a V-shaped pattern. However, as mentioned above there is a wide variation among good surgeons as to how the incision is made. McCollough likes to go along the hairline anteriorly (almost a pretrichal incision) to spare the temporal hair tuft, Ellenbogen does not go above the auricle at all, Beesom goes forward to spare the hair tuft and then posteriorly up above, deep into the hairline. Pitanguay and others go posteriorly on females up over the auricle and then in a sloping fashion onto the superior scalp deep within the hairline. Rolf Muenker (Problems and variations in cervical facial rhytidectomy. Facial Plastic Surgery, 1992;8:33-51.), describes the incision as follows "temporal incision is made in a semilunar line 2 to 3 cm above the side burns and temporofrontal hairline, starting at the top of the ear and running superiorly in an angle of about 50 degrees. They do not include superficial temporal fascia in the incision and flap development. By remaining superficial to the fascia they feel they avoid bleeding from the superficial temporal vessels and that the frontaltemporal branch of the facial nerve cannot be damaged in this plane. The temporal sparing incision is probably most important in males and in people getting a second or third facelift. Pre-auricular Incision: follow the pre-auricular crease. Again there is disagreement here. For males the consensus is to take the incision in the pre-auricular crease. For females some argue for making the incision go behind the tragus, others say just to stay within 2mm of the tragus going slightly onto the tragus, still others just stay in the pre-auricular crease. If the decision is made to go behind the tragus, it is best done when the patient has a sharp, well-defined tragus which does not protrude. Earlobe Incision: closely follow the lobule margin. Avoid undercutting the lobule. - free the lobe completely from the underlying tissue. - close the lobe without tension to avoid inferior pulling (thereby producing a pixie ear). Post-auricular Incision: continue posteriorly on the concha to the level of the inferior crus. May wish to move posteriorly into the post-auricular sulcus for a short distance before making the mastoid incision to help prevent webbing. Some also place a notch or z in the incision to prevent webbing and others (Beesom, McCollough) make the incision right in the post-auricular sulcus. Brennan (personal communication) likes to bring the incision posteriorly at the junction were the auricle crosses the hairline. Mastoid-Occipital Incision: curve posteriorly gently onto the mastoid when the level of the inferior crus is reached or as mentioned above at the juncture where the auricle crosses the posterior hairline. - course postero-inferiorly for some 5-8 cm, slightly above and parallel to the hair line and onto the nape of the neck. By staying close to the hairline you supposedly prevent elevation of the hairline. However some physicians like to take the incision straight back well into the hairline and do not feel this makes the hairline noticeable smaller. B. FLAP ELEVATION - begin undermining in the temporal area. Some recommend initially elevating in a plane deep to the temporalis fascia until the hair line is reached, then changing to the more superficial plane anterior to the hair line. Others recommend staying superficial the entire distance in the temporal area and elevation above the temporalis fascia with blunt dissection. - pre-auricular and malar elevation may be carried as far anterior as needed, some as far as the naso-labial fold. (depending on if long flap or short flap technique is being used.) This dissection is done in the subcutaneous plane above the SMAS. - completely separate the lobule from underlying tissue, then proceed with post-auricular elevation, staying superficial to the platysma. - define the lateral border of the platysma and SMAS. C. HANDLING OF SMAS - once flaps are elevated, there are four choices re: the SMAS: 1. Do nothing. 2. Incise and undermine the tissues to the anterior- medial border of the platysma. 3. Resection of portions of the SMAS below the zygoma and resuturing (imbrication). 4. Suturing, but not cutting into SMAS (plication). 5. The Sub SMAS dissection is usually (see other techniques below) only elevated the distance of the parotid gland and not past the gland. Also the most current technique (again hotly debated) is to include with the SMAS the parotid- masseteric fascia. This means you elevate in the plane immediately below the parotid fascia just barely into the surface of the gland. The safest technique is to have the superior limit of the dissection 1 cm below the zygomatic arch and the inferior limit of the dissection stop at 1 cm above the mandible. The SMAS is then pulled posteriorly and superiorly and the excess resected. The first suture, which is usually an absorbable 3-0 vicryl or PDS, is placed in a direction along a line form the angle of the mandible towards the earlobe. The next suture goes in the direction along a line drawn from the oral commissure to the tragus. Then several other sutures are placed as needed in that general direction. Also a small cut can be made in the inferior aspect of the elevated smas flap and pulled straight backward and sutured to the mastoid periosteum. Some people do elevate the SMAS down onto the neck with the platysma or the superficial cervical fascia and then pull this whole complex posteriorly and superiorly (do not currently recommend this). In the post-auricular area I prefer to elevate a small amount of platysma and superficial cervical fascia and pull this almost directly superiorly, trim the excess and suture it to the mastoid periosteum. This gives a lift to the neck that is similar to what the SMAS is doing to the lower face. There are many variations of this technique including dividing the platysma in a horizontal fashion and pulling it postero-superiorly or just dividing it so that it relaxes and relieves anterior platysma banding or doing nothing with it. D. PLATYSMA BANDING: - Many feel anterior neck deformity is due to failure of formation of the normal decussation of the anterior platysma. This can be handled by plicating this area through a submental incision (I believe this is the best method.) The plication can be combined with resection of redundant platysma anteriorly, or resection can be performed without plication. As mentioned above some surgeons make a posterior horizontal cut to "release" the platysma and others make a horizontal incision and then pull the platysma posteriorly. E. DRAPING OF THE SKIN FLAP Once flap dissection is complete and decisions concerning the SMAS and platysma have been made, direct SMAS and platysma posteriorly and superiorly and suture to the SCM and preauricular fascia and excise redundant areas. - direct skin flaps in the same direction as deeper tissues (see above,) anchoring with deep sutures to the pre- and post-auricular areas. - excise redundant skin as indicated. The skin flaps can usually be placed without tension or very minimal tension as tension is being taken up by the underlying SMAS and platysma. - A drain can be placed posteriorly for 24 hours and a fluffy dressing is placed but with significant pressure to help prevent hematomas. IV. The Long Vs. Short Flap Technique A. Long Flap with out SMAS dissection: this is the classical face lift used since the 50's and 60's. Many surgeons have obtained excellent results with this technique. It is different from the above described technique in that no elevation under the SMAS is made. The dissection is carried out in the subcutaneous plane all the way out to the nasolabial fold and under the neck area it is carried all the way under the chin to the opposite side. V. THE DEEP-PLANE RHYTIDECTOMY (Hamra 1990) A. A sub-SMAS type flap dissection is extended superiorly over the zygomaticus muscles and medially beyond the nasolabial folds, totally releasing all SMAS attachments and creating a thick musculocutaneous flap comprised of skin, all subcutaneous fat of the cheeks, and the platysma muscle. B. Operative Steps 1. Limited subcutaneous dissection. The subcutaneous dissection is carried only 2-3 cm from the jawline. 2. Sub-SMAS dissection in the lower face. The SMAS is incised with a scalpel and the dissection is developed with spreading scissors. Lower extent of the dissection is jawline, upper extent the malar eminence, where the zygomatic (vertical) ligaments are divided. The skin, subcutaneous fat and platysma muscles are not separated. 3. Dissection exposing the orbicularis and zygomaticus muscles to and beyond the nasolabial fold. This dissection This dissection is joined with the sub-SMAS dissection, creating a thick musculocutaneous flap. The skin, platysma and all fat of the cheek are the components of this flap. 4. Advancement and suture of the SMAS flap with 3-0 vicryl sutures are used to attach the platysma muscle to the preauricular fascia near the lobule of the ear. Strong tension is place on this advancement, but not on the skin. 5. Advancement and suture of the upper face lift flap. This is a rotation-advancement flap procedure suturing the dermis of the flap under great tension to the superficial temporal fascia at the level of the helix. C. The Neck Dissection 1. A preplatysmal dissection leaving all the fat on the flap. This dissections's superior extend is the jawline, and it extends low in the neck 8 to 10 cm below the mandible. 2. The anterior excision of the platysma and approximation of the platysma anterior edges. All the midline platysma is excised, and approximation of the anterior borders is done with tension. 3. Defatting the flap when indicated. This is done when it is determined that the flap fat is excessively thick. The flap is defatted with large scissors under direct vision. 4. Horizontal transection of the platysma leaving the posterior border intact. This division is done with cutting cautery. Care is taken to leave the posterior border attached to its original position. D. Advantages of this technique: 1. Hamra claims the face lift lasts longer. 2. Better treatment of the nasolabial fold 3. Better overall appearance E. Disadvantages of this technique: 1. Greater incidence of facial nerve paralysis (or at least weakness) Hamra states "that the since all the nerves to the mimic muscles enter from their inferior aspect, the deep-plane dissection is very safe." 2. More swelling 3. Higher incidence of complications 4. Prolonged healing VI. COMPOSITE RHYTIDECTOMY (Hamra 1992) A. In general this is similar to the deep plane rhytidectomy with the exception that included in the flap is the lower orbicularis oculi muscle. B. Theory of the composite lift: In conventional face lift procedures with SMAS techniques, the intimate relationship between the skin, platysma, cheek fat and orbicularis is disrupted as the skin is initially separated from the deep elements and the SMAS maneuver elevates only the platysma muscle, causing the normal relationship among the four elements to be lost. With this operation a composite flap is developed that is a bipedicled musculocutaneous flap based on the facial artery to the platysma muscle and the angular and infraorbital arteries to the orbicularis muscle. C. Hamra states the three changes that occur with the aging face around the fourth decade are: 1. The appearance of the jowl or broken jawline 2. The increased redundancy of the nasolabial fold 3. Increased distance from the ciliary margin to the "malar crescent" (the inferior most point of the orbicularis oculi on the cheek.) D. Operative steps: 1. First both upper and lower blepheroplasties are done. The lower blepharoplasty incision is made using a skin muscle flap. Any excess orbital fat is removed at this time and the blepharoplasty skin-muscle is excised at this time. (The eyelid skin should not be excised after the facelift.) The orbicularis is elevated off the malar eminence and will be connected to the rest of the flap. 2. a limited sub-cutaneous dissection is done up to a line from the malar eminence to a point approximately 2 cm anterior to the lobule of the ear. A "preplatysmal" neck dissection is done from the jawline down to the inferior cervical crease, keeping all fat attached to the skin of the neck. 3. A subplatysmal dissection is done with vertical spreading scissors after and incision is made in the platysma muscle from the jawline up to the malar area with a knife. This dissection is carried past the level of the facial artery at the jawline but does not disrupt the platysma fibrous connections at the corner of the mouth. 4. After identifying the lateral border of the orbicularis oculi muscle and the origin of the zygomaticus major muscle, a dissection is made on top of the zygomaticus major and minor muscles with spreading scissors. 5. This "prezygomzticus dissection" is done in the deep subcutaneous plane with all the fat being left on the flap. The zygomaticus muscles are visualized as this dissection is carries down to and beyond the nasolabial fold. The fibrous connection between the upper platysma muscle and the zygomaticus major muscle is separated with spreading scissors. 6. Communication is made between the face lift dissection and the previously made blepharoplasty dissection from approximately five o'clock to nine o'clock (on the right side, the opposite on the left side.) The communication could be approached from either dissection. 7. The inferior margin of the orbicularis oculi (crescent shaped) is excised off the flap, with care being taken to remove muscle only. (at this point the dissection is performed on the other side) 8. Closure of the face part is then accomplished after advancing the platysma muscle and suturing the muscle at the jawline under tension to the preparotid fascia just anterior to the lobule of the ear. If the lobule is pulled forward, a knife is used to release it to return it to its original position. 9. The facelift flap that carries the cheek fat is advanced with extraordinary tension and sutured with a dermis to deep fascia 3-0 Vicryl suture at the helical junction excess skin is trimmed and a retrotragal closure is accomplished. 10. After the face lift and brow lift closures have been accomplished, the orbicularis oculi is sutured in a superomedial vector with 5-0 nylon to the periosteum of the lateral orbital rim, thus visibly advancing the lateral orbicularis toward the lateral canthal area. The skin is closed with 6-0 nylon sutures. 11. Neck Dissection: there does not appear to be anything radically different about his neck dissection than other dissections. This is done after the face lift flaps and brow lift flaps have been elevated. The lateral cervical dissections are done in a "preplatysmal" plane (apparently this means a plane just under the superficial cervical fascia and just above the platysma) leaving all the fat on the flap, and incision is made in the submental crease, joining the left and right cervical dissections (essentially a long flap here) 12. The excessive submental platysma muscle is pulled up with an Allis clamp and then cross-clamped vertically with a Kelly clamp. The excessive muscle is then excised, thereby leaving a total decussation of the muscle from the submental crease down past the thyroid cartilage. 13. Inverted sutures of 3-0 nylon are used to approximate the muscle from the hyoid up to the submental crease. Part of the deep cervical fascia is included in this suture to prevent bowstringing of the muscle away from the deep cervical fascia. 14. Following anterior muscle advancement and approximation, defatting of the flap is accomplished. Bimanual palpation of the flap determines the need to reduce the thickness of the subcutaneous fat. 15. While tension on the cervical platysma is anterior, closure of the face lift flap will advance the facial portion of the platysma in a posterior upward direction. The cervical skin and sub-cutaneous fat will be advanced posteriorly with moderate tension. E. Advantages and disadvantages are similar to the deep-plane facelift. In addition this procedure must be performed under general anesthesia. (although Hamra states that you can do it under general or local but that he always does it under general anesthesia.) VII. THE SUBPERIOSTEAL RHYTIDECTOMY OF THE FOREHEAD AND MIDDLE THIRD OF THE FACE (Tessier 1979, Hinderer 1985) A. Useful for patients with severe ptosis of eyebrow, forehead, middle and lower face. He feels this is most patients over the age of 50 who are getting their first face lift. B. Operative technique (Simplified) 1. first a standard sub-SMAS or even ? a deep-plane lift is performed by elevating in the usual areas but it is not sutured in place yet. 2. The temporal incisions are continued across the forehead connecting with the other side (essentially the same as a coronal browlift incision. 3. A small incision is made in the buccal mucosa (similar to that for a Caldwel-Luc) and a periosteal elevator is used to elevate a plane under the periosteum over the maxilla, and malar bone lateral to the infraorbital foramen and elevating periosteum off the bone of the zygomatic arch. 4. In the Brow area the plane of dissection is in the standard subgaleal plane until about 2.5 cm above the orbital rim where you go subperiosteal over and into the orbital rim. Laterally the superficial sheet of the temporal fascia is incised and dissected downward, toward the upper border of the zygomatic arch, connecting with the dissection from below. "At the lateral border of the crista frontalis lateralis and, below at the lateral border of the of the orbital process of the malar bone, the periosteum has to be sharply divided in order to be elevated in continuity with the superficial sheet of the temporal fascia. 5. All the layers are pulled back and closed and a drain is inserted in the subperiosteal space and one immediately in front of the ear. C. Advantages: 1. Longer lasting facelift 2. Addresses the upper as well as the lower face 3. Better appearance D. Disadvantages 1. Must be done under general anesthesia 2. Swelling is severe and recovery prolonged 3. Increased incidence of complications VIII COMPLICATIONS: A. Major - anesthetic/drug reaction, extensive hematoma, facial nerve injury, skin loss or severe hair loss and infection. B. Minor - prolonged edema, ecchymosis, skin separation, permanent discoloration, per- permanent numbness, ear lobe deformity, small hematoma, localized infection, hypertrophic scarring, pigment change and pain. may also classify complications as follows: 1. Anesthetic: reactions to anesthetic used or toxicity from excess dose. May also get facial nerve injury from direct needle trauma or hydrostatic pressure local anesthetic. 2. Intraoperative Complications: unequal pull by plication sutures. subcutaneous bumps from plication sutures; deepening of naso-labial fold with SMAS plication; buttonholing of skin; transection of greater auricular nerve; facial nerve injury; excessive skin excision. C) Post-operative Complications: 1. By products of the operation (not true complications) include tightness, edema, ecchymosis, edema, decreased sensation, or numbness, and incisional scar. 2. Hematoma - overall incidence 4.8%. (range 3% to 15.9%) This is probably the most common post-op complication. Causes include coagulopathies, aspirin or other anticoagulants, excessive pain/wretching in the immediate post-op period, poorly controlled hypertension, poor surgical technique. A good pre-op history and physical (blood pressure) is essential. The most common sign of hematoma is increasing pain. When this occurs the dressings must be inspected and clots evacuated. Early hematomas. a. small - requiring only needle aspiration and pressure. b. Large or expanding - requiring surgical drainage and coagulation. Sometimes a suction cannula can be used to aspirate these hematomas as it has the power to suction even jelly-like clots. Failure to discover expanding hematomas can result in skin necrosis, skin loss, scarring, pigmentation changes, puckering, and subcutaneous masses. Small hematomas will respond to time, massage and judicious use of steroid injections for the scar formation. Large hematomas can be treated by staged aspiration after they have liquified (7 days post-op); aspirating every 2 to 3 days for three or four times. C. Infection - rare due to good blood supply of face, overall incidence 0.7-3.9%. Staphylococcal infection most common, it usually responds well to antistaphylococccal meds. Many physicians give intravenous perioperative antibiotics and post-op antibiotics for 1 or 2 days. D. Facial nerve injury - overall incidence, including intraoperative injury is 0.7% (0 - 3.3%.) Post-operative injury caused by infection, nerve transection, edema, hematoma, blunt trauma, cautery, sutures, pressure and inflammation. Fortunately the vast majority of motor nerve injuries are due to factors other the transection. 80% of these resolve within 6 months and recovery for some may take two years. ( Baker DC, Conley J: Avoiding facial nerve injuries in rhytidectomy: Anatomical variations and pitfalls. Plas. Reconstr. Surg. 1979;64: 781.) Some have suggested that facial nerve damage is more likely to occur in thin patients. Facial nerve injury can be prevented by use of blunt finger dissection and bipolar electrocoagulation. Frontal branch injuries are the least likely to recover, and can be avoided by blunt finger dissection over the course of the nerve. This is the branch least likely to recover and the most likely motor branch to be injured. Buccal Branch is the most likely to recover because of multiple interconnected branches Marginal branch will usually recover spontaneously, but less likely then buccal. This is the second most frequently damaged motor branch. Most motor nerve injuries are discovered post-operatively. If discovered intraoperatively primary microsurgical repair is indicated. If no reason to suspect transection, wait. The vast majority of nerve injuries recover. Rarely reexploration, and electromyography studies are needed. Can be prevented by performing defatting procedures (liposuction, open defatting, curretage) after SMAS-Platysma have been transposed to their new positions. This tightens the underlying tissues, which makes tenting of the platysma and cutting of the marginal branch less likely. E. Skin slough - incidence ranges from 1-6%. Occurs in direct proportion to tension on skin. Much higher incidence in smokers and using long flap techniques. This should be treated conservatively as often with time they heal well. Do not debride eschars unless there is obvious liquefaction beneath them "they act as biologic dressings". Place ointment (betadine) to allow them to flake off spontaneously. Although the initial scarring can be significant, over months and years this scarring will reduce. A secondary facelift can help remove the scars. F. Alopecia - incidence from 0.2-1.8%. caused by many of same mechanisms that cause skin slough (smoking tension, overly thin flaps, decreased circulation, destruction of hair follicles.) May be temporary (follicle shock). Need to wait three months for hair regrowth. Hair transplants and plugs rarely needed. G. Scarring - 9% incidence of scar widening and a 3.1% incidence of hypertrophic scarring. Hypertrophic scars are more likely to occur in the mastoid and preauricular regions and are more likely to occur in younger patients. Common causes of scars include excessive tension (probably the most common reason), smoking, vascular problems, infection, keloidal tendencies and connective tissue disorders such as Ehlers-Danlos Syndrome. Methods to avoid this is closure in at least two layers and leaving sutures in hair bearing areas for 10 to 2 weeks. Once scar has formed need to be patient and wait for scar maturation and consider steroid injections. Secondary facelift of scar excision may help. F. Ear lobe deformity. Pixie ear (lack of an earlobe) often secondary to excessive tension on the ear lobe. There must be no tension on the ear lobe at all. H. Greater Auricular nerve injury. This is the most common nerve injured in face lift surgery. Repair nerve with 6-0 or finer prolene. Injury can be avoided by dissecting in a superficial plane, when you see muscle you're too deep. The nerve lies immediately posterior to the external jugular vein. Immediate severe post-operative pain may be due to sutures that lie in or across the greater auricular nerve. This usually resolves in 6- 8 weeks. If the patient develops delayed severe post- op pain with a trigger point in the neck, reexploration and anastomosis of the severed ends will frequently help. G. Platysma banding: Can be accentuated by facelift if not addressed, and accentuated by submental or sub-platysmal liposuction. Best treatment is probably medial plication of the platysma. Psychological: Transient post operative depression is extremely common. This and all psychological complications helped by proper patient selection and preoperative counseling. ------------------------------------------------------------------------------- BIBLIOGRAPHY 1. Hamra ST: Composite Rhytidectomy. Plast Reconstruc Surg 1992;90:1-13 2. Hamra ST: Repositioning the Orbicularis Oculi Muscle in the Composite Rhytidectomy. Plast Reconstruc Surg 1992;90:14-22. 3. Pellegrini VM: Surgical Anatomy and Dynamics in Face Lifts. Facial Plas Surg 1992;8:1-10. 4. Hamra ST: The Deep-Plane Rhytidectomy. Plast Reconstruc Surg 1990;86:53-60. 5. The Forehead Lift, Kaye, B.L. Plast and Reconstr Surg-Aug, 1977. 6. The Face-lift Incision, Johnson, et al, Arch Otolaryngol-110, 1984. 7. 512 Rhytidectomies, A Retrospective Study, Kamer, et al, Arch Otolaryngol-110, 1984. 8. Preliminary Report on the Complications of the Extended Cervicofacial Rhytidectomy, Dedo, D.D. Laryngoscope-93, 1983. 9. 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